CASE STUDY AND QUESTIONS: To be completed by the 20 th September

Week 9 Case 9 Stan

Stan is 40-year-old male who is referred to you by his physician.

Presenting Complaint
Stan presents to your office with severe pain and paranesthesia in the anterolateral
aspect of his left thigh.

History of Presenting Complaint

The pain and paranesthesia extend from an area just lateral to the right anterior
superior iliac to the anterolateral aspect of the thigh just above the knee of the right
leg. The pain had been present for two weeks and had followed unaccustomed
physical activity (he cleaned his basement out). He felt the pain the same evening
when he stood up after watching TV for an hour or so. There was no low back pain.
An x-ray and CT scan were taken of his lumbar spine; both were negative.
Stan has just been diagnosed as a Diabetic type II. He has a pendulous abdomen.
Any unguarded movement caused severe leg pain. He was only comfortable in lying
but he was able to move about slowly and carefully.
The patient’s medical history was unremarkable. He does not smoke and drinks
alcohol on social occasions.
1. The physician’s diagnosis was L4,5 facet synovitis. Do you agree with this
diagnosis? Explain your answer.

The Dx of L4/L5 facet synovitis is incorrect as it is not consistent with

right anteriolateral thigh which is a L2/L3 dermatomal pattern of Stans
pain.

2. Give a differential diagnosis for Stan’s symptoms. What is the likely

diagnosis?

Groin strain due to a stretch or partial tear of the thigh adductor

muscles, usually adductor longus (62% of cases), adductor magnus,
adductor brevis, pectineus, or gracilis
The primary mechanism is overstretching of adductors by forceful
abduction of the thigh during activity.

3. What areas would you examine and why?

Gait, palpation of the hip and groin area, hip examination

AROM, PROM, Resisted ROM
Diet- diabetes
Vital Signs (blood pressure, temperature, pulse, respiration and weight)
Vascular examination (pulses)
 4. Using only the information in the case history, is it possible that Stan's
symptoms could result from the following:
a. Meralgia paraesthetica

Meralgia Paraesthetica describes a compression neuropathy of the lateral

femoral cutaneous nerve as it passes under the lateral portion of the inguinal
canal.

Applied Anatomy

 The lateral femoral cutaneous nerve arises form the posterior branches of the
anterior primary divisions of the second and third nerve segments. It emerges
at the lateral border of the psoas major and obliquely crosses the iliacus
muscle heading toward the ASIS. It then either passes under or goes through
the lateral portion of the inguinal ligament about 1cm medial to the anterior
superior iliac spine.
 This nerve supplies the parietal peritoneum, supplies sensory information for
most of the skin and fascia of the antero-lateral thigh, beginning
approximately 10cm below the anterior superior spine and ending just above
the knee.
 It appears to be more common in diabetes, bilateral about 20% of the
time, and associated with sudden weight gain or loss.
 Increased intrabdominal pressure, a pendulous abdomen, trauma or
surgery may be related to Meralgia Paraesthetica.

Aetiology

Meralgia Paraesthetica is actually caused by neuro-biomechanical dysfunction of the

lumbo-pelvic complex. It is most commonly caused by an accumulation of factors.
Multiple potential sights for irritation traction and compression are found along the
anatomical environment of this nerve.

Symptoms
  Meralgia Paraesthetica is characterized by burning dyesthesia in the
distribution of the lateral femoral cutaneous nerve and may be associated with
hyperaesthesia, hypaesthesia and/or formication.
 These symptoms are often exacerbated by prolonged walking, standing
and/or bending forward as well as by thigh extension or abduction.

Clinical Findings

Reproduction of symptoms elicited by pressure over the inguinal ligament at the

passage of the lateral femoral cutaneous nerve is highly suggestive of Meralgia
Paraesthetica (MP).

Management

 Treatment must be aimed at normalization of existing mechanical aberrations

which are directly or indirectly stimulating tractioning or entrapping the lateral
femoral cutaneous nerve.
 An appreciation of the direct and indirect effect of spino-pelvic adjustments on
the spinal segmental reflexes as well as on mechanical or vascular
interference associated with its type of neuropraxia appears to be pre-
requisite in its appropriate management.

b. Myofascial pain syndrome

Saphenous Nerve Entrapment

This condition is defined as the entrapment of the saphenous nerve within the
adductor canal. The confines of the adductor canal include the sartorius medially,
the vastus medialis anterolaterally and the adductor longus postero-laterally. The
contents of the canal include the femoral artery, the femoral vein, and the saphenous
nerve. The fascia between vastus medialis and the adductor magnus resides within
the adductor canal and may be thickened. It is through this fascia that the
saphenous nerve passes.

