Clinical Commentary Nerve Entrapments in the Hip Region: Current Concepts Review

Editorial Review

Clinical Commentary

Nerve Entrapments in the Hip Region:

Current Concepts Review

Robroy Martin, PhD PT, Hal David Martin, DO, Benjamin R. Kivlan, PhD PT

International Journal of Sports Physical Therapy 2017 12:7 1163-73

JACO Editorial Reviewer: Richard Corbett D.C.

Published: September 2018
Journal of the Academy of Chiropractic Orthopedists
September 2018, Volume 15, Issue 3

The original article copyright belongs to the original publisher. This review is available from: http://www.dcorthoacademy.com ©2018 Corbett and the Academy of Chiropractic Orthopedists. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Authors’ Abstract:

The purpose of this clinical commentary is to review the anatomy, etiology, evaluation, and treatment techniques for nerve entrapments of the hip region. Nerve entrapment can occur around musculotendinous, osseous, and ligamentous structures because of the potential for increased strain and compression on the peripheral nerve at those sites. The sequela of localized trauma may also result in nerve entrapment

if normal nerve gliding is prevented. Nerve entrapment can be difficult to diagnose because patient complaints may be similar to and coexist with other musculoskeletal conditions in the hip and pelvic region. However, a detailed description of symptom location and findings from a comprehensive physical examination can be used to determine if an entrapment has occurred, and if so where. The sciatic, pudendal,

obturator, femoral, and lateral femoral cutaneous are nerves that can be entrapped and serve a source of hip pain in the athletic population. Manual therapy, stretching and strengthening exercises, aerobic conditioning, and cognitive-behavioral education are potential interventions. When conservative treatment is ineffective at relieving symptoms surgical treatment with neurolysis or neurectomy may be considered.

Level of Evidence: 5

Key words: Anatomy, etiology, evaluation, hip, nerve entrapment, treatment

Methods: This article reviews the anatomy, etiology, evaluation and treatment techniques for peripheral nerve entrapments of the hip and pelvic regions.

The sciatic and pudendal nerves are reviewed with respect to posterior nerve entrapment. The obturator, femoral and lateral femoral cutaneous nerves are reviewed with respect to anterior nerve entrapment:

Results: The article discusses the concept of nerve gliding.
Normal nerve gliding may be disrupted by localized trauma.

Some of the mechanisms through which peripheral nerve entrapment negatively affects nerve function are identified as: changes in vascular permeability, impairment of axonal transport, and the formation of edema.

Posterior Nerve Entrapments: A summary of the common locations of posterior hip and pelvis nerve entrapments and key subjective findings and signs are presented in this table (Table 1 of the article):

Posterior Hip and Pelvis Nerve Entrapments

Involved Nerve

Common Site of Entrapment

Key Signs and/or Symptoms

Sciatic

Piriformis and obturator internus/gemelli complex

Proximal Hamstring

Lesser trochanter and ischium

Positive seated piriformis stretch and/or active piriformis tests

Ischial tenderness

Pain in the posterior thigh to the popliteal fossa aggravated with running

Positive ischial femoral impingement test

     

Pudendal

Ischial spine, sacrospinous ligament and lesser sciatic notch entrance

Greater sciatic notch and piriformis

Alcock’s canal and obturator internus

Pain medial to ischium

Sciatic notch tenderness and piriformis muscle spasm and tenderness

Obturator internus spasm and tenderness

Anterior Nerve Entrapments: A summary of the common locations of anterior hip and pelvis nerve entrapments as well as subjective findings and signs are also presented in Table 1 of the article:

Anterior Hip and Pelvis Nerve Entrapments (* added for clarity)

Involved Nerve

Common Site of Entrapment

Key Signs and/or Symptoms

Obturator

Obturator canal

Adductor muscle fascia

Pain in medial thigh (*exercise-induced)

Aggravation with movement into abduction

     

Femoral

Beneath iliopsoas tendon

Inguinal ligament

Adductor canal (*with involvement of saphenous branch)

Reproduction of symptoms with modified Thomas test position

Quadriceps muscle weakness

(*quadriceps atrophy if severe)

Pain in the anteromedial knee joint, medial leg, and foot

     

Lateral Femoral Cutaneous

Inguinal ligament

Positive pelvic compression test

(* & Tinel’s Sign)

Conservative Treatment: Conservative treatment strategies for nerve entrapments have not been well-studied.

