Chiropractic Management of Low Back Pain and Testicle Pain: A Case Report
Shawn M. Neff, DC, MAS, FACO1, Rebecca Warnecke3
1Staff Chiropractor Martinsburg VAMC
2Adjunct Clinical Faculty, Palmer College of Chiropractic
3Student, Palmer College of Chiropractic
Published: September 2017
Journal of the Academy of Chiropractic Orthopedists
September 2017, Volume 14, Issue 3
This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: http://www.dcorthoacademy.com. © 2017 Neff/Warnecke and the Academy of Chiropractic Orthopedists.
Introduction: This case report describes the chiropractic management of a patient with low back and testicular pain.
Case Presentation: A 68-year-old Caucasian male veteran was treated for low back pain and referred testicular pain with spinal manipulative therapy and a Sacro-Occipital Technique (SOT) ischemic muscle release.
Management and Outcome: The outcome measures used to measure the patient’s pain were the Quadruple Visual Analogue Scale (QVAS) and Back Bournemouth Questionnaire (BBQ). At each visit, a Numeric Rating Scale (NRS) was also used to assess daily pain levels. Lumbar spinal manipulation, initially with an adjusting instrument and later using a high-velocity-low-amplitude (HVLA) drop mechanism, was performed along with a muscle release technique to the right iliopsoas. Immediately after the initial visit, the patient reported resolution of testicular pain. After a total of five visits, the patient reported resolution of low back pain and continued absence of testicular pain. The patient returned to the clinic approximately four months after discharge with reoccurrence of the testicular pain. After one additional treatment, the pain was completely resolved.
Conclusion: This patient was treated with spinal manipulation and a Sacro-Occipital Technique (SOT) muscle release. The result was complete resolution of referred testicular and leg pain, as well as a significant reduction in low back pain. Due to the prevalence of chronic idiopathic testicular pain in male patients, further research in the form of case studies and especially randomized control trials is warranted to provide appropriate alternative management for patients who have not found resolution elsewhere.
Testicular pain is defined as discomfort felt in the testes or scrotum, which may be accompanied by genital tenderness, swelling, and redness. Testicular torsion is a condition that may cause acute testicular pain and swelling and is most commonly diagnosed in individuals under the age of twenty-five.1 If not treated quickly, it could lead to loss of the testicle. This must be ruled out prior to evaluation of other causes via a thorough patient history and physical exam.
Additional causes of testicular/groin pain include: sexually transmitted diseases, kidney stones, infection (epididymitis), testicular tumors, and an enlarged prostate.2 In 50% of cases, when all possibilities have been ruled out, the final diagnosis is idiopathic chronic testicular pain, which may remain unresolved for years.2 Testicular pain may also be referred from a lumbar strain. 2 Little evidence exists regarding idiopathic chronic testicular pain; however, the process appears to be neurological in nature. Sensory fibers from the upper ureter and the testicles are transmitted through the T11 and T12 spinal cord segments and are hypothesized to lead to the sensation of referred pain caused by radiculitis of the respective nerve roots.2 Spinal pain, originating in the lumbar region may be transmitted through the genitofemoral and inguinal nerves as referred unilateral testicular or scrotal pain.3 The ramus genitalis of the genitofemoral nerve is derived from L1-L2 nerve roots of the lumbar plexus and travels through the inguinal canal to supply the scrotum.4 The ilioinguinal nerve arises from the lumbar plexus as well, specifically from the L1 nerve root to supply the skin above the inguinal ligament, medial thigh and mons pubis.5 Both the ilioinguinal and genitofemoral nerves (along with the hypogastric nerve) travel through the psoas muscle.5 Entrapment of the ilioinguinal and/or genitofemoral nerves can cause referred testicular and scrotal pain.3
A substantial body of research exists regarding the chiropractic management of cervical and lumbar radiculopathy/radiculitis.6 Although the mechanisms of spinal pain, radiculopathy, and referred pain are similar, there are only two case studies having reported use of chiropractic care for referred testicular pain.4,7 These studies show the possible relationship between the lower thoracolumbar spine and surrounding musculature and referred testicular pain in patients with diagnosed idiopathic chronic testicular pain. This connection also provides a possible alternative treatment plan for this condition.
