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Bilateral hamstring pain from DISC (even though MRI is clean?)

Exit forum ID Forum Discussion Bilateral hamstring pain from DISC (even though MRI is clean?)

This topic contains 2 replies, has 2 voices, and was last updated by   Christopher Stepien December 6, 2018 at 7:26 am.

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  • #2781

    Christopher Stepien
    Participant

      1st Order:

      • 37 YO Female
      • L – Bilateral posterior thigh
      • Q – ache
      • I – 5/10
      • P+:
        • contracting the hamstrings,
        • walking up stairs (feels like it’s about to pull), 1x/week it does pull and its sore for a few days
        • bending (5 mins of yoga or any exercise)
        • can’t deadlift 40 pounds for 1 rep (used to be able to do much more)
      • P-:
        • rest
        • static stretching

      Initial Dx Hypothesis:

      1. Significant hamstring adhesion
      2. Low back disc referral

      Not happy with this Dx. I don’t like hamstring adhesion alone.

      2nd Order:

      Onset: 14 months ago, the symptoms started 1 week after her last fitness competition during rest, progressively worse since.

      6 YA – slipped a disc in low back and her “hips go out a lot”

      She can’t squat deep, thinks she is compensating with calves and feet because of this (had 1 month episode of plantar fasciitis in Feb 2018). Upon further questioning, she has bilateral foot pain when she isn’t wearing her crocs.

      Upon the history, it was very apparent that there are psychosocial aspects to her pain. She was hyper-concerned about her body image. She claims to be hyper-sensitive to pain.

       Dx Hypothesis:

      1. Significant hamstring adhesion
      2. Low back disc referral
      3. Psychosocial layer

      Exam:

      SLR:

      • R – 95 degrees, severe tightness distal posterior thigh
      • L – 97 degrees, moderate stretch distal posterior thigh to calf

      SHF:

      • R – 1f, mild right anterior hip pain
      • L – 0f, mild left anterior hip discomfort

      QLF:

      • 3/4″ – 4 1/4″ extended – no symptoms (20%)

      KHE:

      • R – 12.5″, severe pain whole right anterior thigh and the left thigh feels weak (confirms disc?)
      • L – 12.5″, moderate tightness whole left anterior thigh

      SLPF:

      • full, mild bilateral posterior thigh tightness

      Sitting and bending to lace shoes up:

      • Right posterior thigh tingling.

      Glute bridge:

      • right posterior proximal thigh, mild increase in tension (confirms disc?).

      – Cannot do a standing quad stretch (did not have her test).

      Palpation:

      • significant adhesion in lumbar erectors
      • moderate adhesion at R Sci n @ ext rots
      • mild adhesion at L Sci n @ ext rots
      • I did not palpate hamstrings because I was convinced of disc referral after exam (esp. with SLR being full)

      Diagnosis:

      1. Adhesion
      2. LB Disc Referral
      3. Psychosocial

      MRI ordered after exam before treatment started:

      I haven’t seen the images myself yet, but the only finding was “Slight disc bulge at L4-L5 without stenosis”.

      Questions:

      1. I’m not super clear on how much we can trust an MRI or MRI report for disc pathology. I believe Bill says “History and Exam findings trump imaging.”  I still think this is a combination of DISC + Psychosocial. Would I be right or is DISC ruled out? KHE on the R confirms that for me.

      She comes in today and I will palpate the hamstrings directly. But at 95 degrees, I don’t expect to find much. I know she can be an outlier.

      Anything else I may be missing?

      #2783

      Carl Nottoli, DC
      Participant

        How was the slipped disc confirmed 6 years ago? Any prior imaging to compare?

        I wouldn’t trust the report in this case as structural pathology still comes to mind with the history.

        Spondylolisthesis or disc sequestration would be my top two differentials based on low load with provocatives, age, prior episodes, and high load as a fitness competitor. Nerve symptoms with SLR beyond full, severe pain with KHE, QLF at 20%, and bilateral post thigh symptoms.

        Sitting and bending to tie shoes puts more compression in the area and closes down the space more, causing a nerve related symptom.

        I wouldn’t palpate hamstrings.

        Before psychosocial or metabolic is ruled in/out confirm or deny structural pathology. Check reflexes and strength, standing and seated extension, check passive hip extension side lying to see if that reproduces the same symptoms with KHE. If not I would expect that moves up sequestered disc/spondy because there’s less axial load, which means the disc and bone takes up less space.

        #2785

        Christopher Stepien
        Participant

          Helpful!

          I’ll report back in.

          I did first treatment yesterday. She also reported she has to very carefully, sleep on her side with a pillow between her knees or her low back will go out. Then she’ll have to self adjust and “whip her legs” to the side to put it back in place.

          Puts spondy higher up for me.

          Will do other tests when I see her. : )

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