How can manual therapists distinguish rectus femoris tightness from femoral nerve pain? In this week’s video, the sidelying quad stretch may cause the client to flinch when the hip is extended and knee flexed to barrier. Sometimes it’s hard to tell if the discomfort is from quad tightness or radicular pain from femoral nerve entrapment.
Since the femoral nerve exits the spine from L2- L4, compression can occur in the lumbar spine or as it winds its way through the iliopsoas and under the inguinal ligament. It controls the muscles that help extend the leg and move the hips and it also provides feeling in the lower leg and front of the thigh. When injured, the femoral nerve may cause pain in the genital region, difficulty extending the knee, and altered gait resulting in compensatory strain elsewhere. During this assessment and treatment, if the client reports a sharp “nervy” pain and not just a quad stretch, try flossing the femoral nerve and retest.
In addition to manual therapy techniques, stretching and strengthening exercises, aerobic conditioning, and cognitive-behavioral education have been shown to be valuable in the treatment of those with nerve entrapments in the hip region. Graded exposure stretching, whether performed independently by the client or by the manual therapist appears to be helpful in relieving femoral nerve compression due to lumbar spine pathology (L2-L4) or musculotendinous entrapment. However, aggressive stretching can be irritating to the nerve and must be controlled in a slow and progressive manner.
Targeted strengthening exercises help facilitate proper load transfer between the lumbosacral spine, pelvis, hip, and lower extremity, and for those with chronic pelvic pain, non-symptom provoking pelvic floor exercises may be helpful. Aerobic conditioning is also useful due to the positive effect it has on overall pain management and to get mood-boosting hormones such as DOSE (dopamine, oxytocin, serotonin and endorphins) flowing, always assure the client they are being heard and respected. It’s important to stay present and engaged from the time they walk in the door. Cognitive behavioral therapy assists the client in gaining a sense of control over their pain by providing an understanding of pain mechanisms and coping strategies. The therapeutic goal of bodywork and corrective exercise is to tilt the balance away from stress and toward relaxation. Below are a couple of techniques I’ve found helpful in reducing pain and improving function is those clients presenting with femoral nerve symptoms.
Femoral Nerve Mobilization (L2- L4) (left sidelying)
- Client uses both hands to grasp her bottom knee towards her chest.
- Therapist’s left hand grasps client’s right ankle and his right hand grasps her knee
- Therapist steps behind client’s knee as it is brought into flexion
- With right hand on her knee and his left securing her ankle, the therapist can create knee flexion or hip extension
- Therapist gently extends client’s hip to painful femoral nerve barrier and backs off to the inter-barrier zone
- The client tucks her chin to traction the femoral nerve
- To floss the nerve distally, the therapist gently adds knee flexion as the client brings her head back to neutral