This topic contains 6 replies, has 2 voices, and was last updated by 
Christopher Codina October 9, 2018 at 9:29 am.
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Christopher Codina
37 yo female
car accident 6 years ago, immediate numbness in L leg, lasted for a few months
6/10
Sx: sometimes sharp, always dull
Provocative: jumping, sitting to standing, sitting for long periods
Pallative: heat, not a lot helps
has done dry needling which has helped
has stayed the same over time
No current numbness
3 PTs have not helped
SLR: L: 78* +D
KHE: L: 8in R: 10in/ pulling in front of hip bilaterally
SHF: L: 3 fingers/ pinch ant hip
QLF: 00112
Sorry to bother you all but I am trying to figure out what I am missing and need an objective view. I have treated her for about a month in which I have gotten her SLR, SHF, and KHE to full or near full. The problem is that QLF has improved little or if at all (I know my technique needs work). In getting her SLR, SHF, and KHE to full, her symptoms changed to numbness that wraps around the front of her quads along the L2 dermatome, making the QLF even more of a priority. She was then referred for an MRI for her hip and low back due to her plateau and her change of symptoms. The report stated that there was nothing of significance. I have since looked at the MRI also and did not see anything to correspond to the symptoms. I am curious what I could be missing, should I have gone to strengthening? Thanks in advance for your time and sorry to waste your time if this is a simple fix.
William Brady, DC
A few points to clear up:
Where exactly are her symptoms? Does she have low back pain or only thigh numbness? If numbness, does she have true neuro findings or does she have “tingling” rather than true numbness?
Can you post a screen shot of the MRI. Sagittal plane. Just to double check the images.
Thanks for post. Looking forward to helping.
Christopher Codina
She has a pinch on the left side of her vertebrae, she points to the general area near her capsule (which is what I have been concentrating treatment on, lots of tension builds up). She does not have true neuro findings just a “tingling” sensation that is located in the buttocks that wraps around to the front of the thigh. Is this a load thing and I should have incorporated strengthening exercises to reduce load/adhesion build up?
Keith Puri, DC
Just a few follow-up questions. Where exactly does she feel this pinching? I know you said on the left but at what vertebral level and does it radiate? As for the numbness, what is the exact route it travels from the glute to the thigh? In reviewing the MRI it looks like there is a tarlov cyst at S1. What does the corresponding axial slice look like? Some radiologist feel these are insignificant and fail to include them in the report. If it is, I might consider reaching out to the radiologist for an addendum.
There will likely be load factors, coping strategies and future strengthening to consider in manageing this case but what is your pathology and tissue specific diagnosis? Also, are you treating the errectors on the lumbar flexion table? If not, there is no way you will be able to effectively tx all relevant errector and facet capsule adhesions. It’s great you can feel a lot of tension building in the capsule but make sure the errectors are cleared first and you are treating the worst spot and not just where she feels the pinching.
Christopher Codina
Thank you for the response. She points to roughly the location of her left lumbar capsules at the L2/L3 level. The route of the tingling is true to the L2 dermatome but she does occasionally note tingling along her lateral thigh (she points out her vastus lateralis, even posterior). The radiologist did point out the tarlov cyst but noted it does not explain her symptoms. My original diagnosis was 1.adhesion (lumbar erectors and capsules, external rotators, and hip capsule) 2. Disc 3. Degeneration but after her failure to progress I questioned those. Now I am unsure. I am not using a flexion table (have to get on that).
Carl Nottoli, DC
Based on response to treatment and information given I would say her diagnoses at this point are 1) Facet capsule adhesion. 2) peripheral nerve entrapment of the lateral femoral cutaneous nerve (find out where).
Christopher Codina
Thanks for the help. I will keep you posted on the progress.
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