pain in back of the thigh

[sharmaphysio]

hi,

i have a patient with pain in hams in both lower limbs and has SLR on rt side-60 degree and on left side 40 degree.

she has no pain in back.

only problem is pain in posterior thigh.

what u suggest to do?

on cross leg sitting pain is in hip joint too.

and on prolonged sitting it is in gluteal region.

how u will treat such a case?

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[physiobob]

You have touched on ideas for a physical assessment.

First you need to do a full neuro to assess pain referral. You also need to test lumbar spine, hip and knee joints and let us know what you find.

You need to ask about aggravating/provoking positions or activities. We need more history about this issue. You are a regular poster but now I am trying to get everyone to be a lot more complete with their questions and surrounding history. For all we know the problem might be that a knife is sticking out of the back of her thigh! Excuse the sarcasm

[davidjack]

Hi since his SLR is positive, it shows his ROM is restricted. Rule out the causes:

1. hip jt arthritis,
2. hamstring tightness/ contracture,
3. sciatica with or without lumbar dysfunction like disc problem/spondylosis, spondylolysis etc.

Watch out for them

[physiobob]

Hi since his SLR is positive, it shows his ROM is restricted.

From the description his SLR is not positive for anything others than they are "tight" or restricted in some way. For any generalized opinion about Straight leg raise and it's clinical relevance to say discal pathology the SLR must produce the symptoms in the first 30 degrees, and remember that in fact a crossed SLR (pain on an SLR causing contralateral symptoms) is more positive than those on the ipsilateral side.

I would suggest your point three is more on track however. But hopefully this poster will provide an update and more clarity on their assessment.

[chunkypuffin]

Hi Physiobob,

interested by your comment on SLR, particularly the specific value of 30 degrees to validate discal involvement. Have you got the references for this value? I presume this would only be valid for discal impingement on the nerve? In this case the degree of impingement is often affected by spinal posture or loading, therefore the 30 degree value would have to be standardised for replication clinically. Additionally, the neural sensitisation that occurs with disc prolapse may also be due to the release of inflammatory mediators from the disc, in which case surely the range in which the SLR becomes symptomatic becomes a combination of degree of sensitivity, current emotional and cognitive amongst others. Would you agree with this or am I off the mark with these assumptions?

Best Regards

Craig

[alophysio]

Clinical Sports Med 2nd Ed states that SLR is positive regardless of ROM if it reproduces the symptoms

[physiobob]

Hi Physiobob,

interested by your comment on SLR, particularly the specific value of 30 degrees to validate discal involvement. Have you got the references for this value?

Hi Craig, don't ahve a reference but I'll look for it. This however is what is in my old notes from the Uni of Sydney. As stated my comment is however in relation to discal herniation and not anything else, hence my comment on the SLR being positive 'For What'. The SLR in many ways is pretty useless as perhaps more of the population have ranges of hip flexion for this under 60 degress than those above 60 degrees, at least it seems that way in the clinic (for males that is).

In one online GP resource I did find the following commment:

# Interpretations: What patient experiences

Interpretations: What patient experiences

1. Radiating pain into the legs

• 1. Suggests radiculopathy
• 2. Higher likelihood findings suggesting radiculopathy
  • 1. Excruciating sciatica-like pain
  • 2. Pain occurs at 30 to 40 degrees of leg elevation

2. Crossed pain into opposite leg

• 1. Indicates severe impingement
• 2. Almost always due to a large disk herniation

Here's also a few interesting abstracts

Spine. 1992 Apr;17(4):395-9.
Straight leg raising test versus radiologic size, shape, and position of lumbar disc hernias.
Thelander U, Fagerlund M, Friberg S, Larsson S.

Department of Orthopaedic Surgery, University Hospital, Umea, Sweden.

In 30 patients with a computed tomography-verified lumbar disc herniation, the relation between the straight leg raising test and the size, shape, and position of the hernia was evaluated before, 3, and 24 months after inception of nonoperative treatment. Hernia size was expressed as an index relating it to the size of the spinal canal. The limitation of the straight leg raising test was not related to size or position of the hernia. Before treatment, straight leg raising was equally restricted in patients with sharply pointed or blunt hernias, but after 3 months straight leg raising was less limited in patients with sharply pointed hernias, whereas after 24 months straight leg raising was regularly normalized. Size index was lower for sharply pointed hernias at all three computed tomography scans. A decrease in hernia size over time, irrespective of shape, was not correlated to a concomitant improvement in straight leg raising. It must be presumed that additional factors, such as inflammatory reactions affecting the nerve roots, are of importance for the magnitude of straight leg raising.

PMID: 1579873 [PubMed - indexed for MEDLINE]


J Bone Joint Surg Am. 1987 Apr;69(4):517-22.
Significance of the straight-leg-raising test in the diagnosis and clinical evaluation of lower lumbar intervertebral-disc protrusion.
Xin SQ, Zhang QZ, Fan DH.

The cases of 113 patients who had protrusion of a lumbar intervertebral disc were analyzed to determine the relationship between the findings at operation and the location of the pain that resulted from the straight-leg-raising test. The study showed a close relationship between the location of the pain and the position of the protrusion of the disc. The degree of limitation of straight-leg raising was also found to have a direct relationship to the size and position of the protrusion and to its relationship to the spinal nerve. The protrusions were classified into three types according to position in relation to the dura mater and to the pattern of pain that was induced by passive straight-leg raising. On straight-leg raising, central protrusions tended to cause pain in the back, lateral protrusions caused pain in the lower extremity, and intermediate protrusions caused both. On this basis, the distribution of pain on straight-leg raising allowed an accurate prediction of the location of the lesion in 100 (88.5 per cent) of the 113 patients.

PMID: 3571310 [PubMed - indexed for MEDLINE]

Spine. 1979 Mar-Apr;4(2):174-5.
Myelographic defect on the side opposite the leg pain. A case report with an explanation of mechanism of action.
Auld AW, DeWall JG.

An explanation for leg pain on the opposite side of the myelographic defect in one case is reported. Disc herniation was located superior to the exit of the root and thus displaced the dura and compressed the root on the opposite side against the pedicle producing contralateral leg pain

PMID: 264033 [PubMed - indexed for MEDLINE]