Differential Diagnosis:  Is That A Lumbar Nerve Issue?

Nari Clemons, PT, PRPC has written the following courses: Lumbar Nerve Manual Assessment/Treatment, as well as Sacral Nerve Manual Assessment/Treatment. She has co-authored the Pelvic Function Series Capstone course and the Boundaries, Self Care, and Meditation Course. Nari’s passions include teaching students how to use their hands more receptively and precisely for advanced manual therapy skills while keeping it simple enough to feel successful. She also is an advocate for therapists learning how to feel well and thrive as they care for others, which is a skill that can be developed.

If you've taken the Pelvic Function Series Capstone or Pelvic Function Level 2B and you've gotten curious about nerves, you've likely started to think about what is nerve pain and what is muscle restriction. In those classes, we discuss several lumbar nerves and how the restrictions could be creating pain in the anterior vulva, anterior hip, lower abdomen, groin, or inner thigh. Or perhaps you've started to notice certain patients have pain along nerve distributions we talk about in either of those courses. Sometimes we have patients who have had surgeries like c-sections, inguinal hernia repairs, or hysterectomy, and we notice they are having a persistent pain or weakness problem that isn't easily explained through muscle alone. I like to think of the nerve as the program for the robot, and the muscle as the way the robot moves.  Nerves are a way to get deeper to the root of what may be happening.

We have separate classes for the Lumbar Plexus Nerves (ilioinguinal, iliohypogastric, genitofemoral, obturator, femoral, and lateral femoral cutaneous) and the Sacral Plexus (pudendal, sciatic, inferior and superior gluteal, and the posterior femoral cutaneous nerves). Here is a clinical example of each Lumbar nerve and some differential cues we may look for, that we may have mistaken for muscle in the past:

Iliohypogastric: an area of pain or weakness, unilateral, or an outpouching in the obliques, a diastasis abdominus that you are treating where the patient continues to have difficulty recruiting the transverse abdominus in the area near the c-section.

Ilioinguinal: a persistent pain in the pubic bone region after pregnancy or high groin pain ( if x-rays do not confirm osteitis pubis). Also, pain in the labia majora or testicle.

Obturator: a pain in the inner thigh, or often after a transvaginal tape (bladder sling), even years later, as the sling goes through the obturator foramen, which can tighten over time, creating pain. This can also be persistent adductor tightness and tenderness that is not consistent with other muscle groups.

Genitofemoral: a pain in the anterior vulva or clitoral area that can also feel like persistent burning or itching (when a dermal condition has been ruled out). This is often called vulvodynia (which just means pain in the vulvar area), but it can be differentiated from pudendal pain in that it is not worse when sitting and is limited to the anterior vulva.

Femoral: a weakness in one quad, a leg that occasionally gives out when stepping off a curb unilaterally, a hip flexor that stays tighter than the other side, despite stretching, often mistaken for "psoas dysfunction"

Lateral femoral cutaneous nerve: meralgia paresthetica: numbness in the outer thigh after pregnancy or LFC injury, or patients will describe feeling like there is a jean seam rubbing the outside of their leg when there isn't, also persistent IT band pain or stiffness.

If nerves are of interest to you, come join us for Lumbar nerve manual assessment and treatment, and learn how to treat nerves from proximal to distal, differentially diagnose more, how to decompress the pathway of the nerve, and then restore the affected structures to normal length and strength.

If you would like to learn more about Lumbar Nerve Manual Assessment and Treatment the join Nari in her upcoming course on March 2-3, 2024.