Keywords; superior cluneal, lateral femoral cutaneous nerve, buttock pain.
Common symptoms are often confusing and overlap with many other conditions. Groin discomfort for example occurs in many diseases; you can't simply assume that you are suffering from this upper lumbar problem.
That part between the lower spine and the midback, where you can feel the last rib, is called the thoraco lumbar region.
This condition causes lower back and buttock ache, and often upper leg and sometimes groin discomfort.
The thoraco lumbar junction syndrome, as it is sometimes called, has been thought to be responsible for up to forty percent of common LBP. This percentage is subjectively based upon Dr. Maigne's personal statistical study of 500 cases and is, in my opinion, rather high but the upper lumbars are certainly often neglected as a source of referred lower back pain.
Because Maigne's syndrome makes for a diagnostic nightmare, it is often overlooked, causing possibly years of unnecessary pain and disability. Read more from the case file found lower down.
As always, not more tests, but a thorough clinical examination is required. Is there a spinal fixation at the thoraco lumbar junction? Is the active trigger point in the quadratus lumborum really an incidental finding? Is the pain in the groin or lateral thigh from a femoral nerve lesion, maignes syndrome, hip arthritis, and so on?
Back, buttock and groin, perhaps.
Dr Maigne, a French orthopaedic specialist, proposed that low back pain could in fact originate from the thoraco lumbar facet joints, mediated by the superior cluneal nerves, lumbar nerve roots 1, 2 and 3, now known as Maignes syndrome. They supply primarily the upper buttock but also sometimes the groin.
A careful examination of the sacroiliac joints, the piriformis, the hip is always in order. Pain in the buttock and groin areas can come from so many different sites. Inguinal hernia, testicular cancer, swollen lymph nodes?
Prostate cancer, the most common fatal cancer of men, should always be upper mind, and not only in the older patient. Controversy reigns in medical circles concerning the best routine examination for prostate cancer, so we at chiropractic help will stay out.
Nevertheless, prevention of all cancers but particular of the not uncommon breast and prostate cancers, is vital in chiropractic practice, because of their tendency to metastasize frequently to ribs, the spine and pelvis; areas treated on a daily basis at the chiropractic coalface. The short answer is every man shall eat a tomato a day, and avocados regularly, and women must reduce animal protein; and take hormone replacement therapy only in cases of extreme necessity.
The dermatomal distribution of the cluneal nerves and the lateral femoral cutaneous nerve, LFCN.
As we shall see, a very similar syndrome originating from this region, but involving the lateral femoral cutaneous nerve, lumbar 2 and 3, a branch of the femoral nerve. The syndrome has no name, so I lump it in with maignes syndrome,
though technically it's not; it causes pain and numbness on the side of
the thigh and or the groin area.
More complex, this lateral femoral cutaneous nerve may be involved in a double crush
syndrome where there is often a subluxation in the upper lumbar spine, and the nerve is crushed in the groin giving symptoms on the lateral thigh only. Then it's called meralgia paresthetica.
A syndrome simply means a collection of seemingly unrelated signs and symptoms. Buttock and LBP are typical of maignes syndrome, but groin pain perhaps, lateral hip and thigh numbness, an anterior thigh burning sensation may all be mimicked by this condition via the lateral femoral cutaneous nerve.
However, as I said, this is not technically Maignes syndrome.
Other conditions often causing buttock pain and affecting this area are the piriformis syndrome, a small buttock muscle through or around which the sciatic nerve must negotiate its way to the leg.
The side of the thigh is also occupied by the iliotibial band syndrome, a long band of tissue stretching from the tensor fascia lata muscle to the side of the knee.
Another condition is the femoro acetabular impingement syndrome which also can cause groin and side of the hip pain. It is characterised by stiffness in the hip, and may be found in young people.
Another is hip dysplasia; mild cases are often missed causing upper thigh and groin pain.
These lead unerringly on to premature hip arthritis if not managed carefully.
These are conditions that chiropractic excels in. Well, hip arthritis in its early to moderate stages. Thereafter it's a surgeon's work.
But, it's a highly complex area also involving medical conditions like an inguinal hernia, aneurisms in one of the iliac arteries, lymph nodes, and many others. Your chiropractor will make a careful examination of the area, and may well ask for a second medical opinion.