A list of conservative treatment strategies would include neural gliding or nerve mobilization, manual therapy, soft tissue mobilization in conjunction with active patient movement, stretching and strengthening exercises, massage, aerobic conditioning, and cognitive-behavioral education.

Those physical techniques listed in the previous paragraph attempt to improve neurodynamics by restoring the balance between the relative movements of the nerve and surrounding structures.

Soft-tissue mobilization using active patient movement along with specialized instruments in treatment administration may be used to induce biological changes to affect scar tissue and to stimulate the regeneration of soft tissues. These techniques may also try to mechanically mobilize tissues that are restricting nerve gliding.

The hypothesized benefits from neural gliding or nerve mobilization techniques include facilitation of nerve gliding, reduction of nerve adherence, dispersion of noxious fluids, reduction of intraneural edema, increased neural vascularity, and improvement of axoplasmic flow.

Treatment goals are: to increase range of motion, reduce pain, decrease swelling, increase flexibility, and/or improve muscle performance.

Surgical Treatment: Surgical treatment with neurolysis or neurectomy may be considered when conservative treatment, including injections, is ineffective at relieving symptoms associated with nerve entrapment.

Conclusions: Nerve entrapments should be considered as a potential generator of extra-articular symptoms in athletes with hip or pelvic pain.

Symptom location combined with physical examination findings can be used to identify the site of nerve entrapment.

Treatment strategies include physical measures as well as cognitive-behavioral education.

Surgical treatment may be considered in those with recalcitrant symptoms.

Clinical Relevance: Chiropractors often see athletes (as well as non-athletes) with hip and /or pelvic pain.
This paper is of value in the differential diagnosis of patients with hip and/or pelvic pain.

JACO Editorial Summary:

  • Posterior and anterior hip nerve entrapments may be causes of pain in the athletic population.
  • The similarity in symptoms, and potential co-existence with other musculoskeletal conditions can cloud the process of identification of nerve entrapments in the hip and pelvic region.
  • Common nerve entrapments in the hip and pelvis in athletes may involve the sciatic, pudendal, obturator, femoral, and lateral femoral cutaneous nerves.
  • Clinicians need to be aware of the potential location, clinical presentation, and treatment options for nerve entrapments in the hip and pelvic region.
  • Examination for Posterior Nerve Entrapments: For those with potential posterior nerve entrapments, examination should include the seated palpation test, the seated piriformis stretch, the active piriformis test, the ischio-femoral impingement test, and the active knee flexion test.
  • For those with suspected pudendal nerve entrapment, careful palpation should be performed for tenderness at the greater sciatic notch near the proximal aspect of the piriformis and medial to the ischium near the sacrospinous and sacrotuberous ligaments, the obturator internus muscle, and pudendal canal.
  • Examination for Anterior Nerve Entrapments: Patients with obturator nerve entrapment may have medial thigh symptoms which are aggravated by stretching with hip abduction and slight extension, but the symptoms are not aggravated by resisted adduction.
  • Quadriceps muscle weakness may be present in patients with femoral nerve entrapment. Should the entrapment be severe, quadriceps muscle atrophy will be present, often with an absent patellar tendon reflex. Passive hip extension and knee flexion may reproduce the symptoms in femoral nerve entrapment.
  • Lateral femoral cutaneous nerve entrapment may be identified by a positive pelvic compression test and Tinel’s sign.

The reader is referred to the original article for a complete description of these tests.

Summary: This is a helpful review of potential nerve root entrapments in the posterior and anterior hip and pelvis.