Welcome again to the monthly newsletter from Chiropractic Help. The first for a few months, I confess. This month some questions about whether a hip condition could actually be the cause of back pain, a few praises for the backbrush, and the inimitable lettuce leaf... it's a long letter, brew a pot of tea, settle back and relax.
I have been hard at work building a new retirement annexe for our home, turning my chiropractic hand to building stairs and built-in-cupboards, fitting solar panels... and 10,000 other things instead of writing books and newsletters for Chiropractic Help. My apologies. Nearly done... Yes, a handrail, of course.
LOWER BACK AND UPPER LEG PAIN
Lower back and upper leg pain are common complaints at the Chiropractic Coalface. They may be connected, for example as in an irritated Femoral nerve in the lower back causing pain, or tightness, or tingling, or numbness on the side or front of the thigh, and/or groin.
Or they may be quite unconnected, or seemly
unconnected. For example, kneecap arthritis and lower back pain.
Traditionally, in Chiropractic, the cause is in the spine (a pinched or irritated nerve) and the effect in the limb, for example, upper leg pain, numbness and/or weakness, or perhaps in an organ. The latter are far more difficult to document, but ask any chiropractor and s/he will tell you of unusual and oft unexpected results in general health. Less menstrual cramps, lower blood pressure, fewer ear infections in a child, less constipation...
Interesting Lower back and
upper leg pain case
A 63-year old woman developed pain in the right groin some four months prior to the first consultation. Then, three months later, pain began in the right upper lower back and flank, progressing to the right lower quadrant of the abdomen.
She had pain all day, a deep ache, and pain at night too. Having a history of malignant cancer, the
worst was presumed, but all tests proved negative.
On examination, internal rotation and adduction of the right hip was markedly painful in the groin, with limited range of motion: early hip arthritis OR Femero Acetabular Impingement syndrome? Or both. The X-ray revealed all: Both. Untreated FAIS becomes arthritic in many cases.
Radiologist's report: A prominent bony bump (known as a CAM deformity) is noted at the head neck junction of the femur. The appearance on the x-ray is that of acetabulum femoral neck impingement.
Range of motion of the lumbar spine was full, but extension and right lateral flexion caused mild pain in the right mid/upper lumbar spine. Femoral and sciatic nerve stretch tests were negative.
Reflexes and muscle strength were normal,
but there was very significant numbness (90%) on the right lateral thigh. Where the Lateral Femoral Cutaneous nerve exits under the inguinal ligament was exquisitely painful.
There was a right sacroiliac joint fixation. Likewise at L2 on the right.
I could add more clinical detail, but it contributes little. What is interesting is the x-ray of her lumbar spine.
Two important features:
- Severe loss of the L5/S1 disc but at this point in time not relevant. She has no pain at this segment and no
radiation in the course of the sciatic nerve. An incidental finding.
- L2-L3 and L3-L4 instability with large osteophytes that the body has built to stabilise the joints.
These are not hereditary features, there is no scoliosis, but are the result possibly of old injury, but none is recalled, or...
This lady has a congenital hip condition called a CAM deformity in her hip. (In fact in both hips, but only the right is symptomatic)
She also has acquired? lumbar spine changes in that part of the lumbar spine that supplies the capsule of the hip. This could not have caused the congenital hip condition. But could the hip condition have caused the changes in the lumbar spine?
Nociception and Neurogenic inflammation
Numerous physiologists have now shown that irritated receptors (such as mechanoreceptors) in dysfunctional joints cause
inflammation in the nerves and spinal cord (nociception) that supply those joints. This inflammation is transmitted to both local muscles, and also back to the spinal cord with the potential to cause weakness both at the local area of injury, and at remote sites.
Could such an irritated nerve from the hip capsule cause weakness in the lumbar spine muscles? Then the body would build those large spurs to stabilise the spinal joints.
This is the area of the spine supplying the side of the leg where she is so numb, sometimes causing a condition called Meralgia Paresthethetica.