To adequately diagnose and treat the myriad of conditions around the low back, buttock pain, groin and thigh really requires good teamwork. Unfortunately Chiropractors are not yet considered part of this team by the majority of the Medical community - to the detriment of the patient. This is why there is a strong move in Chiropractic to vacate the Complementary-Alternative-Medicine (CAM) camp and join the Medical community proper. This movement has its critics - they fear we could lose our identity.
Only this week I have had two new patients who have had severe disabling pain in this area for over a year. I know I can help them both, but anyway it's a relief that the medical conditions have been ruled out. But they have suffered needlessly because of the suspicion that Chiropractic is still treated with. How can I say with such confidence that I can help them? Because it's almost become bread and butter - I see these conditions on a daily basis. What's really needed is some good research ...
A bit more science!
Lateral Femoral Cutaneous nerve (LFCN)
The LFCN arises from the L2 and 3 lumbar plexus. It emerges from the lateral border of the psoas major muscle, not shown, which joins with the the iliacus, seen in the graphic above. The nerve then proceeds obliquely across the pelvis, toward the so called ASIS, a hard bump about 15 cm above and slightly forwards from the hip bone.
Notice how the iliacus, with the psoas, courses down with its tendon inserting into to the femur in the upper thigh. These muscles, together called the iliopsoas, are in part responsible for the intense tenderness in the groin that may accompany the numbness in these syndromes.
It then passes under the inguinal ligament; can you trace the lateral femoral cutaneous nerve in the graphic above? It then goes to the thigh. This is where it is pinched in meralgia paresthetica, dividing into
The result is that lower back and upper leg pain can present with a myriad of signs and symptoms, with many different etiologies (causes).
Thus, lumbar pain, buttock pain, groin and lateral hip and anterior and lateral thigh pain may in fact be a referred pain from the thoraco-lumbar region. Only a careful and thorough examination can clearly distinguish between hip pain, sacro-iliac joint pain, low lumbar pain and Maigne’s syndrome, and it's first cousin Meralgia Paresthetica ...
I increasingly begin treatment of the patient with low back pain with thoraco-lumbar adjusting. The upper lumbars are often fixated explaining why the side of hip (called the trochanteric region) is so often very painful.
Commonly, Sacro-iliac joint fixations may be associated with Maignes syndrome. Clinically, one is faced with a chicken and egg situation. Do the pelvic conditions cause the thoraco-lumbar fixations? Or do the thoraco-lumbar fixations/ subluxations cause the Sacro-iliac syndromes and lumbar pain? Mostly, your chiropractor will pay careful attention to all areas of the lower spine and pelvis.
The real cause may also be a short leg. Read more about Leg Length Inequality ...
Want more information about your spine? SpineUniverse (http://www.spineuniverse.com/)
Lumbar and buttock pain coming from the thoraco-lumbar region, Maignes Syndrome, is a notoriously difficult region to adjust. Thus you should be patient with your doctor. You may not immediately hear loud clicks, and dramatic relief of pain. Common chiropractic adjustment techniques for this low back pain may include a straight straight down adjustment (whilst lying on your tum) which can be very painful, a hyper-extension technique (sitting or standing), a lumbar roll, McManis traction, an activator technique, Thompson drop and others.
An excellent article by Dr Marc Heller, DC on the Chiropractic management of Maignes syndrome can be found at : http://www.dynamicchiropractic.com/mpacms/dc/column.php?c_id=1517/
Do you enjoy light reading? Chiropractor Bernard Preston writes excellent books about chiropractic and life. Described as "Gems, both funny and healthful, from the life and work of a Chiropractor" you will love these Chiropractic books. BERNARD PRESTON homepage.
Another less commonly known technique in the treatment of Maignes syndrome is the supine hyperextension techique. Using a standard adjusting table, the pelvic section is raised to perhaps 45 degrees. The patients sits on the pelvic section with his hands behind his neck. The doctor places his hand behind the back at the fixated segment, flexes the torso slightly, and then makes the corrective adjustment in an anterior to posterior direction.
Active trigger points will often be found in the Quadratus lumborum muscles, the TFL, the Gluteal muscles adding to the low back pain, and will be addressed by a variety of techniques.
Hip hike, and pelvic tilt exercises (especially with the hands under the involved segments) are useful, as would alternating ice and heat treatment help with the lumbar pain.
FROM THE COAL FACE
'Doctor, I have a pain here on the side of my buttock. I've been to my doctor, two physios, and another Chiropractor. I am despairing. It's getting worse. It keeps waking me throughout the night.'
'We had better start with a good examination, Mrs P. Would you slip your down to your underwear, please.'