Applied Anatomy:
  This nerve is a purely sensory branch of the femoral nerve arising from spinal
levels L2-4. It originates near the inguinal ligament and travels through the
adductor canal otherwise termed the subsartorial or Hunter’s canal.
 Just prior to piercing the fascia, the saphenous nerve divides into two
branches. The infrapatellar branch supplies the skin to the medial aspects of
the knee joint. A much longer descending branch lies superficial to the long
saphenous vein and follows its course along the medial side of the leg,
passes anterior to the medial malleoli, and runs distally along the medial
aspect of the foot toward the great toe.
 The saphenous nerve pierces the fascial layer approximately 10 cms above
the medial epicondyle of the femur. A fine branch of the saphenous nerve
passes between the deep superficial collateral ligaments and may give the
impression that inflammation of this ligamentous structure is what is causing
the patient’s problem. The infrapatellar branch of the saphenous nerve may
pierce the musculotendinous portion of the sartorius muscle and become
entrapped there.

Aetiology

Symptoms occur spontaneously. Many times the entrapment is iatrogenically

induced following knee surgery. Coronary bypass surgery has recently been
performed using more distal segments of the saphenous vein, which have a similar
diameter to the coronary arteries. Because of the proximity of the saphenous nerve
to the saphenous vein during saphenous vein graft procedures, the nerve may be
damaged.

Symptoms

 Point tenderness over the exit of the saphenous nerve through the adductor
canal.
 The patient may have essentially normal sensation, hypaesthesia, or
hyperaesthesia.
 Activities that involve the sartorius muscle with knee in extension tend to
aggravate the patients symptoms. This may occur by compressing the
infrapatellar branch of the saphenous against the posterior margin of the
femoral condyle.
Diagnosis

 Pain in a sensory distribution typical of the saphenous nerve (medial aspect of

the lower extremity in the regions of the distal thigh knee or leg)
 Essentially normal motor function in the affected area.
 Tenderness upon palpation of the adductor canal region.

This disorder should be differentiated from medial meniscal lesion, medial collateral
ligament disorders and pes anserine bursitis.

Conservative Management

Although ultrasound therapy has been used clinically for other entrapment type
neuropathies, it has had limited effect with this disorder.
Allopathic and operative management: the patient may have a saphenous nerve
block rendered to the adductor canal as therapy.
 5. From your likely diagnosis in question 2, how would you treat Sam?

 Treatment must be aimed at normalization of existing mechanical

aberrations which are directly or indirectly stimulating tractioning or
entrapping the lateral femoral cutaneous nerve.
 An appreciation of the direct and indirect effect of spino-pelvic
adjustments on the spinal segmental reflexes as well as on mechanical
or vascular interference associated with its type of neuropraxia appears
to be pre-requisite in its appropriate management.

6. Sam is a little overweight (see a picture below). Do you think this has any
impact on your management of the patient?

Yes causing pendulous belly

Further References
Magee D.J. (2014). Orthopaedic Physical Assessment. 6 nd Edition. Elseveir.
Riverport Lane, Missouri 63043

Zouza TA (2016) Differential Diagnosis for the Chiropractor, 5 th Edition, Jone and
Bartlett Learning, 5 Wall st, Burlington MA 01803

Hammer W. 2nd Ed. Functional Soft Tissue Examination and Treatment by Manual
Methods. Aspen, Maryland.

Hawkins R.J. (1995). Musculo-skeletal Examination. Mosby Year book.St. Louis.

Reid D.C (1992). Sports Injury Asssessment and Rehabilitation. Churchill
Livingstone, New York

Gatterman M.I, 1990 Chiropractic Management of Spine Related disorders Williams

and Wilkins, Baltimore, Maryland USA

Lawrence D.J, 1991, Chiropractic Diagnosis and Management Williams and Wilkins,
Baltimore, Maryland, 21202, USA

Souza T: Differential Diagnosis and Management for the Chiropractor: Protocols and
algorithms, Jones and Bartlett Learning, 2016

Trescot A.M Peripheral Nerve Entrapments, Springer International publishing 2016.