Pain in upper leg

Case File @ Chiropractic Help

(Keywords: pain in upper leg, chiropractic help, Femero Acetabular Impingement syndrome, upper leg pain, Maignes syndrome)

Mrs V (63 years) has had left low back pain for about ten years. There was no obvious cause. One year before her first consultation (July 2009) severe pain began in the left groin, radiating down the front of the thigh towards the knee. Periodically her upper left leg would suddenly 'give', partly with a sharp stab of pain, and partly due to a weak feeling. Frequently she could barely walk, the pain in her upper left leg was so bad.

She wore a heel lift in her RIGHT shoe; that brought some measure of relief.

Treatment by an orthopaedic surgeon specialised in manipulation brought some relief of pain, especially the insert in her shoe, but her leg continued to buckle under her, and walking remained very difficult. After several months, this doctor referred her to our clinic for evaluation.


Right Choices ... follow your instincts.


    On Examination @ Pain in upper leg

In bare feet, it was clear that she had a very short RIGHT leg, a sharply tilted pelvis, low RIGHT, and accompanying scoliosis, convex right. Or, was it left? Was I going crazy, the X-rays told a completely different story.

Ranges of motion of the lumbar spine were good, without radiation of pain to the leg, or significant pain in the back.

Left hip: Flexion and rotation (internal and external) rotation were full, and without pain. Thus, no hip arthritis. However, adduction, pulling the knee towards the opposite shoulder caused sharp pain in the groin.

The test called Patrick's Faber test, was also strongly painful and some movements were limited in the groin. Hip arthritis? Femero Acetabular Impingement Syndrome?


Most odd, was that the Slump test provoked pain in the front of the thigh - it's a test for the Sciatic nerve which, when pinched or irritated, would cause pain down the back of the leg. In that sense, the Slump test for sciatica was negative.

 
However, the Femoral nerve stretch test was positive, with pain in the front of the left thigh. A pinched nerve, either in the groin or lumbar spine? Upper leg pain always calls for careful examination.



Neurological examination of pain in upper leg

Once again there were contradictory results: The reflexes were normal and there were no sensory changes, but the Quadriceps muscle was weak - the probably the cause of her leg suddenly giving under her weight, particularly on the stairs. Unusual with a normal reflex.


Chiropractic Help examination

She stood very prominently with a short RIGHT leg, and attendant scoliosis. There were fixations in the right sacroiliac joint anatomy, and at the L1 joint.

With groin and pain in upper leg (front of leg), the involement of the Femoral nerve and a possible Maignes syndrome was high in my list of differential diagnoses of upper leg pain. Sacroiliac joint anatomy ...


X-rays


There's no mention whether this X-ray of the pelvis was taken standing, or lying supine. That's important when making decisions about a heel lift. The strong implication here was very short LEFT leg.

Was I going crazy? I have got it wrong before, and sometimes an apparent short leg can change after treatment of the pelvis. So, a phone call to the hospital. Indeed, the radiograph was taken lying supine. It was just a bad set-up by the radiographer.


Confusion

This whole case is loaded with difficulties.

  1. Severe pain in upper leg, lasting a whole year, despite various medical treatments is obviously a serious concern.
  2. The X-ray report of the hips was "normal". But she had severe pain in the hip - in the groin.
  3. No recent X-rays of her back were available.
  4. Physical examination by both the orthopaedic specialist, and myself, confirmed a short RIGHT leg. But the X-ray of the pelvis suggested a very short LEFT leg.
  5. Any condition that causes "hard neurological signs" - altered reflexes or sensation, or weakness, are serious.
  6. But weakness in the large thigh muscle, the Quadriceps, with no change in the knee jerk reflex? That makes no sense. Diabetes mellitus?


Treatment

Following the Thompson drop protocol we adjusted the sacrum on the right, L1 on the left with the so-called "million dollar" roll.