The examination was unremarkable in many respects. All the neurological and orthopaedic tests were negative. The previous practitioners had successfully treated the lumbar spine and the pelvis. But the pain remained. A raw, gnawing pain. X-rays didn't show much of interest, but indeed a moderate curve with the apex at the thoraco lumbar junction, where we found a massive fixation. It was solid as concrete. I don't diagnose it as Maignes Syndrome until the buttock pain has been successfully cleared by the thoraco-lumbar adjustment.
Early in my career, I had the good fortune, to walk past an elderly chiropractor giving a colleague an adjustment at a chiropractic congress. I had never seen the technique before. Or since, for that matter, but I use it every day. I call it the FIST EXTENSION, simply because I know of no other name.
I've only cracked four ribs in nearly thirty years in practice. One of them was using this technique! But it's fixed hundreds of Maigne's syndrome sufferers. Fortunately, a large bouquet of flowers, and a humble letter of apology saved my bacon. I suppose in America I would have had the pants sued off me, and those hundreds of people would still be suffering because I would be too afraid to use FIST EXTENSION again!
The cost of low back pain is becoming a massive burden to society, not least of which because the enormous insurance premiums doctors have to pay. If this little understood Maignes syndrome makes up 40% of low back pain ...then no wonder we are making little progress. (personally I think 40% is over the top. That was Dr Maigne's opinion). Once you start to factor in lost time at work... If you are interested, read on about the economic burden of LOW BACK PAIN ...
Uncomfortable though the thought may be, if you are a smoker you WILL suffer from more low back pain, quite apart from the cancers associated with smoking. Strong research reveals that the lumbar arteries become furred in smokers reducing blood flow to the spine, and a strong correlation between smoking and lower back pain.
Worse, you are likely to respond poorly to both chiropractic and surgical treatment for lower back pain. Low back pain and smoking is the greatest risk factor.
This is quite an emotive subject; every doctor of any ilk is likely to be upset on hearing that you have left or greener pastures on the other side of the hill. Yet, it shouldn't be so; every chiropractor has his strengths and his weaknesses too.
You're likely to find there are chiropractors, and certainly medical doctors, who have never heard of Maignes's syndrome. I hadn't for the first twenty years of practice.
It's easiest if there are several doctors in the practice; awkward perhaps but if you know you aren't getting better, it's best to discuss with him or her, could you consult a colleague for an evaluation. Chiropractors should have a thick skin and small egos. If they haven't, well that's their problem, not yours.
So, if changing chiropractors seems sensible to you, don't hesitate.
I receive many questions about Chiropractic. It might be help with a spinal condition, but it might also be from a person who can't walk after a hip operation, or some such thing.
I will do that by answering your questions personally, but it will be converted to a Web Page so others can benefit from your questions. Omit your name if you like.
However, do understand that, in the main, I'm going to be directing you, should it be pertinent, to a Chiropractor in your neck of the woods. I'll respond to all reasonable inquiries, but please be specific, and give as much detail as you can.
Google has taken a very strong stand against webpages with poor grammar. Please don't use capitals, dots, hyphens and brackets. Don't write from your smartphone because I simply don't have the time to correct your grammar, and won't answer.
There is no charge for this service, however if you find my answer useful, you might like to consider purchasing my latest book, Stones in my Clog. Gems, both funny and healthful, from the life and work of a Chiropractor. It's only $2.99. http://www.bernard-preston.com/Stones-in-my-Clog.html
Pose Me A Question! Pretty please, in decent grammar and spelling.
I will never give or sell your email address to anyone.
Do understand that lower back pain is extremely complex, so I can only give general guidelines. There's no substitute for a careful thorough chiropractic examination.
Click below to see contributions from other visitors.
If you find my answer useful, please ask friends to grade it.
Buttock, thigh and hip pain with severe swelling
I'm fifty two and had acute onset of pain in grocery store over a year ago. Six months later I had arthroscopic hip surgery due to a torn labrum and femoracetabular …
Right lower back- and right gluteus pain, spasm & irritation
Struggling almost 2 years with this. Was a hurler most of my life (leading right leg. Went to fisio, chiro & docter. Outcome of evaluation: left leg is …
Pain in my lower back radiating down the right buttock and leg.
