Meralgia Paresthetica

[Nick Law]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3867081/

Above is a link to a recent article reviewing the condition meralgia paresthetica. It is a good article published by physical therapists and gives a good summary of the identification and treatment of the condition.

Eric and I evaluated a man yesterday who had some signs and symptoms consistent with the condition, but I must admit the condition was not at all on my radar of potential differentials. I wonder if I haven’t missed this condition in the past.

At any rate, just thought I would share a good article on a not-so-common condition that should probably be in our list of differentials for lateral thigh pain/numbness.

Has anyone seen or treated this successfully?

[Michael McMurray]

Thanks for the post Nick, not a common diagnosis, but definitely should be on the differential with sensory changes > motor especially in a very specific distribution. Good review article to have in your library.

Anyone else treated this or had a presentation with this as a differential?

Have to post this article as well: Jim Beazell’s first article published: Classic_ JOSPT 1988:

http://www.jospt.org/doi/abs/10.2519/jospt.1988.10.3.85#.Vg0ZnX2Ps2o

Article in Shared Dropbox

[omikutin]

Thanks for sharing Nick!
It’s interesting how Cheathman et al mentions that MP has a higher predilection in adult males while the risk factors are “obesity (BMI ≥ 30), pregnancy, tight garments such as jeans, military armor and police uniforms, seat belts, direct trauma, muscle spasm, scoliosis, illiacus hemotoma, and leg length changes”. In school we learned this condition as the “Britney spears phenomena” due to the common presentation in females. One of my coworkers saw only 10-13 cases over the past 25 years (more female than male with BMI typically > 30). His first approach was posture. Greater than half of these cases his patients were sitting cross legged with their weight distributed over their anterior hip. Once that habit was broken prognosis significantly improved.

I would love to hear about your patient’s demographics, MOI, and symptoms. What approach did you take and what findings made you think MP?

Something that fascinates me is how the patient from Beazell started to have symptoms 3 years prior of lateral knee pain which leg length was not addressed. Why would symptoms start right then? I wonder how many years she has been a runner prior to pain starting. It’s great that a heel lift was given to decrease the shear on the inguinal ligament. Brilliant, thanks for sharing!

[Myra Pumphrey]

Thanks for sharing Nick! Just a thought, it is important to consider the anatomy of this nerve when prescribing the use of an SIJ belt for patients. I warn patients that the belt should feel supportive, but not excessively tight. I advise them to loosen the belt if they start to feel any symptoms in the distribution of the LCNT and to DC use of the belt if loosening does not resolve the symptoms.

[Laura Thornton]

Interesting topic. Like Nick, this hasn’t been on my radar but I’m glad I can add to my differential diagnosis list. The Pelvic Compression Test is a pretty creative idea by placing the inguinal ligament on slack and therefore decreasing tension on the LCNT.

I would be curious to see if adding cervical flexion/extension to the neurodynamic test described in the article would further change the symptom response even though we’re looking at entrapment distally. If so, thoracic mobility intervention?

The article states multiple anatomical variations involve close proximity of the LCNT to the origin of the sartorius muscle. I wonder if performing the Thomas Test would be valuable for symptom provocation by placing LCNT on tension while evaluating iliopsoas, rectus femoris, and sartorius flexibility. You could also add medial rotation of the femur to place more tension on sartorius.

[Laura Thornton]

Hard to believe, but we had a male with signs and symptoms at Progress yesterday that we concluded to be Meralgia Paresthetica.

Asterisks:
– numbness in exact distribution as LCNT on L lateral thigh
– sharp pain in L lateral thigh that were reproduced with L extension quadrant (which we previously thought lumbar spine related, but could be placing tension on LCNT as well)
– previous history of inguinal hernia and repair with mesh placement bilaterally***
– upper lumbar hypomobility and pain
– VERY tender iliopsoas tendons B (L>R) to palpation
– positive for symptom reproduction femoral nerve tension test on L with cervical flexion
– positive sidelying pelvic compression that eased symptoms
– one of the biggest things we changed is his sleep positioning, he tended to lie on his R side with his head and trunk flexed (increased dural tension from above) so we had him position with his head and spine in a neutral position

Thanks for posting about this topic, definitely helped us with treatment and plan of care.

[Myra Pumphrey]

Thanks for posting about this interesting patient Laura!

I saw this patient on day 1, Laura and I saw him on his second visit. I have the advantage of having his EMR up at the same time I am posting so here are a few more details:

Complaints: L SIJ (+Fortin finger test), L lateral hip (deep), L lateral leg. Pain in all 3 areas. He is’ aware’ of the L/S and L L/L region.He also has numbness, C, NV, entire L lateral thigh. No symptoms below the knee or on contralateral side. No c/o headache.

Agg factors:

Upon first getting up to stand after sitting. Walking is o.k. He hasn’t walked prolonged recently, but since the onset, if he went for a 2 mile walk, he would have delayed increase in pain.

He stopped running 2 weeks ago due to incr. pain during running. He played tennis last week and had increased pain after.

Getting in and out of the car: He has to lift his left leg (Pt. is tall and also tends to flex his cervical-lumbar spine to get into the car) due to pain.

