Leg Pain & Groin Pain with NO Back Pain

Problem: Today I had a man present with groin pain and leg pain to the foot worse on sitting and lying down and better with standing and walking. He has had similar groin pain in the past over the years but he has had no similar leg pain. He thinks he hurt himself lifting something heavy a week ago. Today, he had no back pain to speak of. In fact on examination, the low back had very little tenderness or spasms. He had a little edema over the sacrum. His groin and leg pain however he rated at a 9. During the exam his pain was so intense he could hardly carry on a conversation. My exam revealed several things. First, I could make the pain worse by having him sit on the table and raise a leg to 90 degrees. Secondly, with him lying on the table, when I lifted his uninvolved leg up to 35 degrees, pain shot down his leg and into the groin. Third when I tested his lower extremity sensory nerves (dermatomes) he had moderate hypersensitivity (too much) in one area of the involved leg followed by moderate hyposensitivity (too little) of the along the outside of the foot (S1) dermatome. Forth, his muscle strengths were somewhat diminished with some loss of strength at the involved leg quad and hamstring muscles both rated a 4/5. He had a negative heel walk and toe walk and denied any change to bowel. Finally he had a negative braggard's ruling out simple sciatica. Treatment: He had a defibrillator so e-stimulation was out. So I went with moist heat followed by laser to the sacrum and lateral/posterior leg along the nerve route and ultrasound to the upper lumbar para spinal muscles at T12 -L3 on the side of involvement. I did some manual therapy on his low back and sent him for X-rays at the local hospital as I want a radiologist to read these films. I think he has two things going on. First I think he has stenosis (narrowing of the central spinal canal) and secondly I think he has superimposed a bulging disc at L5. He also may have one at L4. I think he has neuroforaminal encroachment (disc pressing on the nerve root) causing inflammation. I will order an MRI after I get the x-rays back. I talked to him about anti inflammatory meds but he was already on Mobic. Discussion: Diagnosis is the key. If a doctor does not know what is causing the problem he can't fix it. God gives us the right to have more than one thing going on at a time. Most people have multiple pain generators. I talk everyday to patients that tell me that the doctor did not touch them in the examination. That means the doctor is guessing and that's why we have so many failures in low back pain treatment. Greg Millar DC CCEP




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