I am a 55 year old female in pretty good health.I have had this pain for two and a half years now with little or no help from twenty three different doctors/ …
severe pain in hip/lower back when standing straight Not rated yet
The pain started about a year and a half ago with just numbness down the side of thigh all the way to foot. I was still able to move around just with a …
severe gluteal pain Not rated yet
I suffered of Discitis in T10 and was treated for it 2 years ago. This year I got an attack of lumbar pain which ended up with severe pain in the "upper …
confused about my low back and rib pain Not rated yet
Hello I have pain in my left rib and goes down my back, butt and leg. Four years ago was in a car accident and had damage to my lower ribs very painful. …
stiffness and tightness in low left part of my back Not rated yet
I sit for a long duration of time at work, but I have no pain when I am sitting. I noticed the pain creeping into my hips when I am sitting though and …
Right buttock and leg pain for 1-1/2 years Not rated yet
Iam a 67 years old female with Parkinsons disease. I have had significant pain in my right buttock and right leg which gets extremely painful when I walk. …
Pain in left leg without numbness or tingling Not rated yet
I have been dealing with pain in my left leg, originating in area of crease in top of leg with pain radiating down to lower calf area. It is very difficult …
Left upper buttocks pain and groin, spinal lumbar stenosisp Not rated yet
Pressure when walking creates the pain in buttocks. You'll to give me a lot more detail if you want a sensible answer. Dr b
pain in lower back, upper hip thigh groin and legs. Not rated yet
This pain is on both sides. Some times left side sometimes right side. But when it is on right side I have only back pain upper hip pain. But in left I …
buttock pain and pain in line at top of leg Not rated yet
Burning pain in buttock. You'll have to give me some details, Teresa, if you want a serious answer. I can't suggest anything with this. Dr B.
Maignes? Not rated yet
Maignes? Something happened to me whilst horse riding two and a half years ago. I felt something go on the right side but I don't know what. Afterwards …
Left side pain starting from middle of back that radiates down to my big toes. Numbness from knee down. Not rated yet
I am 27, and was an active, on the go kind of person until I had my daughter in October 2011, and my back was never the same. I ended up having surgery …
Pubic bone pain Not rated yet
Pubic bone pain, at times feel a numbness in my tail bone area and history of ovarian cysts and pubic bone pain is always just said to be from the cysts …
Maignes Syndrome Not rated yet
Hello, I've had all the typical symptoms of maignes syndrome for nearly a year now, but I'm unable to find someone who can help treat it in Sydney …
Painful right hip and groin. Not rated yet
for 3 years - Groin pain right hand side; right hip pain, unable to sleep on right side; very painful right hip when walking; unable to lift right leg …
Possible Cluneal Nerve Entrapment Not rated yet
Hi there, I have been suffering for lower back pain deep in my left side and in my buttock for about 6-7 year. I have had scans and x-rays followed …
I have a limp but no pain Not rated yet
I have a limp but no pain I don't have much pain anywhere. Some low back discomfort at times but not really any pain. My feet do tingle in different …
Unable to put weight on leg after prolapse disc Not rated yet
Unable to put weight on leg after prolapse disc Hi, My boyfriend prolapsed his disc whilst working on a car back in May, he said he tried to get up …
My legs/hips/low back/pelvis area hurt when I walk and I can't stand with my two feet together sometimes. Not rated yet
My legs/hips/low back/pelvis area hurt when I walk and I can't stand with my two feet together sometimes. Hi there, I will try and explain the best …
Maigne's Syndrome (?) and other lower back issues Not rated yet
Maigne's Syndrome (?) and other lower back issues Doctor, I have a long history of back injury and issues, all beginning with a car accident in 1993. …
groin, upper leg pain Not rated yet
I frequent chiropractor off and on for years. I am a retired wallpaper hanger and painter for the last 30 years. I am 69 years old. My problem accuser …
Pain in the upper groin area toward the inside front of my left leg. Not rated yet
This just started. I thought I had been bit by something right along the "panty-line" on my left leg. It is up high, runs parallel to the pubic bone, …
Gnawing pain in right buttocks has moved to the left Not rated yet
I've experienced a gnawing, dull pain in the right buttocks for about 2 yrs, but after sleeping horizontally one night, the pain has moved from the right …
Low back Aching/ Side Leg Upper Buttocks Not rated yet
Hi, I am a 54 year old female with aching pain ONLY WHEN LYING DOWN ! The pain starts in my low back ( I have severe stenosis at L4 or 5. I have had …
Extreme back pain, Femoral nerve pain, numbness Not rated yet
