Meralgia Paraesthetica... help!

[karinavan@gmail.com]

A 59 year old patient presented to me today with a 2 week history of left lateral thigh numbness, after doing a lunge-type stretch in gym. Whilst lunging he experienced a sudden "electrical" sensation in his left hip which eased immediately, but he was left with the mentioned anaesthesia. No pain, but he does experience some discomfort/ache in the lateral thigh when standing for prolonged periods of time.

I might also mention that he suffers from hypoparathyroidism and has been using long term cortisone (more than 10 years).

My first thoughts were lumbar radiculopathy, but I cleared his back (apart from some tenderness over L5). No motor or reflex changes. He demonstrated sensation loss over a very defined area on the lateral thigh - distribution of lateral cutaneous nerve.
Prone knee bend was painless, but much stiffer on the left when compared to right.

When lunging with the right leg forwards, he experiences a tight feeling over his left lateral thigh and hip.

Palpation revealed marked tenderness in the soft tissues around the left greater trochanter (his hip joint was cleared from involvement too) with a very tight, tender iliotibial band.

I have never seen a patient with lateral cutaneous nerve injury (and I am still a young physio ) but the more I think about this case, the more I suspect this to be the likely diagnosis... also taking into acount the chronic metabolic disorder which might put the peripheral nerves at greater risk.

I would appreciate any input... have I missed something? Neurology is not my strong point... How does something like this progress, and what would be the best treatment approach? All I can think of is increasing flexibility of iliopsoas, ITB and so on... neural mobilisation... Please help!

[Shaxy]

Morning Karina,
Cold in Stellies?
just logged onto the site after looking up some other stuff and saw your question. Thought I would add something as from what you have written you are so on the right track anyway.
As you know by now the lateral femoral cutaneous nerve (LFCN) arises from the ventral rami of the L2 and L3 nerve roots. This purely sensory nerve is formed just deep to the lateral border of the psoas muscle, then descends in the pelvis over the iliacus muscle deep to the iliacus fascia. Just medial to the ASIS, the nerve exits the pelvis by passing through the deep and superficial bands of the inguinal ligament as they attach to the ASIS. The nerve is also passes the inguinal ligament (where your illiopsoas runs too), but then it takes a vertical course out to the surface of the thigh. When doing lunges you are going to be leaning a little to the ipsi-lateral side "crunching" that area. (check pelvic stabilizers) and also possibly setting off illiopsoas spasms so check for MFTPs at least compare the 2 sides. (I find gentle PNF works well)
Ultimately you should check and mobilize gently L2 and L3 on the right opening up the IVFs. Should this not work then referral for an MRI is necessary for prolapsed disc.
Questions to keep in mind are osteoporosis(bone density scan) and discs especially after long term corticosteroid use and hypoparathyroidism. Unfortunately with that combination an MRI is likely to pick up further but as of yet unsymptomatic pathologies.
I am not sure if this helps but thought i would put something in and I wish you all the best.
Rich

[karinavan@gmail.com]

Rich!

Yep, might as well be snowing here

Thank you so much for your reply, it does help a lot and I will definitely check everything you mentioned.

I have seen the patient twice since my original post, did some soft tissue and neural mobs, ultrasound and stretches. He has noticed a SLIGHT improvement in his condition - no more discomfort, just the anaesthesia. He is still very very tender locally with palpation (superior/posterior to greater trochanter as well as the ITB).

Anyway, thanks again for your input, hopefully I can avoid that MRI...

Cheers
Karina