Pain in upper leg

Case File @ Chiropractic Help

Keywords; pain in upper leg, femoro acetabular impingement, Maignes syndrome.



Mrs V, a  63 year old woman has had left LBP for about ten years. There was no obvious cause. Twelve months before her first consultation severe pain began in the left groin, radiating down the front of the thigh towards the knee. Periodically her upper leg would suddenly give, partly with a sharp stab, and also due to a weak feeling.

Frequently she could barely walk, the ache 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, and 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.

On examination, bare foot, it was clear that she had a very short right leg, a sharply tilted pelvis, low on the right, and an accompanying scoliosis, convex right; or, was it left? Was I going crazy? The xrays 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 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? Femoro 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. 


Pain in upper leg



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?


Chiropractic Help

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 is always part of chiropractic help for any chronic condition.

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. Till, DC


Femoro Acetabular Impingement syndrome


The spot xray 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 xrays and, depending on the result, an MRI. Those 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 the upper leg usually; it's silent and deadly.

Like all case files, this is in development, and will always remain so. She thinks the future is rosy, but I have unanswered questions. Meantime, she walks, she does her back and pelvis rehabilitation exercises, and she's happy. They are off hiking in the Black Forest in the south of Germany this week; life is full.

Three years later, I've just had the good fortune to see her whilst doing a locum in the Netherlands; she continues to do fantastically well, coming in every six to eight weeks for maintenance care. 


Here is another difficult pain in upper leg file. 

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 percent 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 S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Mrs T looked like the leaning tower of Pisa; she had a slipped disc at L5 making her lean towards the opposite side. It's called the postero lateral disc hernia; she's much better after two weeks of treatment and will go back to work next week, part time. Lateral discs are more difficult; both take a minimum of six weeks to heal. In my opinion, antalgic patients need what I call exercising bed rest. Sit and it won't get better.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months. He has a pincer deformity in the hip causing the groin pain, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your lower back is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her hip, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Hypermobility is more difficult that too stiff in my opinion. Chiropractic is for kids too.

8. This 65 year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

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. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

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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