An elderly gentleman presented with a 3 week history of intermittent right leg and buttock pain which was aggravated when bending to the right, after golf or after sitting or lying down. He could not recollect any incident, which was the cause of his pain. He did not have any medical history or other symptoms suggesting he needed referral to the Doctor.
He did have a history of previous back surgery to partially remove a disc at L5/S1 for right sciatica (nerve pain radiating down the back of his leg due to compression of the sciatic nerve from a prolapsed disc).
Likely Causes of his Leg Pain
Lumbar Spine Facet Joint Syndrome
Either side of the spine where the vertebrae form a joint between the vertebra above and below is called a facet joint. These joints control all the movements of the spine and in certain directions they become compressed and in others are opened up. If there is stiffness in one of these joints then it cannot move as required and therefore stays in a compressed or opened out position which causes pain and or restricted movement of the spine or hips. There are several tests a physiotherapist will perform to determine which facet joint is the problem and whether it is a compression dysfunction or opening up dysfunction.
These joints are highly innervated with nerve endings and can refer pain into the buttocks, leg and groin and can mimic the pattern of sciatica.
Sacroiliac Joint Dysfunction
The pelvis is made up of two hemi pelvis parts, which are joined at the front by the pubic symphysis and at the back to the sacrum forming the sacroiliac joint. It is debateable how much this joint moves but the small amount it does move causes a dysfunction if it moves too much or too little. This joint can be injured from direct trauma, tripping on a step, during or after pregnancy and poor static or dynamic postures. It can be painful locally or it can refer pain into the groin, buttocks and leg.
If there is significant arthritis in the hip joint, which means the surface of the joint has a degree of wear and tear, it can become stiff and painful in the hip but it can also refer into the groin, lower back and the front of the thigh. It may not be painful in the hip itself.
The knee can refer pain into the leg, above and below the knee, if there is any dysfunction or arthritis of the knee.
Lumbar Spine Dysfunction
The lumbar spine can refer into the hip, groin, back or leg if there is stiffness or pain at any of the intervertebral or facet joints, if there is a movement dysfunction through poor technique in sport or posture at work, if the muscles either side of the spine are tight or weak they too can produce pain locally or into the hip, groin or leg.
Thoracic Spine Dysfunction
The thoracic spine can refer into the lumbar spine, hip, groin, buttocks or leg possibly due to tight paravertebral muscles of the spine pinching on the spinal nerve, or if there is stiffness of the intervertebral joints.
Muscle Referral – Multifidus, Erector Spinae, Glutei, Tensor Fascia Lata
All these muscles if they become tight can squeeze on the trigger points within the muscle or the fine nerve endings and refer pain into the back, leg, groin, buttock or hip.
If any of the structures mentioned above are put under repetitive or sustained stress whether in a compressed or opened position, they will produce the pains as described above.
This gentleman, had a negative slump test (no true sciatica), no weakness or pins and needles. He had pain with right side flexion and palpation of his T7,8, 9 vertebrae reproduced his pain and they were very stiff. He had an increased thoracic kyphosis (thoracic spine was more flexed/rounded) which could be due to postural habits or congenital, but would fit with the stiffness of his T7, 8,9 into extension.
Leg pain can come from a number of structures as described above and its important as a Therapists we make sure to always check these structures including the thoracic spine. As patients, if you think your symptoms in other areas are not significant to mention, please always do mention however slight to give the Therapist more information to make a true diagnosis.