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Painful arc in SLR

Exit forum ID Forum Discussion Painful arc in SLR

This topic contains 3 replies, has 2 voices, and was last updated by   Brandon Cohen DC, CSCS October 22, 2018 at 2:48 pm.

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  • #4917

    Brandon Cohen DC, CSCS
    Participant

      37 y/o female

      Location: Left posterior hip, lateral left knee, plantar ball of foot on left.

      quality: tight, sore, and cramping in the posterior hip, numbness and paresthesia

      in the leg and foot.

      Intensity: 4/10

      Provocative: standing and leaning slightly forward 15 minutes

      Palliative:  hindu squat (hip and knee flexion, neutral ankle, toe extension.

      position. Posterior hip stretches, knee and hip flexion.

      Ice. sitting for 30 seconds.

      onset: 4 weeks

      course: intermittent

      occupation: pours wine both sitting and standing.

      SLR: 90 degrees B. R. posterior thigh tension. L. posterior hip pain 55-85 degrees.

      SHF: Thigh to ribs B. No pain.

      QLF: Flat 2-4″. No pain.

      KHE: 10″ R. 10.5″ L. L. lateral hip pain when B. leg forward.  83% 88%

      Lunge test: L. weakness.

      SLPF: 2nd knuckle to the floor. L. tension posterior hip and SI joint area.

      Palpation:

      L SN at superior gemellus 2

      L Piriformis: 4

      L SN at piriformis: 2

      L Sacrotuberous ligament: 1

      B. Psoas Major: 2

      Dx: Adhesions in Piriformis, and SN entrapment. Question of SOL/Nerve root involvement.

      There are a couple of outliers in this case. The biggest question I have is what could create a painful arc in SLR? I have seen her for 2 treatment visits, and we have reduced the size of the arc to 60-70 degrees.

      Nerve entrapment doesn’t make sense for the provocative (low load) when compared to the SLR.

      Disc/nerve root is questionable due to SLPF, and it getting better with sitting.

      She has many limited tests, which could be improved upon. I’m hopeful to find one dx that fits all buckets, but the more I go over it, it sounds like there might be multiple components to this, but none of them appear reverse compatible to me.

      I have not checked lumbar extension or looked much at the lumbar spine. Communication has been that this is a hip and lumbar problem, and we will need to work on both, but there are too many outliers for me to be comfortable with our current diagnosis.

      Please advise.

      #4919

      Michael Vibert

        Totally agree that this has to be multiple diagnoses. My initial thought is that her hip may have cartilage damage. That could certainly cause a painful arch in the posterior thigh with SLR. It could also explain the hip and SI pain with SLPF.

        What is your differentials list?

        #4920

        William Brady, DC
        Participant

          Tough to do on the forum but… Full range with symptoms = pathology (regarding SLR). Then provocative in sustained flexion. These two stand out to me for lumbar disc SOL. Some other things appear inconsistent with disc (palliative with sitting) which suggests it’s sequestered (a large sequestered SOL will be relieved with sitting because it creates space around the cord and nerve roots).

          #4921

          Brandon Cohen DC, CSCS
          Participant

            Thank you both.

            Bill, Full range with symptoms = pathology. Yes. With the data set I have, I have a hard time placing that in the low back. I suppose the question is, when I get imaging (which is really soon), what do I start with? Your answer implies the lumbar spine is the most likely location, and hip would be secondary to that. I understand that there can be a lot of nuance with discs, but thought that the sitting being palliative, and (mostly) negative SLPF together would have ruled it out.

            To add a bit more detail to the SLPF, she moves very well all the way to the floor. She only reports symptoms after being prompted and apparently thinking about it for several seconds.

            Michael, I would imagine the hip tests would have been more positive for hip pathology. My current list is Piriformis, SN entrapment (seems less and less likely), and SOL (somewhere, but not sure where).

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