Meralgia Paresthetica is a stubborn "double-crush" syndrome where the Lateral Femoral Cutaneous nerve is irritated both in the mid/upper lumbar spine and as it exits from the pelvis under the inguinal ligament frequently causing low back and groin pain or numbness, sometimes on the side of the
Notice the three features of this difficult case:
As a patient, perhaps, you are not particularly interested in the ins and outs of your condition, be it diabetes,
high blood pressure, lower back and upper leg pain ... just fix it, doc.
However in these difficult syndromes, full patient participation in the treatment and after care are vital. The diabetic who won't exercise and watch his weight and diet, the hypertensive patient who won't stop smoking, the lower back and upper leg pain patient... there's big trouble coming.
This particular case had a very promising start. Chiropractic Help directed at:
- Mobilising the hip
- Painful crossfriction of the hip capsule and the exit of the LFCN from the groin
- Chiropractic sacroiliac joint treatment ...
- Lumbar spine McManus traction
- A vigorous rehab programme addressing both the hip, the lumbar spine and the deep core muscles of the lower back and deep pelvic muscles. Lower
back exercises ...
Within a month she was much improved and had six months of almost no pain. Then the exercises began to wane... most chronic chiropractic conditions are not cured and need on-going monitoring and maintenance care ... Happily, she is once again much improved, and reproved for quitting the exercises and maintenance programme. Vital in difficult cases, medical or chiropractic.
Motor Muscle Inhibition
This has been very adequately theorised and demonstrated. For example, Le Pera has shown that an irritated nerve is unable to stimulate the muscles it serves, altering the biomechanics of the entire region. For example, a frankly pinched Femoral nerve may cause profound weakness in the quadriceps muscle. Can you hop on one leg without the knee tending to give?
However, can a
knee or hip condition cause changes within the spine?
Certainly a short leg ( leg length inequality ) can cause a scoliosis, and consequent arthritic changes within the spine. Since a short leg also causes an increased incidence of knee and hip arthritis, leg length is an important focus of Chiropractic practice.
The short leg alters the biomechanics of the lumbar spine, pelvis and knee resulting in an increased degree of pain and disability. What constitutes a short leg remains controversial. In medical practice there needs to be at least a 10mm difference, but in my experience even a 3-5mm insert in the shoe can make an enormous difference to the health of the lower back and pelvis.
However, could a knee condition such as Patello Femoral Pain
Syndrome (pain under the kneecap) or Femoro Acetabular Impingement Syndrome be the cause of arthritic changes within the spine?
This month a book for Chiropractors. The EXSTORE Assessment System by Dr Anthony J. Lombardi has been well received in Chiropractic Economics: A new angle on assessment. The value of a focused examination is worth exponentially more than any amount of treatment.
I couldn't agree more. Success with difficult cases like this Lower back and upper leg pain case is totally dependent on a focused examination.
"Share your knowledge. It's a way to achieve immortality."
No salad is complete without some lettuce. If you look carefully you can count five different lettuces that we are growing in our garden this summer. Rich in soluble fibre, the stuff that keeps you regular, and particularly in folate, that most vital B vitamin. High Folate levels ...
Add to the lettuce your favourites; today I'm enjoying apple, avocado for healthy fat, hummus for a great vegetable protein source, radishes for a bit of extra bite and of course a few olives and you have the perfect lunch. A squeeze of fresh lemon juice, dribble olive oil... and voila, you've had your five obligatory colours for the day. That's if you want to avoid
"The key to immortality is first living a life worth remembering."
In praise of the backbrush; ask any chiropractor and s/he will tell you that there's one area of the body where many of us cannot reach to wash properly. Between the shoulder blades. Whether it's because of a frozen shoulder that has permanently left you with reduced internal
rotation, or simply short ligaments, the midback doesn't get the attention it deserves. I can't see it helping with low back and groin pain.
There are two possible solutions. A weekly scrub by your spouse in the shower or a backbrush. Either will suffice. Better still, both. A loofa?
Till next month, then...
Yours in better health,
Barrie Lewis DC
PS. Feel free to forward this to family and friends, your chiropractor and even your medical doctor!
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