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784 Views 2 Replies Latest reply: Apr 7, 2013 3:39 PM by JamesJohnsonLMT
hnation Rookie 1 posts since
Feb 6, 2012
Currently Being Moderated

Apr 6, 2013 2:17 PM

Is this really a pinched nerve?

I am a marathon runner, and have been running long distance for a number of years.  A month ago, I began experiencing a pain along my groin, but pushed through it on a tough 20 mile run with hills.  Now it is too painful for me to run at all.  Physical Therapists say it is a pinched nerve in my lumbar region of my spine... I have been going to PT for a month, but have had no major progress. 

 

Is it possible that I need to see a Chiropracter or some other specialist? I am wondering if anyone has experienced a pinched nerve, and how long it takes to recover.  ?

  • Damien Howell Legend 312 posts since
    Feb 27, 2008
    Currently Being Moderated
    1. Apr 7, 2013 4:47 AM (in response to hnation)
    Is this really a pinched nerve?

    You raise an interesting question.  Physical Therapist debate among themselves how many visits should you use to show and demonstrate progress before referring the patient on to someone else if you do not see progress.  Generally for healthy orthopedic type problems the range most Physical Therapist suggest is 3 to 6 visits.  If you have not shown progress it is very appropriate for you to ask your Physical Therapist "I am not getting better is there someone else I should see".  A pinhed nerve in the back can cause groin pain, but groin pain can be coming from tissues in the hip or groin as well.  If this is truely a running injury it is more probable that the pain is a local problem, that is, a problem in the groin or hip joint. 

    Damien Howell PT, DPT, OCS - www.damienhowellpt.com

  • JamesJohnsonLMT Legend 1,167 posts since
    Aug 23, 2009
    Currently Being Moderated
    2. Apr 7, 2013 3:39 PM (in response to hnation)
    Re: Is this really a pinched nerve?

    I agree with Damien that the cause for your groin pain is more likely to be local if it is related to running. Unless you left out important information from your brief account, it appears to be aggravated by your running. Spinal causes for groin pain are within the list of differential diagnoses for groin pain, but not commonly reported.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096235/table/i1524-5012-9-1-11-t01/?report=previmg

    NOTE: The second bulleted item in the table above was truncated by the content viewer, but reads "avulsion and fracture of the" (pelvis including...) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096235/table/i1524-5012-9-1-11-t01/

     

    The conclusion of spinal nerve impingement begs some questions about the month of therapy you received. There wasn't any mention of scans being done before or during treatment. While it may seem that a therapist would be better informed by an MRI or x-ray, studies cast doubt on the objectivity of practitioners who view such scans before a thorough physical examination has been done. Significant bias can result from a hypothetical link between visual abnormalities and pain. Just because something looks unusual and results in a specific treatment protocol, does not mean the diagnosis is accurate. I believe you were wise to see your PT before definitive medical diagnosis was sought. However, it would be helpful to know what tests were performed before or during therapy, and when/how the conclusion of spinal nerve impingement was reached.

     

    What interests me is the amount of time they worked with you before reaching this conclusion, plenty of time to perform a number of tests to determine the origin of your pain, and an appropriate course of therapy. I'm sure that absent a clear sign of what is wrong, there are some who may happily proceed with treatments that have worked for them in similar cases, but a month should be sufficient time to test more than one hypothesis. During this month of therapy, the PTs surely performed tests to determine whether the pain was originating in the spine. If they properly interpreted the results, it might be a "looks like a duck quacks like a duck" scenario. Nevertheless, here are some case study examples of how confusing your symptoms can be to many practitioners when clear signs of a cause are not determined by exhaustive testing. "Nerve impingement" is sometimes a catch-all term for symptoms that do not make sense.

     

    We often assume as patients that there is time to review all possibilities before medical treatment is performed. But professionals make some assumptions, too, because there isn't enough time in the average practice to cover all the bases. It costs too much, and many insurers will only pay for so much exam time. At the end of the day, health care professionals have to make money too, which means they tend to follow probability and guess a lot.

     

    That's one reason why I favor patient education over simple trust. The other benefit of knowing before going is that it allows professionals time to handle more advanced cases. There are many times when a life can be saved by proactively seeing a healthcare provider, but repetitive motion sports injuries do not often fall into this category. Nine times out of ten, a doc is going to tell you to stop running, so it's always a good idea to cut back and take advantage of your downtime to learn as much as you can about your injury. You will be better informed if and when you do go, and will be more likely to provide helpful information. Doctors know rest is often the most important part of healing. In the meantime, you may be able to solve the problem yourself with what you learn. That is a better outcome than allowing a race calendar or the zeal of athleticism to compromise your health.

