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Scott Glidden October 1, 2018 at 1:05 pm.
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Scott Glidden
Today I had a 35 year old female new patient who reported an annoying/uncomfortable sensation at her left hip for the last 6 months that wrapped around from her iliac crest to just medial of her ASIS.
At best a 0/10, at worst a 10/10, currently a 6/10.
Prov: sitting with poor posture, laying in certain positions
Pall: Good posture, standing or activityAll of her lower back and hip stuff were healthy and unremarkable, but when I tested thoracic flexion there was a 3.5″ flat section T10~L1 and the discomfort started to creep in after being in that position for about 90 seconds. There was mild to moderate adhesion at the effected levels bilaterally. Thoracic rotation to the left was 42%-2/10 tension and right was 76% 1/10 tension.
I’m glad I found what could recreate the discomfort, but the reverse compatibility part I struggled with. The T12/L1 dermatomes could wrap around anteriorly, but she noted that some times the pain would go from the crest down into the glute. How is that explained? Does anybody have a chart that shows scleratogenous referral to that area? I’m confident that I will see improvement, but the foggy “why” bothers me.
Seth Schultz, DC
From the description of symptoms the L1 and L2 disc do have scleratogenous refferals to those areas. This helps explain the symptoms from the crest to the glute (L2) and crest to ASIS (L1). This seems to be more disc related pain rather than nerve root or dermatomal in nature. I’d be more curious about which positions when laying cause her symptoms as that will help you determine what tissue is affected. 10/10 pain is worrisome as well and MRI will help change your treatment plan and prognosis as needed.
Christopher Stepien
What’s the diagnostic hypothesis after the 1st order Hx points and after the exam?
The thoracic exam findings don’t seem relevant.
I’m thinking:
1. Lumbar Disc with Sclerotogenous referral
2. Nothing else.I’d want to be getting an MRI, then load managing.
I don’t do enough TF or TR to know, but I imagine TF pencil test loses relevance the lower in the T spine we go as the kyphosis moves to lordosis in that area, causing some natural flatness.
Thoughts?
Scott Glidden
The more I thought about it, the more an L1 and/or L2 disc injury seemed likely. We are still loading those discs by forcing flexion upon them and the referral patterns Seth shows makes sense. I’ll order up an MRI and report back with results.
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