PAIN IN UPPER LEG
Case File
(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.
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 was negative.
SLUMP TEST ...
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?
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NEUROLOGICAL EXAMINATION
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 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 diagnoses.
SACROILIAC JOINT ANATOMY ...
MAIGNES SYNDROME ...
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. - Severe pain in upper leg, lasting a whole year, despite various medical treatments is obviously a serious concern.
- The X-ray report of the hips was "normal". But she had severe pain in the hip - in the groin.
- No recent X-rays of her back were available.
- 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.
- Any condition that causes "hard neurological signs" - altered reflexes or sensation, or weakness, are serious.
- 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 of the Chiropractic College in Durban, South Africa.
"Remember, the patient may have two different conditions."
Dr G. Till
FEMERO ACETABULAR IMPINGEMENT SYNDROME
PAIN IN UPPER LEG
The "spot" of her left hip reveals no arthritis to speak of, mild signs of Femoral Acetabular Impingment Syndrome Pincer and CAM, and an 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 she 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 leg. 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...
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