I have had back problems since 1999 but with the exception of a few very bad flare ups I have seemed to manage to live a somewhat normal but careful life. …
Curved spine Not rated yet
Hi I recently had a Full Hip Replacment which was very succesful, However i now have a curved spine from limping to one side for 3yrs while i waited for …
pain and stiffness in my right buttocks area immediately after an adjustment Not rated yet
My right leg was slightly shorter than my left. I went 2 times to the chiropractor and both times he readjusted my right hip. The pain that I had at the …
Feel like I will fall when walking. Take very small steps. Have very little balance. Not rated yet
Have fallen 3 times, hitting left hip on curb. Chiropractor stretches but not helping. Have very little pain --- just can't walk sometimes because of inability …
Extreme pain in lower leg Not rated yet
I have pain in my right leg that starts a few inches below my knee and radiates down and towards the outside of my leg. I noticed the pain last week, but …
Chronic Pain in left leg, hip, groin, upper thigh, calf and big toe. Not rated yet
Hi there, First thank you for your site :D I will first start with the beginning of my pain and the injury that caused it. In May of 06 I fell backwards …
Low back pain Not rated yet
I have a crushed T12 vertebra. Two years ago I hurt my R lower back in a twisting injury. This was a sailing racing injury and the season lasted another …
severe pain in left buttock Not rated yet
I have had pain in my left buttock for nearly 9 years,with lots of different diagnosis,pulse radio frequency,epidurals,all to no avail.All scans are negative. …
Pleaes help! URGENT request! I will pay your office visit costs. PLEASE! I have to find out asap-I think I am going to lose my toes and feet soon. PLEASE. Thank you, Not rated yet
Oh MY Gosh, I am so excited to have found this site. SO excited. PLEASE can you help me! I will gladly pay you for it. I think what i have is …
Pain in lower back, buttocks region and the right side thigh bones leg Not rated yet
I am an overweight person who is currently on a doet p[lan. I first noticed the lower back pain when i couldnt bend or get out of bed correctly. I have …
extreme sudden pain in lower back directly above the coccyx and total numbness directly over coccyx Not rated yet
48 year old female, gave birth 1 time, never had any surgeries. Was in a wreck Nov. 1990 while 5 months pregnant, severe whiplash down whole body, it …
Low back pain that radiates into my hip down to my groin. Not rated yet
Hi! I am a 49 year old female with a history of disc problems. Two in my neck and one in my lower right side of my back. I had a series of injections in …
Low Back Pain Not rated yet
My daughter, age 16, has had low back pain since age 9. The muscles on either side of the spine are hard as a rock 24/7. She is in constant pain at …
T12 wedge fracture Not rated yet
Hi, I had a bad fall around 2 years ago. I attended A&E and they said I had pulled a lot of muscles. No x-ray was done. However I suffered pain for a long …
tingling and numbness on the knee Not rated yet
Hello Jomei, One night I got sore muscle form my right buttock and I did massage with a little machine. After that morning, I started to feel numbness …
Upper & Lower back, deep left hip pain Not rated yet
I am a 36 year old mother of two. About 3 years ago I started noticing upper back pain (bra strap level), but worse chronic low back and a deep pain in …
Pain in left buttock, lateral left leg and popping in hip after traumatic blow to left buttock Not rated yet
I was forcefully slapped on left buttock. Within a couple of days I began having terrible left lateral leg pain, and pain in my left buttock. The buttock …
Thoraco lumbar junction pain (Maignes syndrome) Not rated yet
Thoraco lumbar junction (TLJ) pain (Maignes syndrome) I just stumbled upon a page about TLJ Syndrome. And then I found your page. I was reading …
Help with piriformis, and possibly more Not rated yet
Hi, Came across your site and have the following for the last 6 months or so. Have visited two physio's with the following condition. This has all …
Femoral nerve pain in the buttocks area that sometimes moves to front right leg Not rated yet
Femoral nerve I typically have pain in the buttocks area that sometimes spreads to the side and front right leg. I've never experienced this on my left …
Maignes Syndrome Not rated yet
Maignes Syndrome I appreciate your web site. Just wrote an article on Maignes syndrome, for Dynamic Chiropractic. http://www.dynamicchiropractic.com/mpacms/dc/ …
Elbow pain and tingling in 4th and 5th digit Not rated yet
I bumped my elbow during a fall. Now when I bend my elbow for long periods, e.g. During typing, using my cell phone to text, I get pain and discomfort …
lower back pain left side - worse at night! Not rated yet
lower back pain I am 60 years old, have confirmed lordosis of the spine and degeneration of the spine applicable to my age (MRI scan). Over the …