This topic contains 2 replies, has 1 voice, and was last updated by 
Scott Glidden February 22, 2019 at 12:09 pm.
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Scott Glidden
I’m a little concerned with a patient of mine. She’s on a maintenance program for her hip, which had been contributing to an existing disc problem but has lately been having shooting, burning pains while sleeping into her anterior left thigh.
34 year old female
6/10 shooting/burning pain at left proximal anterior thighHappens during sleep, she thinks when changing positions. Has been happening more and more frequently as of late.
Nothing makes it feel better, it is transient and can’t reproduce in office
SLR (from initial exam 11/14/18)
L 90 deg, 5/10 hamstring tension +Dorsiflexion minimal adhesion
R 90 deg, 6/10 hamstring tension +Dorsiflexion minimal adhesionSHF (from today)
L 0F/2 anterior hip pinch/lower back tension, mild hip capsule adhesion
R 1F/1 anterior hip pinch, mild hip capsule adhesion
(Initially L was 2F/4 back pain)QLF (checked today, but same as exam) 11222, minimal adhesion at L4 bilaterally.
KHE (today): L&R 12″+, 1/10 psoas stretch
SLPF (exam) 100% with back pain L>R going down, mild pinch coming up.
Initially I diagnosed her with an L5 disc injury aggravated by adhesion in her left hip capsule/adductor and that was resolved. Today I was thinking disc OR even a malignancy since this is also the lightest she has ever been and she isn’t trying to lose weight. She is however still nursing and claims “I just can’t get enough calories in.”
About 2 months ago this burning problem popped up and with some MAR to the iliacus I was able to resolve the symptoms for about 3 weeks. It has now happened 3/4 previous nights. I told her that if her symptoms come back within the week to call me and I’ll order some imaging. My question is:
1) Is my thought process sound?
2) If it is, what imaging do I order?
Seth Schultz, DC
It sounds like she has a disc injury in her mid to upper lumbar spine. SLPF + and location of sx when provoked point towards middle lumbar disc. MRI of lumbar spine will confirm your clinical suspicion and change her prognosis, if needed.
The proximal anterior thigh symptom matches potential femoral nerve involvement that is sensitized when the disc is inflamed. That explains the positional changes when in bed. Check for any local nerve entrapment to that area and re-palpate all areas of the lumbar spine and hip flexors to continue to decompress the damaged disc.
Once the adhesion is cleared out, continue to strengthen and manage her load. She’s young so the disc is still well hyrdated. This still seems musculoskeletal in nature, I wouldn’t jump to malignancy until everything that can be treated and managed has stabilized.
Scott Glidden
Thanks Seth! Palpation of her lumbar erectors was pretty clean with the exception of some mild adhesion at L4 (and I just watched the QLF palpation video, so I palpated EVERYTHING) so I’ll re-check and then address potential entrapment and go from there.
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