A 68-year-old Caucasian male. presented to the clinic with a chief complaint of low back pain beginning 10 weeks prior after tripping and falling onto his coffee table in November 2016. Following this accident, he developed constant low back pain. The patient then presented to an emergency department where a lumbar X-ray was ordered, revealing a compression fracture of L3 not present on an old computed tomography (CT) scan. The emergency department physician instructed the patient to follow up with his primary care provider who ordered an MRI to further evaluate the L3 compression fracture. Dual Energy X-ray Absorptiometry (DEXA) was also accomplished and revealed decreased bone density with a T-score of -1.8 and a Z-score of -1 indicating an increased risk of fracture for his age. Prolonged standing at the sink or stove were described as provocative, while sitting combined with lateral bending relieved his low back pain. He described the pain as a constant ache and endorsed shooting pain into his right lateral thigh and right testicle two to three times per day. The back pain was constant at a severity of 6/10 on a Numeric Rating Scale (NRS). The score on the Quadruple Visual Analog Scale (QVAS) was 66.7/100 and the Back Bournemouth Questionnaire (BBQ) score was 32/70.
The patient’s medical and surgical history were significant for a cholecystectomy and a bilateral inguinal hernia repair. He had hypertension, was prediabetic, and was prescribed and took calcium and vitamin D for his bone density. He had no known allergies and had never received chiropractic care. He smoked 25 cigarettes per day and drank two to three rum and cola beverages per day.
Review of systems was notable for night sweats, occasional left anterior costal angle chest pain, and depression. Vitals were within normal limits as follows: blood pressure 124/85 mmHg, height 68 inches, weight 165.6 pounds, pulse 76 beats per minute, and respiration 20 breaths per minute. Patellar deep tendon reflex was +2 bilaterally. Postural assessment revealed a left head tilt, an elevated left shoulder, and elevated right ilium with decreased sagittal curves. Thoracolumbar active range of motion was within normal limits in all directions but provocative on extension and right rotation. Kemp’s test was positive bilaterally for low back pain while the Straight Leg Raise test, Patrick’s, Ely’s, Nachlas’, Hibb’s, and Yeoman’s were negative bilaterally. Strength was rated 5 out of 5 for the following myotomes: knee extension (L3), ankle dorsiflexion (L4-5), ankle plantar flexion (S1), and knee flexion (S2). Severe pain was elicited upon palpation of both sacroiliac (SI) joints, the left being more severe. A right psoas contracture was noted upon arm check8 (Figure 1). There was decreased fluid motion of the left SI joint. Following the history and physical exam, the patient was diagnosed with: low back pain, osteopenia, testicular pain, and iliopsoas contracture.
Management and Outcome
Spinal manipulative therapy was performed using the Impulse thrust adjusting instrument (Neuromechanical Innovations, Chandler, AZ) to minimize force with consideration for osteopenia, and a right iliopsoas release was performed utilizing the Sacro-Occipital Technique (SOT). Following treatment, the patient reported reduced low back and testicular pain, rated 2/10 on an NRS. The patient was then scheduled for a trial of care at a frequency of one visit per week for a total of four weeks.
The patient returned 41 days later for his first of four follow up appointments. He denied radiating leg pain and right testicular pain since initial treatment. He had undergone a kyphoplasty of L3 18 days earlier and rated his low back pain as a constant 5/10. Manipulation of bilateral SI joints was performed utilizing the Impulse thrust adjusting instrument, and the patient reported reduced low back pain rated at 3/10 on an NRS.
One week later, the patient returned for his second follow up. He rated the low back pain as a 5/10 on an NRS but stated that he was doing much better. His symptoms had improved following treatment but returned after lying in bed for an extended period. He also noticed radiation into his right thigh and testicle for the first time since beginning treatment, but this was transient and improved upon standing. Manipulation of bilateral SI joints was performed utilizing the Impulse thrust adjusting instrument, and the patient reported reduced low back pain rated at 3/10 on an NRS.
