Date: Wed, 5 Mar 1997 10:01:09 -0500 (EST) From: "Mark Wells, DC" Subject: left thigh numbness Docs, Help me out here with some suggestions: A 34 year old male smoker, with a previous complaint of low back pain one year prior(which "naturally" responded to adjusting and myofascial release,) returned one year later complaining of minor low back pain and spasms above the iliac crest on the left, but most noticably, numbness over the left anterior thigh, down to the knee. The only provocatory tests were seated Laseague's and digital psoas pressure. He can reproduce his numbness by standing, sitting, and lying supine or on his left side. The only relief he can get is lying on his right side. He works at a rental company, which requires him to stand or sit on a stool all day. He opts for the stool, so his numbness doesn't cause him to fall. Although seated Laseague's was the only provocatory test, he did have moderate active iliopsoas, TFL and quadratus lumborum trigger points; extension fixation the L4 and L5; neuro tests were unremarkable except for pin-prick over the above mentioned area(not dermatome specific); no orthopedic tests were remarkable including hip, knee, and lumbar spine tests; no signs of vascular compromise were apparent and there was no history of urinary or sexual dysfunction. Initially, I was worried about renal or vascular involvement, but psoas pressure caused the area to go numb, but removal of pressure did not relieve his symptoms. I then considered meralgia paresthetica, but after tracing the lateral femoral cutaneous nerve, there was not a correlation. I had him lie on his right side and applied interferential current to the psoas and TFL, which caused his symptoms to worsen slightly after 10 minutes. After that I used trigger point therapy and adjusted his lumbar spine. This helped his numbness subside, but when I called him last night to check on him, it had returned as soon as he got in his car. I guess my question is what special test or other treatment protocol would some of you use at this point? Thanks, Mark Mark Wells, DC Beltsville, MD ****************************** Date: Wed, 5 Mar 1997 12:35:25 -0500 (EST) To: drhondo@erols.com, chirosci-list@silcom.com Subject: Re: left thigh numbness In a message dated 97-03-05 10:02:43 EST, drhondo@erols.com (Mark Wells, DC) writes: << I guess my question is what special test or other treatment protocol would some of you use at this point? >> Did you do the femoral nerve stretch test? [Patient prone, passively extend the hip (with the knee at 90 degrees) and note if the symptoms are reproduced or exacerbated. Then (if the sx are increased or not) lower the hip just a little (the sx should decrease) and then flex the knee. If it reproduces the symptoms it is potentially indicative of an L4 nerve root problem.] Bill Updyke, D.C. SurfDoc1@aol.com ******************************** Date: Wed, 05 Mar 1997 10:28:51 -0800 From: "Mark Street, D.C." Subject: Re: left thigh numbness L2-L3 nerve roots. Hmmmm, does he sit to one side on this stool of his? does he stand for long periods during the day? How do you get interferential current or TP to the Psoas??? Man, that sucker is deep!! Have you checked prone leg lengths? RSL or LSL? I have seen gluteus minimus/medius sp/st, TP's refer pain down the lateral aspect of the thigh to the knee, and just below. Extremely painful, pt tends to stand with leg and thigh slightly bent. Pt prefers the involved side down to lie down. How did you create "psoas pressure" to invoke symptoms? What and how did you adjust his Lumbar spine? Be specific please. How did the numbness return when he got in his car? Getting in, or driving? Is he comfortable sitting in his car and driving or does he have to squirm to get comfortable? Sounds strange.... DDX; Psoas spasm. w/entrapment, L2 disc-femoral nerve stretch, Mark Street, D.C. jet@sonic.net ****************************** Date: Wed, 5 Mar 1997 15:11:06 -0500 From: "Mark Wells, DC" Subject: Re: left thigh numbness Mark, Thanks for your input. At 10:28 AM 3/5/97 -0800, you wrote: >L2-L3 nerve roots. Hmmmm, does he sit to one side on this stool of his? >does he stand for long periods during the day? How do you get >interferential current or