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Ilioinguinal Neuralgia?

 
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Ilioinguinal Neuralgia? - June 14, 2004 11:34:00 PM   
MickeyPT

 

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I needed to poll your opinions for this patient. A 21 y/o female referred to PT with dx of iliopsoas strain which presented immediately after an appendectomy in September of 2003. All resisted tests of LE's were negative and the only reproduction of pain was with passive and active hip ext. In standing and sitting, motions which stretched the area just lateral to the naval elicited a pulling sensation. Obers neg., Thomas neg. with pain, femoral nerve stretch test pos. for pain but so was strait leg extension. Pain distribution is just lateral to the naval sometimes radiating into anterior ipsilateral thigh (approx. L2/L3 dermatome). Pain also with crunches and situps so I'm also leaning towards strain of rectus abdominis. I was wondering what everyones opinion is on this case and if anyone thinks it may be ilioinguinal neuralgia. I appreciate your feedback.

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Re: Ilioinguinal Neuralgia? - June 15, 2004 9:21:00 AM   
MickeyPT

 

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I forgot to mention, resting pain of 6/10 and pain with activity 9/10.

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Re: Ilioinguinal Neuralgia? - June 15, 2004 8:14:00 PM   
pablo w

 

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MickeyPT,
If she developed the complaint immediately after the surgery, I doubt it would be a psoas strain. A nerve entrapment or pain due to nerve damage is more likely, and these would give the same examination findings that you listed. My best suggestion is to assess the area to see if there are any signs of sensory loss, hyperpathia, anything suggestive of a nerve injury. It is not unusual for these cutaneous nerves to be injured during surgery on the abdominal wall. Check the scar. If stretching the scar or palpation of the scar reproduces or increases the pain, but adjacent areas do not, you're probably dealing with an irritated or injured nerve. If you find this is positive, I'd refer back to the doctor, for referral to a pain medicine specialist or anaesthetist who may be able to infiltrate the area with a local anaesthetic, quite often with very good results. Don't leave this too late, as nerve pains can become well entrenched through central processing changes. I don't think you're treating a muscle strain.

Pablo

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Re: Ilioinguinal Neuralgia? - June 15, 2004 11:22:00 PM   
rodgere

 

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Hello,
Don't know if naming it is going to get you anywhere.I personally think specific diagnosing can confuse the situation. Constant pain would send me to the lumbar spine. Lie patient prone for 3-5 minutes and see if Sx. change. Look for geographical changes as well as centralization. I wouldn?t send patient back until lumbar spine repetitive movement exam was completed try at least 3-6 treatments.
Thanks and keep us posted
Rodger (go pistons)

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Re: Ilioinguinal Neuralgia? - June 15, 2004 11:27:00 PM   
rodgere

 

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sorry, i ment intensity changes as well as geographical changes

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Re: Ilioinguinal Neuralgia? - June 16, 2004 12:53:00 AM   
bonmar

 

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Was the appendectomy performed by a scope? Was the patient guarding the area after surgery (eg. hunched over, using a cough pillow, etc.)? If so, for how long?
Truthfully, I am not sure how an appendectomy is done these days(scope or a large incision) but if she had abdominal sx and had alot of guarding post-op, I would be curious if she had trigger points of the psoas/scarring(?)
Travell and Simons book, "Myofascial Pain and Dysfunction: The Trigger Point Manual" is an excellent reference for trigger points, causes, and treatment.
Keep us posted...

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Re: Ilioinguinal Neuralgia? - June 16, 2004 1:16:00 PM   
MickeyPT

 

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The appendectomy was an open surgery which left a scar approx. 4" in length. Palpation of the scar and surrounding area is highly sensitive. I asked the physician (anaesthetist)if he had concidered the possibility of nerve entrapment. His response was I should continue tx directed at psoas myofascial pn and notify him if it is not successful. I asked the patient to describe the pain in her leg and she stated it is inconsistent and only present when she is very active. Very strange case. Since the palpation of lower right quadrant of the abdomen increased the pain, I think you're suspicians may be correct Pablo. I will ask her about her condition directly after surgery next time I meet with her bonmar. The only thing I can say now is when I asked if there were any complications with healing time she said "no". I'll get a more specific answer. I think the physician may be on the same page you since he is telling me to treat iliopsoas myofascial pain. Thank you all for the comments. I'll keep you updated.
Mickey

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Re: Ilioinguinal Neuralgia? - June 17, 2004 1:10:00 AM   
pablo w

 

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Mickey,
Consider that the physician may be faced with an unhappy patient if you suggest to the patient that the current pain was actually caused by the operation. It is a common complication. I would raise it with the doctor again if there was enough evidence of nerve irritation. I have seen a significant number of these type of patients, with persistent pain after surgery (I work in a pain clinic). It's also possible that the surgeon knows something about what happened during the procedure, such as an incidental injury to the psoas muscle. In any case, my money is on a neuropathic aetiology to the pain. Keep us posted.