Standing for a few minutes increases pain. He is worse first in the morning.

Ease: Lying on right side, sitting, unloading on grocery cart when shopping.

Additional Asterisks:

*Weak hip flexors on the side of the symptoms w/ myotomal testing (left), 3+/5, slightly improved on day 2.
*on day 2, numbness on the lateral thigh was increased when palpating the direction and depth of greatest restriction of soft tissue at site of the hernia repair.
*Flexion was limited on day one at less than 50% with increase of left lateral thigh numbness.
*Extension was limited to 25% w/ increase of left lateral thigh numbness
*Slump incr. thigh pain at -25 deg. knee ext on the L, no incr. w/ neck Flexion or DF
*SLR L incr. thigh pain at 55 deg, incr. w/ neck flexion and dorsiflexion.
*Femoral nerve slump test, noted by Laura above, was much more significant for reproduction of symptoms.
Hip and SIJ clearing exam = negative

Recent History (Initial Evaluation on 11/10) – He was taking the sails down on a 47 feet sailboat the weekend of Oct 2nd, due to a hurricane. This involved a lot of reaching and pulling from combined movements in extension and flexion. He also did a lot of lifting that day and noticed a gradual onset of symptoms during that day (L lumbar to L lateral thigh). He was supposed to run a 1/2 marathon on the 14th. He tried to run twice after the episode and got really severe pain in his back and L hip/thigh. Now, the past 24 hours, significantly less pain, but numbness on the outside of the L thigh. It did not keep him out of work (deskwork), but the pain awoke him, every night for the past 10 days, difficult to RTS.

Past History: 2 previous episodes, one was also since the hernia repair (’09), 18 months ago ago, onset with pulling himself out of a kayak, reaching above for a ladder at a dock into combined extension and contralateral sidebend/rotation. Both previous episodes resolved spontaneously without treatment, but with rest/decreased activity for weeks.

Previous episode, 16 years ago, worse then. He could not get off of the couch for 2 weeks. He was treated with ECI, lumbar, unknown level, and P.T., including traction. Symptoms resolved.

Findings from recent x-rays – DDD, OA of lumbar spine.

Steroid dose pack – Finished 1 week ago. He said it ‘helped marginally’.

Day 1: P/A unilateral left upper lumbar // After treatment: Slight improvement in symptom-free range of motion into extension and flexion. Gapping mobilization of upper lumbar left // decreased paraesthesia at rest, slight additional improvement in symptom-free range of motion into extension and improved lumbar range of motion into forward bend to 75% after treatment (much better improvement with gapping mobilization), increased ROM into SLR, no change in hip flexor testing. On visit 2, we needed to bring him into extension quadrant to reproduce symptoms, his improvement into flexion was maintained, he was significantly improved for the rest of the day and the night of treatment. On the second night after treatment, he awoke with significant pain/paraesthesia.

Day 2: Besides education on posture modification, we added soft tissue mobilization of the soft tissue restrictions around the hernia surgical site // decreased numbness after the soft tissue massage. We repeated the upper lumbar gapping technique.

Questions:

Meralgia Paresthetica appears to be one probable component. The lateral thigh numbness began only 24 hours prior to coming to P.T. What are the other hypotheses on the list at this point?
What do you think about the history of episode 9 years before the hernia repair?
What other details would you like to know about his past history?
Would you contact his referring physician?
If so, would you note and specific concerns or recommend any special testing at this time? Are there any questions you have for the physician?
If he returns improved in symptoms and all objective asterisks, but not resolved, what would be on your list for possible progression of treatment?
Do you think the physical therapy prognosis is good? Why?

[Myra Pumphrey]

Thanks for posting about this interesting patient Laura!

I saw this patient on day 1, Laura and I saw him on his second visit. I have the advantage of having his EMR up at the same time I am posting so here are a few more details:

Complaints: L SIJ (+Fortin finger test), L lateral hip (deep), L lateral leg. Pain in all 3 areas. He is’ aware’ of the L/S and L L/L region.He also has numbness, C, NV, entire L lateral thigh. No symptoms below the knee or on contralateral side. No c/o headache.

Agg factors:

Upon first getting up to stand after sitting. Walking is o.k. He hasn’t walked prolonged recently, but since the onset, if he went for a 2 mile walk, he would have delayed increase in pain.

He stopped running 2 weeks ago due to incr. pain during running. He played tennis last week and had increased pain after.

Getting in and out of the car: He has to lift his left leg (Pt. is tall and also tends to flex his cervical-lumbar spine to get into the car) due to pain.

Standing for a few minutes increases pain. He is worse first in the morning.

Ease: Lying on right side, sitting, unloading on grocery cart when shopping.