After another week, the patient returned for his third follow up and reported near complete resolution of low back pain which he rated at 3.5/10 on an NRS. He denied any testicular or radiating leg pain. The left SI joint was manipulated utilizing a drop piece mechanism with a manual thrust. After treatment, the patient reported complete resolution of pain.
The patient returned for re-evaluation one week later. He rated his pain at 2/10 on an NRS and stated that he felt he was getting better with every visit. There was no recurrence of radiating pain. His score on the QVAS was reduced to 23.3/100 (a 65% reduction). The score on the BBQ was reduced by 38% to a score of 20/70. There was no pain on palpation and no muscle spasms were noted on examination. The lumbar and SI joint fluid motion were found to be within normal limits upon palpation, and the patient was discharged from care.
The patient returned to the clinic approximately four months after discharge stating that his right testicular pain had recurred after 10 weeks, though his low back remained asymptomatic. Palpation revealed moderate hypertonicity of the middle lumbar paraspinals, predominantly right sided, without notable tenderness. There was decreased intersegmental flexion and extension at the L2-L3 motion unit. The right iliopsoas was again identified as contracted utilizing the SOT arm check. The lumbar spine was manipulated at L2 utilizing an anterior manipulation technique, and the right iliopsoas was treated utilizing an SOT iliopsoas release. Immediately following treatment, the patient reported resolution of right testicular pain.
This case report details the successful treatment of low back and referred testicle pain with iliopsoas ischemic muscle release and five treatments of spinal manipulation.
Chiropractors should be aware of common causes of testicular pain and how to identify them based on the patient’s history, presentation, and a detailed physical examination. This case report suggests that chiropractic care may improve the pain associated with idiopathic chronic testicular pain. Further research is warranted regarding the potential role of manual therapies in the treatment of patients experiencing idiopathic testicular pain.
The results from this case report may not be generalized to all patients because of the uncontrolled nature of this case report. There are many uncontrolled variables in case studies and the treatment of one patient does not ensure equivalent results are to be expected in other patients. Spontaneous remission of the patient’s pain may also play a role in individual cases, as temporal associations do not translate to statements of efficacy.
Written consent for this publication was obtained from the patient.
The authors declare that they have no competing interests.
Supported by the Department of Veteran Affairs. The contents do not represent the views of the Department of Veterans Affairs or the United States Government.
1. Ringdahl E, Teague L. Testicular torsion. Am Fam Physician 2006;74:1739-43.
2. Gordhan CG, Sadeghi-Nejad H. Scrotal pain: Evaluation and management. Korean Journal of Urology. 2015;56(1):3-11. doi:10.4111/kju.2015.56.1.3.
3. Masarani M, Cox R. The aetiology, pathophysiology and management of chronic orchialgia. BJU Int 2003;91:435-7.
4. Treatment of testicular pain using conservative management of the thoracolumbar spine: a case report. Doubleday, Kathryn L et al. Archives of Physical Medicine and Rehabilitation. Volume 8r, Issue 12, 1903-1905
5. Anloague PA, Huijbregts P. Anatomical Variations of the Lumbar Plexus: A Descriptive Anatomy Study with Proposed Clinical Implications. The Journal of Manual & Manipulative Therapy. 2009;17(4):e107-e114.
6. Hahne, AJ et al. Conservative Management of Lumbar Disc Herniation with Associated Radiculopathy: A Systematic Review. Spine (Phila Pa 1976). 2010 May 15;35(11):E488-504.
7. Robert M. Rowell and Steven J. Rylander. Low-Back Pain, Leg Pain, and Chronic Idiopathic Testicular Pain Treated with Chiropractic Care. The Journal of Alternative and Complementary Medicine. April 2012, 18(4): 420-422.
8. Monk R, 2006 SOT Manual, SOTO-USA: Winston-Salem, NC, 2006.