     

    Now let's explore some other possibilities. In my view, it is best to test for the most common and easily found (or solved) injuries and conditions before jumping to conclusions about more serious pathologies, not only because this has to be done anyway, but because of the known risks of overdiagnosis and invasive testing. Unfortunately, common soft-tissue conditions are sometimes missing or obscured in some diagnostic charts, but they are easy to test for. Things to look into are groin strain, shortness of hip flexors, disk herniation, hip joint, or sacroiliac joint problems radiating to the groin, and trigger points that refer to the groin.


    My guess is that these were already tested for by the PTs, but you would probably remember the tests, and that is important. If they were left out, they should be pursued before submitting to chiropractic. Here's why:

     

    The typical office visit will include some or all of the above evaluations, maybe more. That's great, but a spinal x-ray is often done. Where MDs and DCs differ about spinal health, is in the interpretation of the term "subluxation." This means, that therapy may proceed without any visible danger of nerve impingement. If you find the treatments invigorating, fine.. but there can be other pathologies such as cysts or Neural-Foraminal Stenosis to look for. An example of a bona-fide spinal problem known as "listhesis," or the slipping forward of one spinal segment onto another, can mechanically narrow the neural foramen enough to pinch the nerve. Here's a picture:

    http://ts4.mm.bing.net/th?id=H.4567651477097131&pid=15.1&H=160&W=114

    The small line points to where the nerve root exits the spine. You can see how a clamping action would occur. However, this would occur during normal activity as well as running. In other words, I don't see how you could get through a hilly 20-miler and a boat-load of therapy without this becoming quite obvious. Same goes for other spinal pathologies, which are either there or they are not. The only relief you usually get from these conditions is when sitting certain ways or laying down. Nevertheless, it's another thing, albeit unlikely, to check for, and a single lateral x-ray can suffice, but suppose it is not so obvious?

     

    The best x-rays are not simple static x-rays, done standing or lying straight, but a series done with the spine and legs in various positions to test for soft tissue anomalies such as lax ligaments or disk pathologies that might not be readily apparent. I say "best x-ray" with some reservation, since x-radiation, especially considering the concentration of organs around the lumbar spine, causes damage on the molecular level within cells, and can increase your risk of cancer, although the additional risk is considered small. If you have already had x-rays, and are concerned about overexposure from further studies, use this risk calculator.

     

    Of all the remaining possibilities that may not have been tested for, the myofascial injuries I work with are the easiest for you to test for and treat yourself. A trigger point in the Pectineus muscle, for example, would be felt deep in the groin on the inside of the hip, and locate on the inner thigh, about where it intersects with the lower edge of bikini underwear. Pressure along this line can find the location of this mini-spasm, if it is present. Be aware that it can be quite painful, will not usually show up in most range of motion stretches, but can present when walking with long strides and extending the thigh far to the rear, as in the passive leg during some lunges. You could strain this muscle doing a soccer-style field goal kick. If it hurts when you press, hold the pressure deeply for several seconds to feel for spontaneous release.

     

    The adductors are a bit lower on the front inner thigh, and can radiate pain locally along the inner thigh, as low as the knee and into the hip joint. The rearward portions lateral to the anus can shoot pain through the pelvis into the genital region. These kinds of pains can be frightening, are serious, and do not respond well to stretching or exercise. You have to feel along the entire adductor region for sensitive spots and test sustained pressure for the same effect as Pectineus. A small spasm composed of a few fibers may not tighten the entire muscle, but will cause the whole area to feel sharp or burning pain. If you have trouble spreading (abducting) your legs apart, or turning your legs so the toes point outward, the adductors are suspect.

     

    What is the condition of your abs? If you have been doing situps or extreme kicking motions, a strain to the abs can produce groin pain. The abs attach at the groin, and are important to hip flexion by stabilizing the pelvis when other flexors are operating. Otherwise, a contraction of your flexors would pull the pelvis forward. The main trigger points for the abs are below the belt line between the rim of the pelvis and genital area. Don't expect therapists to work on these, you'll have to do it yourself. Find the sore spots, and treat them with several seconds of sustained pressure. Otherwise, you've left a major source of groin pain untreated.

     

    Other, deeper muscles that produce severe groin, hip, and pelvic pain are even harder to access, but it's possible. Intrapelvic muscles, taboo for most therapists, can be treated by simply sitting on a tennis ball and rolling it between the front and rear body cavities. Sure, it can get more complicated than that, but you can see why they may be left untouched under professional care.

     

    The Iliopsoas is one of your largest and most powerful muscles, and your main hip flexor. It originates on the front sides of the lumbar spine, deep to your organs, and attaches to the top of your inner thigh. Its power is evident in how little leverage it has. Its pain is wide-ranging and can make standing erect difficult. I'll leave you with an instructional video of Psoas work, made for students by a doctor who knows what he's doing. Any further discussion is welcome, but I hope your investment of time in this post has been productive, and that I have otherwise saved you time, and of course, money and pain.

     

     

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