Pablo

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Re: Ilioinguinal Neuralgia? - June 17, 2004 12:43:00 PM   
MickeyPT

 

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bonmar, my patient reported being doubled over after surgery for a couple of weeks and even stated she used a pillow. Good insight. I'll keep you posted.
Mickey

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Re: Ilioinguinal Neuralgia? - June 17, 2004 8:36:00 PM   
bonmar

 

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Micky, I looked up the iliopsoas in the book, "Myofascial Pain and Dysfunction: The Trigger Point Manual/Lower Extremeties" by Janet G. Travell, M.D. and David G. Simons, M.D.
There were a few points that I felt pertained to your patient. On page 101, Section 10. "Entrapments", it says:
"The iliohypogastric, ilioinguinal, later femoral cutaneous, and femoral nerves all emerge from the later border of the psoas major muscle. The obturator nerve emerges from its medial border. The genitofemoral nerve passes anteriorly through the center of the belly of the muscle, emerging on its anterior surface. Sometimes, the iliohypogastric nerve and the ilioinguinal nerve also pass through the belly of this muscle.

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Re: Ilioinguinal Neuralgia? - June 17, 2004 8:46:00 PM   
bonmar

 

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Sorry, I pressed enter before I was done. To continue (from the same reference as above),
"Although symptoms of entrapment of these sensory lumbosacral nerves have not been specifically related to TrPs (trigger points)in the psoas major, this possibility should be considered when a patient suffers enigmatic pain and disturbance of one or more of these nerves. For example, entrapment of the genitofemoral nerve by taut TrP bands in the psoas muscle could cause pain and paresthesias in the groin, scrotum or labia, and proximal anterior thigh."
"Lewit suggests the possibility that the lateral femoral cutaneous nerve may be entrapped by an iliopsoas muscle that is enlarged (in spasm) as it passes through the lacuna musculorum where nerve and muscle exit the pelvis together." "The femoral nerve and the femoral branch of the genitofemoral nerve also pass through this foraminal space. Since at this level the psoas is mostly tendobn and the iliacus is still largely fleshy, it is more likely that such an entrapment would be caused by TrP shortening or reflex spasm of the iliacus than of the psoas muscle. Some enigmatic femoral nerve entrapments may arise in this way."
There is an approx 20 page chapter on the iliopsoas in this book, which would give you more insight into this muscle.
Whenever I attempt palpation of the psoas (for a ?psoas release) in a young woman or a woman of childbearing age, I always make sure there is no chance of pregnancy. If in doubt, I stay away from this deep palpation.
Keep us posted...good luck, Bonnie

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Re: Ilioinguinal Neuralgia? - June 17, 2004 9:33:00 PM   
Diane

 

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I agree with Bonnie, but sometimes it isn't necessary to look as deep as psoas..

http://xnet.kp.org/permanentejournal/sum02/acnes.html

I treat bellies a lot with soft tissue work, skin stretching etc. (Doubt that the nerve entrapments really need anything so invasive as injection..)

Inguinal areas do quite well if the ab layers that comprise them (Internus reflecting back to become externus, and rectus on top and transversus below) can all move adequately upon each other.. there are lots of cutaneous nerves with exit points all along the bottom, right through all the layers of the inguinal area, as Bonnie mentioned (and also along the vertical borders of rectus, and obliquely along the edge of the pelvis, front and back...) They all have to be able to slide freely within the soft tissue tunnels and over edges of the fascial expanses.

There are some interesting pictures in the link. Have fun.
Diane

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Re: Ilioinguinal Neuralgia? - June 17, 2004 9:55:00 PM   
Dr.Wagner


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Ohhhh I have seen this before...numerous times. What kind of meds is she being treated with??

Nothing in the surgery would cause this, save retained foreign body. Appendectomies are easy procedures done virtually blind folded. This is a VERY common complaint...once again how long since the operation and what meds and how often does she take them?

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Re: Ilioinguinal Neuralgia? - June 18, 2004 9:23:00 AM   
MickeyPT

 

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Dr. Wagner
Her surgery was 10 months ago in September of 2003. The only medication she is currently on is Mircette (I'm not sure of the spelling but it is birth control).
Bonnie and Diane, thank you for the helpful information. I'll keep you posted.

