When we look at x-rays, we most often observe no problems with the mid to upper lumbar disc spaces. More frequently, we observe lower lumbar disc thinning and facet imbrications. Treatment to these regions must be preceded by other diagnostic indicators predictive of problems, such as hyper-or hypomobile joint functions.
Even if such problems are found in the middle to upper lumbar regions, treatment of such spinal dysfunctions rarely brings relief to anterior thigh pain. More often, treatment of lower lumbar and sacroiliac dysfunctions will relieve anterior thigh pain.
As a young practitioner, I studied the works of Dr. James Cox and his research dealing with L-4 and L-5 facet syndromes. He showed that L-4 and L-5 facet compression disorders could cause anterior thigh pain. Dr. Deborah Pate, an esteemed columnist for DC, recently showed the same relationship of anterior thigh pain and lower lumbar facet disorders in one of her articles.
In the mid 1980s, I attended a lecture by a neurosurgeon as part of a chiropractic continuing education seminar. He stated that during a surgical procedure, a patient, who was able to give verbal feedback while the operation took place, said that tugging on the posterior longitudinal ligament at L-4/L-5/S-1 region produced anterior thigh pain. His conclusion was that anterior thigh pain could be caused by derangement of the longitudinal ligament, which would be present with posterior disc bulges or herniations.
In previous articles for Dynamic Chiropractic, I showed the connection between the AS ilium fixation and groin and anterior thigh pain. In summary, according to my clinical observations, anterior thigh pain has been related to the following conditions:
1. femoral nerve irritation (L-2, L-3, L-4);
2. L-4 and L-5 facet imbrication or irritation;
3. AS ilium hypomobile dysfunction, leading to strain of the quadriceps muscles;
4. posterior longitudinal ligament stress.
Obviously, one cannot discount the occurrence of direct trauma to the quadriceps muscles. Also, indirect problems such as foot pronation can lead to increased lower lumbar facetal stress with resulting lumbar pain and anterior thigh discomfort.
When a patient presents with anterior thigh pain, the following are potential procedures to be used to determine the origin of the pain:
Femoral nerve irritation:
a. x-rays to rule out disc thinning and eventual nerve root irritation at L-2, L-3 and L-4 levels;
b. MRI views to rule out any kind of nerve root irritation.
L-4 and L-5 facet imbrication or irritation:
a. x-rays to rule out or in facet loading; b. exam findings, such as extension pain, suggesting facet irritation; c. motion palpation signs indicating L-4 or L-5 facet dysfunction.
AS ilium hypomobile dysfunction:
a. motion palpation of the sacroiliac joints and lumbar spine;
b. static palpation of the sacroiliac joints and lumbar spine.
a. x-rays and/or MRI findings.
a. examination of the feet.
Once one determines the cause of the anterior thigh pain, treatment can begin. For degenerative disc disorders, traction or flexion traction will be appropriate. Also, adjusting to correct mechanical dysfunctions may be appropriate. For facet imbrication, one is dealing with a degenerative disorder or a congenital hyperlordotic lumbar curve. Flexion traction, such as the Cox protocol, is very appropriate. Adjusting according to valid diagnostic determinants also may be necessary. The Bray technique for distraction also may be appropriate. For that matter, any form of distraction may be useful. One should also evaluate the possibility of home therapy utilizing an inversion unit for facet and lumbar degenerative disorders. For disc problems, distraction techniques are most safely applied to the level of disc involvement, but adjustive procedures can be applied to related areas to ease excessive compensatory motion at the stressed disc areas. Where AS ilium fixation is the main culprit, adjustive procedures to the lumbar and sacroiliac regions will be necessary. This involves knowledge of the concepts of nutation and counter-nutation and the lower lumbar spine as it relates to sacroiliac function.
I cannot possibly elaborate the details of this subject in an article such as this. For foot related problems, casting the feet for orthotics can be very helpful.
The main point here is to be openminded in your evaluation. There are several possible contributions to anterior thigh pain. It is up to your thoroughness of evaluation to determine the cause or causes.
Dr. Joseph Kurnik practices in Torrance, Calif. He is a former columnist and longtime contributor to DC; previous articles are available online at www.dynamicchiropractic.com.