lumbar or sacral radiculopathy

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  • #1119
    Marian Blum
    Participant

    Female, 51 years old, works as pastry chef, average weight. For approximately 6 months she’s had dull, achey pain (~ 5 on 1-10 scale) at back of right thigh and ischial tuberosity. Pain provoked more with sitting. Sometimes in car, or sleeping on right side pain goes to sole of foot. For 1 month, pain is around greater trochanter and in buttock, as well. Denies any low back pain.

    Findings on initial exam on symptomatic right side:
    AROM – no limitations or significant provocations of her usual pain
    Seated slump – slight positive for the pain in buttock
    SLR – a little pain in buttock at 70d hip flexion
    FADIR – a little pain in front of right hip
    FABER – pain near ischial tuberosity and front of hip joint with passive over-pressure.
    MMT: TFL, piriformis, psoas, hamstrings, quads, all 5/5
    normal DTR; normal sensation to alcohol cotton swab at dermatomes
    Palpation – normal muscle tone, free of trigger points and adhesions (didn’t seem like cupping or guasha was warranted)

    She said she had an X-ray of her low back which was normal. No MRI yet.

    She did PT for awhile and was told that the problem was her right side was too dominant and she was given exercises to balance right and left. She says it has not helped. Nor has massage.

    Working diagnosis: S1 radiculopathy

    Treated 6 times in 6 weeks with electrostim crossing spine at lumbar/sacral UB points. Also treated local tender points in buttock (UB54, Tunzhong, Huanzhong, GB30, etc.) and along UB in hamstrings, though local points were not very tender to palpation. Also used these points on and off: GB34, UB62, SI3, left Ling Gu, Da Bai, SI4. Points were also selected to treat a painful left medial meniscus and severe allergies.

    She didn’t improve with treatment. The treatment before the last one left her feeling a little sore in her low back. I told her this looked like a nerve in her low back may be impinged. She made an appointment with an orthopedist for this week.

    Anything pop out that I am missing or might consider if she wants to come for further treatment? I usually don’t have great success with lumbar radiculopathy and will not encourage person to keep coming if there’s no improvement with 6 visits.

    #1121
    Dadali Ziai
    Participant

    hmm, to me, the results of your slr and seated slump tests dont sound positive for radiculopathy. how deeply are you palpating the piriformis and glutt medius or the margins of the it band for tenderness? if it’s not major pathology, i’m not as confident in the orthopedist’s helpfulness.

    i dont personally rely on electro-acupuncture for these situations as much as my hands for identifying and then treating (along with manual stim acupuncture) the myo/neuro-fascial tissues often implicated.

    call if you ever want to talk more!
    peace

    #1123

    the SLR 70* and slump sounded positive to me. Check the iliopsoas. You can do the needling from the side as Anthony described a couple months ago.

    #1124
    Marian Blum
    Participant

    Thanks for your ideas, Dadali and Jess! I have palpated for tenderness and TrP in glut med, min, max, piriformis, hamstrings, attachments at ischial tuberosity and IT band margins. Not the psoas because I didn’t think the pattern of pain corresponded with psoas TrP. I didn’t find much tenderness, no provocation of her typical pain–much less than I see with others who have myofascial pain syndromes in that area.

    #1126
    Dadali Ziai
    Participant

    if slr and seated slump don’t produce neuropathic responses below the knee i don’t interpret them as positive for radiculopathy, but nerves can be strange. not sure about the psoas but it is so effectively ruled out/in by mmt that i always check it that way and it responds well to treatment at the inferior insertion (and in the belly manually if you’re so inclined) as anthony demonstrated.

    #1127
    Dadali Ziai
    Participant

    gotcha. well if all that palpation is negative, maybe it is s1. i wonder if the sciatic can get trapped by a bone spur or other osteoarthritic changes in the region of the sciatic notch/hip joint? and if the x-ray covered that low? seems like a lot to do a nerve conduction study. i did see a protracted coccydinia case clear up with the help of a cortizone injection once.

    #1165
    Marian Blum
    Participant

    This patient had an MRI of her hips that showed:

    1. Severe right ischiofemoral impingement syndrome characterized by severe narrowing of the right ischiofemoral space .7cm, moderate edema and atrophy of the right quadratus femoris muscle, severe right obturator externus bursitis and a partial tear within the deep fibers of the origin of the right common hamstring tendon

    2. Severe narrowing of the left ischiofemoral space .9cm with minimal edema within the left quadratus femoris muscle

    3. Small anterior labral tear .2cm

    No wonder acupuncture didn’t help! She was referred to Stanford by the local Monterey orthopedist.

    #1167

    I don’t know how I missed this discussion thread before, but thanks for the interesting case, Marian, and the clear and insightful presentation and discussion! The initial physical exam findings that pointed towards the hip joint as the likely root of the problem are the “FADIR – a little pain in front of right hip and FABER – pain near ischial tuberosity and front of hip joint with passive over-pressure.” Very characteristic of labral tears. Also, the normal non-provocative lumbar AROM would be unusual (but not impossible) with a radiculopathy, and the pain distribution is more characteristic of local gluteal, hamstring and hip joint problems vs. radicular which is usually felt most strongly in the feet and low back.

    If she is still seeing you, it would be worth trying to stabilize the hip joint through deep anterior and posterior needling, being sure to palpate for the femoral artery in the front and avoid it. But if she doesn’t respond within 2-3 visits of this approach, I’d discontinue tx. Labral tears can be difficult to treat by means other than surgery.

    #1191
    Marian Blum
    Participant

    I am just seeing your post now, Anthony. Excellent points. Now it seems obvious that the physical exam points to the hip joint, except that the pain sometimes went to the sole of her foot. I’m surprised her quads were strong given the atrophy.

    I read this abstract about treatment. The last line: “Arthroscopic iliopsoas tenotomies in combination with a resection of the lesser trochanter will provide complete relief of the painful snapping, groin and buttock pain caused by ischiofemoral impingement.”

    I didn’t continue to see her but will give your suggested treatment a try if she returns.

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