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Michael McIntosh PT, MBA

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Re: Ilioinguinal Neuralgia? - June 18, 2004 1:10:00 PM   
Dr.Wagner


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I am being very much a doubting Thomas in this case...And personally I doubt very heavily this has anything to do with the surgery...21 year old girls have a tendency to be pretty dramatic. She is on no pain meds...are you sure?!
Other parts of this differential also includes Follicular and Luteal cysts so a diagnostic US may be warrented at some point, just to be thorough. I have a feeling that this will continue long after you have discharged her...there will be no resolution in this case. She needs hands on therapy primarily because I think she also has other issues. The hands on therapy will provide her with the One on one that she needs and desires.

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Re: Ilioinguinal Neuralgia? - June 22, 2004 6:23:00 PM   
MickeyPT

 

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Dr. Wagner
I asked her once again if she is taking pain medications...she denied any usage. I understand your thoughts and since I work in a chronic pain facility, that is always my first suspicion. This one is unique however and my intuition and objective findings don't point to psychogenic pain. At her last treatment she states her pain was helped with IFC over the iliopsoas muscle and the HEP is helping decrease her resting pain. I did some more testing on the last session and hip ER combined with hip flexion reproduced her pain. This makes me more likely to think the iliopsoas is at least a major contributor of her pain. On the initial exam, she didn't state hip flexion increased her pain. Therefore I was way confused on how this could be iliopsoas pain. Now my suspicion is growing that it may just be a type of myofascial pain as Bonnie had suggested. Still strange that medium pressure over the surgical area is painful and that the origin and insertion of the iliopsoas aren't symptomatic. Hopefully she isn't just trying to please me by saying her pain is decreased. I'll keep in mind the Follicular and Luteal cysts tests if the pain doesn't continue to decrease. Only time will tell. Thank you for your input. I'll keep you posted on the progression of this case.

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Re: Ilioinguinal Neuralgia? - June 22, 2004 10:52:00 PM   
bonmar

 

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Mickey, you stated that this patient had increased pain with crunches and sit ups. This is a common c/o with TrPs of the iliopsoas.
In the Travell and Simon trigger point book, it is stated that after working with the soft tissue of the iliopsoas(psoas release/stretching is how I address this issue), have the patient perform slow, eccentric(only)sit-ups with the legs extended out in front of you. Also, address sleeping/resting positions..i.e. trigger points are exacerbated with sleeping in a fetal position or sitting for an extended period of time(esp in deep, soft chairs).
I cannot figure out what IFC is? Did you perform a psoas release? If yes, was there a significant difference from the symptomatic side to non-symptomatic? Thanx, Bonnie

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Re: Ilioinguinal Neuralgia? - June 23, 2004 8:18:00 AM   
CarolinaPT

 

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Bonmar, How do you do a psoas release?

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Re: Ilioinguinal Neuralgia? - June 23, 2004 8:56:00 AM   
MickeyPT

 

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Bonnie
Very good suggestions, I'll implement them next time I see her. IFC is interferential current. Currently I have been performing psoas stretching, gravity resisted hip ER, hamstring curls, strait leg raise, and quad stretches. Pain management with heat and IFC. I would be interested in knowing how you perform the psoas release. Thanks, Mickey

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Re: Ilioinguinal Neuralgia? - June 24, 2004 7:50:00 AM   
bonmar

 

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Have the pt lie supine with hips/knees flexed (eg. legs resting on 2 pillows/bolster) to relax the iliopsoas. Establish,first, that the pt is not pregnant. Stand on one side of the pt, place your fingers approx 2" from the umbilicus. Have your dip/pip/mp joints extended. Gently begin to push down in a ant-post direction. The pt will be slightly uncomfortable (a little crampy, maybe).
Push down fairly deep until you locate the iliopsoas. It should feel fairly soft (but, if there are Tps, it will feel hard)...it will run parallel/oblique to the umbilicus. If you are not sure if you have the right spot, have the pt slightly flex his/her hip(and feel the contraction). Then, begin to cross massage the ms...keep your dips,pips extended and flex your mps. The pt definitely will feel uncomfortable if the ms is tight. Follow the ms down towards the inguinal area going at an oblique angle.
Begin on the side that you feel will be the most normal (for comparison).
Follow up with stretching.
Of course, it would be better to be shown but I hope this helps. I am not the best writer....hard to get my thoughts onto paper!! Good luck...Bonnie

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