Lower back and upper leg pain

Lower back and upper leg pain traditionally means a spinal condition but there are some indications that peripheral conditions can cause lumbago too.

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, and down the inner lower leg.

Or they may be quite unconnected, or seemly unrelated. 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, or less constipation.

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, in the jargon ) 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 the stiff hip be the cause of arthritic changes within the spine?

Lower back and upper leg pain

Here's an 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 of the hip, internal rotation and adduction of the right hip was markedly painful in the groin, with limited range of motion: early hip arthritis OR Femoro Acetabular Impingement syndrome? Or both.

The X-ray revealed all: Both. Untreated FAIS becomes arthritic in many cases.  First and foremost, a daily set of range-of-motion exercises is what is required. Simple. One minute, twice a day.

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.

Meralgia paresthetica

Meralgia paresthetica is a less common cause of lower back and upper leg pain; on the side of the thigh.

Examination of the lumbar spine.

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...

My point?

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 that supply them. 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 supplied by the nerve should it have a motor component.

Could such an irritated nerve from the hip capsule cause weakness in the lumbar spine muscles? Yes, certainly. Then the body would build those large spurs to stabilise the spinal joints.

All this confirms the age-old chiropractic claims that subluxated spinal joints can have far reaching effects on joints, muscles, and even organs.

This is the area of the spine supplying the side of the leg where she is no 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 in the groin causing numbness and sometimes severe pain in the side of the thigh and/or the groin.

Medical sites report that MP is particularly resistant to treatment, but by addressing both and the upper lumbar spine, chiropractic in my experience can claim to successfully treat this knotty condition. I know of no research confirming this opinion.

Lower back and leg pain go hand-in-foot.

Tingling in feet and legs

Tingling in feet and legs is a very common complaint at the chiropractic coalface; there may be associated lower back and upper leg pain, or it may radiate down to the foot, or only be in the lower leg.

Careful evaluation is required in each and every case to make the diagnosis; very rarely even advanced arthritis in the cervical spine cause cause signs and symptoms in the leg; it's caused spinal stenosis.

Notice the three features of this difficult case:

• The primary: a congenital hip condition (a CAM deformity) causing limitation of movement of the hip and ultimately, untreated, hip arthritis. Femoro Acetabular Impingement Syndrome ...
  
• A secondary? mid/upper lumbar spine instability.
• A further irritation of the LFCN causing numbness on the side of the leg. 

Another not uncommon condition is an extrusion of a midlumbar disc into the intervertebral foramen; what's seemingly mystifying then is that bending backwards, and to the side provokes the pain radiating down the leg.

If it is down the back of the thigh, then it is affecting the sciatic nerve, but the front of the upper leg, groin or inner side suggests the femoral is affected.

You can see the femoral nerve in the above diagram as it proceeds down the front of the upper leg, with branches to the side and inner thigh.

I have personally had femoral nerve damage causing severe lower back and upper leg pain, radiating down to the inner lower limb below the knee; if the motor nerve is affected there will be loss of the knee jerk and and weakness of the quadriceps muscle.

Chiropractic help

All in all, lower back and upper leg pain are common complaints and chiropractic help is effective in most cases, but each and every one has to be carefully evaluated; there are many ifs and buts.

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 who won't stop for a period and then exercise daily... 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 of every lower back and upper leg pain case.

• My own personal case of femoral nerve damage.
  
• To go from Lower back and upper leg pain to slipped disc rules.
  

Lower back and upper leg pain case file

Every chiropractor can write umpteen case files like this one. What makes this degenerative lumbar disc disease case file is that this elderly lady would have been red carded on two counts for consulting a chiropractor. She has osteoporosis and had severe upper leg pain.