TP to the Psoas??? Man, that sucker is deep!! Yes. Long periods of standing and sitting on a stool. The insertion of the iliopsoas is readily available at the inguinal line. >Have you checked prone leg lengths? RSL or LSL? Yes. A 3mm LSL. >I have seen gluteus minimus/medius sp/st, TP's refer pain down the lateral >aspect of the thigh to the knee, and just below. Extremely painful, pt >tends to stand with leg and thigh slightly bent. Pt prefers the involved >side down to lie down. The inferior asect of quadratus seems to be crossing over with the upper G. medius. >How did you create "psoas pressure" to invoke symptoms? Digitial pressure medial to the ASIS. >What and how did you adjust his Lumbar spine? Be specific please. Side posture, P to A and lateral to medial @ L3-L4.(Gonstead PL) >How did the numbness return when he got in his car? Getting in, or >driving? Is he comfortable sitting in his car and driving or does he have >to squirm to get comfortable? After sitting for 30 seconds, no help from squirming. >Sounds strange.... DDX; Psoas spasm. w/entrapment, L2 disc-femoral nerve >stretch, I agree it's strange. Upon exam, femoral stretch didn't make it any more numb than it was. He admitted a "stretch pain" but nothing bad. He'll be back tonight and the lan is to continue restoring function of the psoas and quad. lumb. I'll let everybody know how he does, Mark Wells Mark Wells, DC ****************************** Date: Wed, 5 Mar 1997 15:11:10 -0500 From: "Mark Wells, DC" Subject: Re: left thigh numbness Bill, At 12:35 PM 3/5/97 -0500, you wrote: >Did you do the femoral nerve stretch test? [Patient prone, passively extend >the hip (with the knee at 90 degrees) and note if the symptoms are reproduced >or exacerbated. Then (if the sx are increased or not) lower the hip just a >little (the sx should decrease) and then flex the knee. If it reproduces the >symptoms it is potentially indicative of an L4 nerve root problem.] Great advice. I did just that with no remarkable findings. However, when performing Lewin-Gaenslen(spelling?), extending the left leg off the table(in effect stretching the left psoas) seemed to increase the numbness. Everybody, please note that there is minimal pain if any. Numbness is the chief complaint here. Also, I may be barking up the right tree, and the patient just needs a little chance to heal. But I feel like there might be a little more than my educated mind can realize. Mahalo, Mark ************************* Date: Wed, 5 Mar 1997 20:01:10 -0500 From: "Mark Wells, DC" Subject: Re: left thigh numbness Mark, At 02:12 PM 3/5/97 -0800, you wrote: >I don't know why but my gut feeling says L-2 disc disorder. Well, Mr. leg numbness returned, with continued numbness but less intense. He rates it as 5 on a 10 vs. the previous 9 on a 10. Decreased sensation is definitely overlapping L2 and L3 dermatomes. All attempts to increase intrathecal pressure had no effect on severity of numbness, and seated Laseague's was unremarkable today. However, being a little more precise with my digital pressure, he reported increased numbness AND severe pain over the same distribution when I contacted the neurovascdular bundle at the inguinal ligament. If I remember correctly, the nerve is most lateral to the vein and artery, and as I moved laterally his symptoms increased dramatically. That's great that I can pinpoint it now, but what's next? I've worked with HNP's and nerve entrapment in other areas, so for now I will treat conservatively. Tomorrow, I'll call my local neuro-man and see what he has to say. Mark Wells, DC ****************************** Date: Thu, 06 Mar 1997 12:56:07 -0600 From: "Noel A. Taylor" Subject: Re: left thigh numbness Mark, this area of affect is consistent with an anterior disc bulge. The one thing that puzzles me is that I normally see the area being one of pain, as opposed to numbness. IMHO, adjusting in induced extension, either with an extension table such as that developed in conjunction with Logan College of Chiropractic, or with use of SOT Category III blocking and Lovett-based distraction protocol, seems to have the best effects For all you hard@$$ science types, The above represents clinical experience only. -Noel ****************************