Upper lumbar thigh pain

There is a strong correlation between the upper lumbar spine and thigh pain; and it moves in both directions via the femoral and superior cluneal nerves on the one hand, and the psoas muscle on the other, making it often difficult to decide which is chicken and what is egg.

The superior cluneal nerves emerge from the L1, L2 and L3 nerve roots; the posterior rami for anatomical boffins, whereas the femoral originates from the anterior fibres of L2, L3 and L4.

Between the two, the nerves supply the skin of the upper part of the buttock, the side of the upper leg, the front of the thigh and the groin.

  • Superior cluneal nerves; posterior rami of L1, L2 and L3.
  • Femoral nerve; anterior rami of L2, L3 and L4.

This may not interest you particularly but you have upper low back pain, radiating to the buttock and the thigh.

This complex scenario may be further complicated by hip conditions; for example a hip dysplasia or impingement syndrome frequently causes uppert thigh and groin pain, quite independent of what is happening in the lumbar spine.

Furthermore, the sacroiliac joint syndrome often also causes buttock and groin pain.

Not infrequently these conditions form a complex syndrome of lower back, buttock and groin pain. Identifying the individual components of the syndrome is vital if treatment is to be successful, as each has to be addressed and an exercise programme for the various parts devised. A "cure" is unlikely, but most patients who have chronic, unresolved pain are not unhappy with a 60-90 percent reduction in pain and disability, coupled with daily specific exercises and an acceptance that certain activities are verboten; the vacuum cleaner, for example.

Upper lumbar thigh pain

This may be further complicated by the presence of a short leg, causing a distortion in the pelvis and a lumbar scoliosis extending up into the mid back and cervical spine where further problems are caused. It is not unusual for these patients to have neck and thoracic pain, in addition to lower back and thigh symptoms.

An orthotic in the shoe may help to correct the short leg and subsequent scoliosis, but the making of inserts is an art form in itself. Frequently, if not correctly done, they add to the problem causing knee, hip and lower back pain.

All in all, it's a complex scenario requiring your chiropractor to carefully evaluate the various components of these upper lumbar, thigh and calf pain syndromes.

Mrs L is a 50 year old woman with chronic right buttock and lower back pain; the latter has two foci, one at L5/S1 and the other at the thoraco lumbar junction. A tightness in the calf, anterior thigh pain and upper buttock numbness are features of this case.

The pain began some two years previous, with no known cause. Her doctor had only anti inflammatories to offer.

She is a lithe and otherwise healthy lady; her weight is perfect. She is active and busy but has annoying upper lumbar and buttock pain. Two days before the first consultation she went for a run, developing acute right upper leg pain.

An lateral xray of the lower back reveals an unusual alteration in the normal lordosis at the thoraco lumbar junction; nothing specific but confirming her extreme sensitivity in the region.

On examination of this upper lumbar with thigh and calf pain case, the pelvis appeared mildly low on the right giving a right convex scoliosis.

On motion palpation, there was a right sacroiliac fixation. That in itself is unusual; normally the fixation is on the opposite side to the short leg.

In the lumbar spine there were no obvious lower lumbar spine fixations but at the thoraco lumbar junction L1 was markedly fixed on the right and extremely tender. L5 was also particularly tender on the right, but not fixated.

On forward flexion there was no lumbar pain or restriction but tightness in the posterior right thigh and calf suggestive of a low grade sciatica. This was confirmed by a positive Slump test with pain in the calf. Lasegue's test verified this with restriction in the lower leg at 60*, but no LBP, with a positive Braggard's test. Motor findings were NAD with normal reflexes and muscle strength.

In addition, the femoral stretch test was positive giving pain in the anterior thigh.

On pinwheel testing, there was distinct hypoanalgesia in the upper buttock, the distribution of the superior cluneal nerves, confirming a Maigne's syndome as being a major part of the whole pain complex.

A closer look at the spot of L5/S1 reveals the presence of a large spatulated transverse process of L5 on your reading left (black arrow), together with a sagittal facet (red arrow); on the right is the conventional coronal facet.

Again, on the lateral spot, there is the suggestion of incomplete union between S1 and the remainder of the sacrum; fortunately the disc space at L5-S1 is normal. Or, using other conventions, the partially fused segment is in reality L5, making this a sacralisation.

The irritation of the sciatic nerve is almost certainly not for a bulging disc, but that could only be confirmed by MRI scan. Rather, this is the release of noxious chemicals from the joint cartilage.

The mild lumbar scoliosis continues up into the torso, resulting in pain in the midback and neck.

Rudimentary ribs are seen at T12, a common feature of a sacralisation or lumbarisation. Naming is not important; whether the last discrete vertebra is L4 or 5 makes no difference. What is significant is the presence of a transitional segment, asymmetrical facets, a transverse ilio anomalous joint and those little appendages arrowed at the thoraco lumbar junction.

These anomalies sometimes produce quite unusual and even bizarre patterns of lower and upper lumbar pain with diverse thigh and calf radiation.

Treatment of this two year old pain consisted of

  • Prone drops on the pelvis using the Thompson protocol.
  • Side posture adjustments of L2 and L5.
  • Prone P to A adjustment of T12.
  • Stretching out of the sciatic nerve in the posterior thigh and calf.
  • Soft tissue therapy to the active trigger point in the quadratus lumborum muscle. 
  • An inexpensive heel lift in the right shoe.
  • Home exercise program. 

The response was dramatic with 80 percent less pain after only three treatments but after a long car trip some pain has returned, and clearly a course of treatment is indicated. A cure is unlikely and she will join the group of people for whom an occasional but regular treatment is vital.

Other conditions going along with this upper lumbar and thigh and calf pain case.

Due to the scoliosis and other injuries, midthoracic pain, tingling in the right arm due to a first rib fixation, with a mildly positive Adson's test but negative upper limb tension test, and headaches are also being treated.

Useful links @ upper lumbar thigh pain

» Upper lumbar and groin pain

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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. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost painfree. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

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 stabs in the groin, 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 spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, 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. Increased range of motion is more difficult than too stiff in my opinion. Our care 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.

Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?

Interesting questions from visitors

CLS writes:

Greetings, Dr B.
You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.

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