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Persistent L Calf/Hip pain/Bilateral posterior hip/hamstring tingling

Exit forum ID Forum Discussion Persistent L Calf/Hip pain/Bilateral posterior hip/hamstring tingling

This topic contains 3 replies, has 2 voices, and was last updated by   Scott Glidden November 28, 2018 at 5:20 pm.

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  • #3092

    Scott Glidden
    Participant

      This is a patient that was referred to me from a hip surgeon.  She saw 2 chiros, a PT, lumbar spine surgeon consult, hip surgeon consult, and a pain specialist before she saw me.  I saw 5 visits and then referred her out when I no longer saw any objective improvement after 3 visits. I referred her out for pain management and it did not help.  She trusts my opinion and wants direction in what to do next. I’m circling back around to see what I missed and make the right decision.

      55 y.o. female patient
      Persistent L Calf pain, left groin pain, left lateral hip pain, bilateral posterior hip/hamstring burning/tingling/pain.
      Intensity is during exam is 5/10, is 7/10 at worst after sitting in the car for long periods of time (ride to my office is 40+ minutes), 3/10 at best.

      P+ Sitting
      P- No idea

      The symptoms have been around for 11 months. Has similar problem 15 years ago in her left glute and a cortisone shot to her piriformis resolved those symptoms.

      valsalva= negative

      Reflexes: Patellar WNL bilaterally, achilles mildly reduced bilaterally
      Strength: all WNL besides L knee extension (3/5), R knee extension (4/5) and foot eversion (4/5 bilaterally)
      Sensory: WNL

      SLR Left: 90/ 3-4 tingling to toes +D (2) sciatic adhesion at external rotators
      Right: 90/4-5 calf tension +D (2) sciatic adhesion at external rotators

      SHF: Left: 2 fingers/3-4 anterior pinch (2) hip capsule bilaterally
      Right: 2 fingers/3 anterior hip tension

      QLF: 00002 (2) adhesion at R L4/5 joint capsule, (3) adhesion at L3 multifidus bilaterally, (2) adhesion at supraspinous ligament L2-L4.

      KHE: L 8″/4 anterior thigh stretch
      R: 9/5″/1 anterior thigh stretch bilateral protective tension, possibly (1) adhesion on L psoas

      SLPF: 100% with calf and glute tension bilaterally, R foot tingling.

      Lunge: Fail

      Lumbar dysfunction could cause most all of the symptoms and the function reflects that.  Focus on QLF.

      Fast forward 5 visits in:
      QLF: 00122
      Treated SHF and went from 2f to 0F bilaterally on visit #4, made symptoms worse by visit #5.  No subjective improvement regardless of objective improvement.

      MRI is attached. I made the suggestion that her lack of QLF function is not due to adhesion (which is still present, but did see a great deal of reduction) but likely due disc injury at L5 and that hypertonicity is trying to stabilize the disc.  I talked to her pain management doc and his last cortisone shot was in her R SI joint.  I told him to consider treating the L5 disc with cortisone to get the muscles to calm down and perhaps I could then  continue treatment.  3 weeks later I heard from the patient that the shot made things worse and he wants to do another round of shots at a different angle.

      Everything points to disc (in my mind) but the surgeons say there’s nothing to work on.  I might be able to find more adhesion if there was less hypertonicity, but I have no clue how to achieve that. What should I suggest as a next step? More MAR?

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      #3126

      Adam Holen D.C.

        I don’t see any massive disc protrusion other than potentially L1, but with the improvements in QLF that should have unloaded that portion. I’ve had a few cases where QLF progress slows/plateaus because their KHE (L = 66%) is genuinely limited and not secondary to QLF limitation. You could try treating that to get the hypertonicity to calm down in the lumbar erectors. Any indication of hip pathology from the specialist? She seems to have multiple symptoms around the joint (lateral, posterior), plus inflammation from treatment.

        Another tip is that if she has a lot of hypertonicity in the erectors, especially Longissimus, the joint capsules may be the primary limitation. If the capsules pull tight early, the erectors will naturally work harder to compensate.

        Have you tried the hip lift? She has full ROM so she should be able to strengthen the hamstrings, which could also alleviate some of the erector tension. Then modified G-morning (about 45 degrees tops) when her hammies are strong.

        The other two options that come to mind with having seen so many providers with no relief, plus you making decent functional changes and no symptomatic relief, or even worse, is a constant inflammatory state. Has her diet, sleep, etc. ever been addressed?

        Lastly, psychosocial comes to mind with “no idea” for a palliative. I would exhaust all ID material/options before recommending any further injections.

        #3127

        Christopher Stepien
        Participant

          Good job with describing the patient Scott.

          What’s the working diagnostic list and why?

          #3128

          Scott Glidden
          Participant

            The patient has no dietary allergies (it was checked), negative with autoimmune disease markers, and no hip pathology of note per the hip surgeon, which I disagree a bit–you don’t get improved ROM after tx but feel worse after tx. Psoas could be a contributor, but she was so sensitive when checked that I wasn’t sure if I would be able to get any worthwhile treatment in without her guarding. I’ve attached the intake paperwork diagram as well as some of my notes on it.

            My diagnosis list was as follows:
            1. L5 disc injury–it would explain the radiating symptoms, especially since it wraps around to the top of her foot for the tingling. L5 is most loaded when seated, and that is precisely when symptoms are the worst.
            2. L1 disc injury- MRI confirmed, would explain her left lateral hip symptoms and some groin symptoms on that side.
            2. L hip pathology- the laterality of the hip symptoms, as well as some groin symptoms on that side, leads me to think of there being SOMETHING in the hip joint. She had even restriction bilaterally with SHF, but only symptoms on the left, so i slid this down my list

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