The left hip was mobilised and the Adductor magnus, pectineus and psoas with treated with the Active Release Technique (extremely painful).

A vigorous rehab programme.

Progress 

Mrs V consulted me again today. She comes with her husband once every six weeks.

She's a very happy lady, but I'm still confused. She can walk long distances without her leg collapsing under her, and without pain in her thigh. But I still don't confidently have the correct diagnosis. Many years ago I learnt an important lesson from Dr Glynn Till, president (now retired) of the Chiropractic College in Durban, South Africa.



"Remember, the patient may have two different conditions."

Dr G. Til, DC



Femoro Acetabular Impingement Syndrome

Pain in upper leg


The "spot" of her left hip reveals little arthritis superiorally to speak of, mild signs of Femoro Acetabular Impingement Syndrome Pincer and CAM, and several unnoticed cystic lesion in the ball of the femur.

It's time for new X-rays and, depending on the result, an MRI. X-rays of her lumbar spine, taken standing WITH the heel lift in place in the right shoe, and a new spot of the left hip. And a test for Diabetes.

That diabetes test is just routine. I'm not expecting it to be positive. She is not obese, there is no urinary frequency, no loss of weight, no abnormal thirst and, when a diabetic neuropathy causes weakness in the Quadriceps muscle, there's no pain in upper leg usually. Silent and deadly.


The Future

Like all case histories, this case is in development, and will always remain in development. She thinks the future is rosy, I have unanswered questions. Meantime, she walks, she does her back and pelvis rehab exercises, she's happy... they are off hiking in the Black Forest in the south of Germany this week. Life is full...


Another difficult Pain in Upper Leg

Mrs S came for treatment for terrible headaches. An elderly woman, I was shocked at how many analgesics she was taking. Rebound headache is actually caused by taking bucketfuls of pills...

There was nothing simple about her upper neck headaches, but they have now stabilised at about 80% better and she needs little medication.

The problem is that she is always very sore for about three days after an adjustment. So now she comes once in two months, and is very happy.

But her upper leg?

After an operation to remove a sickly ovary she developed severe pain in the groin and upper thigh. I suspected they knicked a branch of the Femoral nerve and there was little to be done. But she did have a L2 fixation - the Femoral nerve comes from the upper lumbar spine.

As with her neck, she was VERY sore in her lower back for three days, but hey presto, no more restless legs at night, no more hanging the leg outside the blankets, no more pain. And she does her lumbar exercises very faithfully.



Spondylolysthesis

 Health is additive. The positives and the negatives. This lady has been has heavy as 160kg, now 117kg has a double spondylolysthesis (old trauma most likely), has Femero Acetabular Impingement Syndrome and severely arthritic knees. An interesting case: Pain and tingling in feet and legs Casefile...



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Interesting challenges of the day

1. Mr D has very severe midback back. He bent and twisted, feeding his son, and then laughed. Every breath is a nightmare. A sprung rib is every chiropractor's delight. He or she has golden hands. 30 percent better after one treatment.

2. Mrs C has a long history of severe, disabling migraine headaches since having her wisdom teeth removed. She clenches her teeth at night. After six treatments she has no migraines but some jaw joint discomfort remains; a bite plate is in the offing.

3. Mrs U has the trophy for the worst back this year. After major surgery with plates and screws two years later she still had paresis in the lower leg and severe disabling back pain. She's doing far better than expected, in no little part due to a lift in her shoe for a very short leg.

4. Mr V is 86 years old and hurt his back helping his wife into the car. Just one treatment of the sacroiliac joint and he's eighty percent better. It's not always like that.

5. Mr W lay on his back knocking down a pillar. Turning his head causes severe vertigo. He needs the Epley exercises, not pills, research shows. Update, he's fine.

6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.

7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.

8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.

9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine. 

10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.

13. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks 75 percent improved. No longer vomiting all falling. She's not enjoying the Brandt Daroff home exercises.

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.



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