Case Report: Meralgia Paresthetica – A Manual Physical Therapy Approach

Entrapment syndrome of the lateral femoral cutaneous nerve (LFCN), known as Meralgia Paresthetica (MP), is a possible cause of pain and paresthesia in the lateral thigh. It has been proposed that MP is not rare, but is often unrecognized or misdiagnosed for other conditions, such as lumbar radiculopathy. Medical treatment for chronic MP often includes prescription medications and injections. If medical management fails, surgical decompression of the LFCN is considered.

This case report describes a patient with chronic MP and the physical therapy clinical reasoning process and treatment rationale using an integrative orthopaedic manual physical therapy (OMPT) approach.

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Possible processes that can adversely affect the LCFN along its course due to injury, compression, or disease:

  • Trauma — seatbelt forces during MVA or pelvic fracture
  • Mechanical — obesity, pregnancy, tight fitting garments/belts/braces, tumor and other space occupying lesion, L2 or L3 nerve root compression
  • Metabolic — diabetes

History

A 67-year-old female presented with an eighteen-month history of severe burning pain and numbness in the left lateral thigh after prolonged walking and biking. Additional symptoms included left groin and anterior hip pain. Diagnosed with MP at nine months post onset. Condition unresolved with subsequent treatment by medication and physical therapy. Complaints aggravated by prolonged standing and walking; improved by sitting. QVAS (Initial): Right Now 3/10, Average 5/10, Best 3/10, Worst 8/10.

Physical Examination

Examination revealed hypoesthesia of the LCFN distribution, segmental facilitation of lumbar spine, biomechanical spine and sacroiliac joint dysfunction, myofascial trigger points, and adverse neural tension. Pertinent findings in regards to current functioning and level of disability:

Body Function and Body Structures

  • Dysesthesia & hypoesthesia of LCFN
  • Tenderness to palpation of LCFN at intersection with inguinal ligament
  • L2, L3 segmental facilitation
  • Trigger points (iliopsoas, sartorius, rectus femoris, adductor longus and L2-4 multifidi)
  • Painful & limited hip mobility
  • Biomechanical spinal & sacroiliac joint mobility dysfunction
  • Adverse neural tension of femoral nerve and LCFN

Activity

• Decreased ability for squatting, standing, and walking

Participation

• Unable to participate in exercise program
• Unable to participate in recreational activities

Evaluation and Diagnosis

Primary pathoanatomical diagnosis of MP was confirmed by burning pain and hypoesthesia in the LFCN distribution, pain with stretch of the LFCN (hip extension), relief with hip flexion, adverse neural tension, and palpation tenderness at intersection of the LFCN with the inguinal ligament. History, normal objective findings and extensive radiological studies rule out serious pathology, disc pathology, stenosis, hip arthritis, or space occupying lesions.

Clinical presentation is of a chronic, highly irritable condition with signs of peripheral and spinal pain generators. It is reasoned that late diagnosis, inadequate treatment and other related neuromusculoskeletal dysfunctions were contributing to prolonged entrapment of the LFCN and bombardment of the spinal cord by abnormal afferent impulses leading to continued persistence of neuropathic symptoms.

Intervention

Initial aim of treatment was to normalize muscle tone, improve muscle extensibility, decrease peripheral nociceptive input, resolve signs of segmental facilitation, and to restore mobility of the lumbar spine and sacroiliac joint.

Later aim of treatment was to restore pain-free peripheral neural mobility and hip mobility, normalize sensation deficits, improve motor control, and to establish a functional exercise program. Nerve mobilization and high grade intensity treatment was not performed initially due to the likelihood of exacerbating the condition.

Patient was treated with an integrative manual physical therapy approach for ten treatment sessions over a two-month period of time.

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Outcomes

Two months after the onset of therapy, patient reported:
• 90% improvement with functional ability to squat, stand, and walk
• Minimal, manageable pain substantiated by pain scale
• Normal sensation
• QVAS (Discharge): Right Now 0/10, Average 2/10, Best 0/10, Worst 3/10.

Conclusions

Although a case report does not allow the inference of a cause-and-effect relationship between intervention and outcome, true and meaningful changes in a previously worsening, chronic condition does imply that the OMPT management described was at least contributory to the positive changes noted.

Research is limited with regard to providing a causal link between LCFN entrapment and the neuromusculoskeletal impairments that might be amenable to OMPT management.

This case report warrants future studies to examine the effectiveness of OMPT versus other medical and surgical management in the treatment of acute and chronic LFCN entrapment.

References

1. Ivins, GK. Meralgia Paresthetica, the Elusive Diagnosis: Clinical Experience with 14 Adult Patients. Ann Surg 2000;232(2):281-286.
2. Dutton M. Orthopaedic Examination, Evaluation and Intervention. 2nd ed. New York: McGraw-Hill; 2008.
3. Travell J, Simons D. Myofascial Pain and Dysfunction – The Lower Extremities (Volume 2). 1st ed. Philadelphia: Lippincott Williams & Wilkins; 1993.
4. Luzzio, C., Lorenzo C. Physical Medicine and Rehabilitation for Meralgia Paresthetica Clinical Presentation. Medscape Reference. http://emedicine.medscape.com/article/308199-clinical#a0218.