This topic contains 8 replies, has 2 voices, and was last updated by 
Christopher Stepien October 27, 2018 at 9:43 am.
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Christopher Stepien
1st Order:- 44 YO Female
- Right glute/lat hip
- Q: ache/strain
- I: 6/10 (1/10 at best – 3/10 most days)
- P+: 5 mins of walking or standing (gets fatigued), worse as day goes on
- sitting increases symptoms a tiny bit
- P-: stretching, massage, sleeping, gentle manipulation of spine
2nd Order:- Bilateral calves are very tight
- Right ant hip (sharp)
- Has tingling in Rt. plantar foot (L5 distribution)
- Bilateral Leg weakness (when standing)
- Has had spasms in low back before (correlate with disc pathology)
- Onset: 2014 when pregnant (increase in CSF pressure)
MRI:- 3 tarlov cysts in S1 and S2 NR
- No disc pathology (looks clean to me)
- Minimal facet arthrosis in L4-S1 facets
Disc?- YES: Lx, Q, I, walking/standing (maybe), spasms
- NO: MRI was clean from disc perspective, no sitting symptoms, no obvious disc episodes (although she did have spasms)
Tarlov Cyst?- O: pregnancy (increase CSF fluid)
Questions:1. To see no obvious pathology on the MRI and to have symptoms with 5 mins of standing and no sitting symptoms makes me question the disc diagnosis. Add that with the 3 tarlov cysts and the onset of pregnancy and now I don’t know what her diagnosis is.
Carl Nottoli, DC
Tarlov cysts can create symptoms but it’s pretty rare. It should also follow the nerve root distribution.
Have you considered right hip cartilage degeneration as a DDX? That would fit really well with your 7 first order Hx points. The outlier being the tingling in the right foot. Is it only the plantar side of the foot? It’s my understanding that L5 would cover the dorsal and plantar sections of the foot and toe/toes (depending on what image you look at).
So you could have an additional diagnosis of nerve entrapment in the foot.
Christopher Stepien
Beautiful. TY Carl.
I did exam yesterday and will confirm against that possibility.
Matthew Ellerbrock
How did this turn out Chris? I have had several female runners who develope pain in the hips/ groin area after pregnancy. Thinking right hip as well.
Christopher Stepien
Out of respect for Carl’s time, I plan on following up with this case.
Short answer: I don’t know yet.
I believe it may be a nerve root entrapment at the psoas. I’ll follow up at end of week.
Christopher Stepien
Carl and Matt:
Since focusing on deloading the lumbar spine, she’s started feeling relief in her low back/hip symptoms and her calf tightness/fatigue.
: )
Carl Nottoli, DC
Great work, Chris. What’s the working diagnosis with this case?
Christopher Stepien
- L5-S1 Minimal facet arthrosis | Tarlov Cysts in S1 NRs (confirming calf tension when standing) with resulting moderate atrophy in spinal muscles at L5-S1 (as evidenced in MRI report – No disc pathology)
- Moderate adhesion in lumbar spine.
- Psychosocial
I’m not 100% on #1 – but I need some dysfunction to explain the atrophy.
I’m also sensing some emotional/traumatic causes in #3. My only data point besides my intution is childbirth (although I know hormones completely change a woman’s body). I may play with some energy healing with her to see how she does.
Please let me know thoughts.
Christopher Stepien
Follow-up out of respect for Carl’s time.
This patient is 30% better after 10ish treatments to her low back for the initial diagnosis to her low back. Her leg fatigue while standing is also somewhat better.
She started doing her stretching again (without my consent), but said that the relief is noticeably better when she stretches. I’ve let her continue doing them for this reason.
The low back seems the right cause, but I still don’t understand how.
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