Additional Asterisks:

*Weak hip flexors on the side of the symptoms w/ myotomal testing (left), 3+/5, slightly improved on day 2.
*on day 2, numbness on the lateral thigh was increased when palpating the direction and depth of greatest restriction of soft tissue at site of the hernia repair.
*Flexion was limited on day one at less than 50% with increase of left lateral thigh numbness.
*Extension was limited to 25% w/ increase of left lateral thigh numbness
*Slump incr. thigh pain at -25 deg. knee ext on the L, no incr. w/ neck Flexion or DF
*SLR L incr. thigh pain at 55 deg, incr. w/ neck flexion and dorsiflexion.
*Femoral nerve slump test, noted by Laura above, was much more significant for reproduction of symptoms.
Hip and SIJ clearing exam = negative

Recent History (Initial Evaluation on 11/10) – He was taking the sails down on a 47 feet sailboat the weekend of Oct 2nd, due to a hurricane. This involved a lot of reaching and pulling from combined movements in extension and flexion. He also did a lot of lifting that day and noticed a gradual onset of symptoms during that day (L lumbar to L lateral thigh). He was supposed to run a 1/2 marathon on the 14th. He tried to run twice after the episode and got really severe pain in his back and L hip/thigh. Now, the past 24 hours, significantly less pain, but numbness on the outside of the L thigh. It did not keep him out of work (deskwork), but the pain awoke him, every night for the past 10 days, difficult to RTS.

Past History: 2 previous episodes, one was also since the hernia repair (’09), 18 months ago ago, onset with pulling himself out of a kayak, reaching above for a ladder at a dock into combined extension and contralateral sidebend/rotation. Both previous episodes resolved spontaneously without treatment, but with rest/decreased activity for weeks.

Previous episode, 16 years ago, worse then. He could not get off of the couch for 2 weeks. He was treated with ECI, lumbar, unknown level, and P.T., including traction. Symptoms resolved.

Findings from recent x-rays – DDD, OA of lumbar spine.

Steroid dose pack – Finished 1 week ago. He said it ‘helped marginally’.

Day 1: P/A unilateral left upper lumbar // After treatment: Slight improvement in symptom-free range of motion into extension and flexion. Gapping mobilization of upper lumbar left // decreased paraesthesia at rest, slight additional improvement in symptom-free range of motion into extension and improved lumbar range of motion into forward bend to 75% after treatment (much better improvement with gapping mobilization), increased ROM into SLR, no change in hip flexor testing. On visit 2, we needed to bring him into extension quadrant to reproduce symptoms, his improvement into flexion was maintained, he was significantly improved for the rest of the day and the night of treatment. On the second night after treatment, he awoke with significant pain/paraesthesia.

Day 2: Besides education on posture modification, we added soft tissue mobilization of the soft tissue restrictions around the hernia surgical site // decreased numbness after the soft tissue massage. We repeated the upper lumbar gapping technique.

Questions:

Meralgia Paresthetica appears to be one probable component. The lateral thigh numbness began only 24 hours prior to coming to P.T. What are the other hypotheses on the list at this point?
What do you think about the history of episode 9 years before the hernia repair?
What other details would you like to know about his past history?
Would you contact his referring physician?
If so, would you note and specific concerns or recommend any special testing at this time? Are there any questions you have for the physician?
If he returns improved in symptoms and all objective asterisks, but not resolved, what would be on your list for possible progression of treatment?
Do you think the physical therapy prognosis is good? Why?

[Laura Thornton]

The way I try to make sense of how happened to this patient is by referring back to the Cascade of Spinal Degeneration theory. Similar to the case presentation at the course weekend, I see this patient as traveling down the cascade from most likely initial herniation and upper lumbar radiculopathy episode, into instability stage with lateral nerve entrapment, and now possibly one level stenosis category. The addition of the inguinal hernia has added extraneural restriction to an already compromised nerve root. So, I would think that treating both upper lumbar and increase mobility along the nerve route would be treatment options for him.

Further details I would like to know: specific age (60-70?). Did he have any previous, more mild back pain before the first episode?

I would probably want to contact his physician to inform him of the findings and the hypothesis of peripheral entrapment. Since his neurological findings have gotten worse since he has seen the physician (hip flexor weakness? numbness?), I would at least want to communicate this to him/her so they are aware of the changes especially since he had a medical procedure in that region.

[Myra Pumphrey]

Thank you Laura – He is 65. Other thoughts?

[omikutin]

Great case! He had no pain during his desk job, that potentially could mean that the LCN was potentially put on slack. His MOI involved lumbar extension and reaching/ pulling which could have caused increased abdominal pressure and perhaps some somatic pain due to prolonged extension positioning. His pain is similar to his past so I’m thinking any sort of pressure on the inguinal ligament is irritating potentially to a peripheral nerve? As well, post surgery scar tissue could be limiting some nerve gliding. What side was his hernia repair? And how long did it take for his previous symptoms to reside?

Hypothesis: You said his hip flexion was 3+/5 (how was his L2 dermatome?) As well how was his knee extension (and L3 dermatome)? He could have a nerve root irritation.?

Progression of Rx: How much tension is on his rectus femoris/ Sartorius? Are they hypertonic? How does his femoral head sit (is it sitting more anteriorly?) As well from the last class we learned to position joints in the least stressful physiological position. What if there was direct treatment when he is place in more extension (SL).

Myra- what was that book called again “Current concepts by Edwards 2nd edition?)

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