I recently began treating a patient who presented to clinic with a referring diagnosis of bilateral patellofemoral pain syndrome (PFPS) with intermittent low back pain. She had many common movement impairments associated with PFPS- pain with ascending and descending stairs, adduction and internal rotation of the lower extremities with squatting activities, weak posterior glut med and hip extensors. Her low back pain was consistent with Sahrmann's lumbar extension syndrome with several positive functional instability tests.
Second Visit Assessment
During her second visit, the patient also had new complaints of pain around the medial tibial plateau. Specifically she had tenderness to palpation along the infrapatellar branch of the saphenous nerve. Palpating proximally the patient had tenderness to palpation along the femoral nerve as well. Further objective testing revealed a positive sidelying femoral nerve tension test and tenderness to palpation with L3 and L4 PA assessment.
Second Visit Treatment
Following the brief daily assessment, I performed a lumbar gapping manipulation at L3-L4, long axis hip distraction, and a tibiofemoral distraction manipulation. To maximize gains, I performed neural mobilization along the femoral nerve tract as well. Pain was completely relieved and neural tension testing was negative following treatment. More impressively, the patient was able to perform a single leg step down pain free and with improved lower extremity mechanics (an activity that previously provoked pain).
Just as the sciatic nerve can develop tension, adverse neural tension can develop in the femoral nerve. Since the patient has low back pain and poor lower extremity movement patterns, there are several regions where the femoral nerve and it's distal branches can become compressed or tensioned. The femoral nerve exits from the L2-L4 nerve roots and travels along the anterior and medial thigh across the medial knee where it gives off the infrapatellar branch of the saphenous nerve and medial crural cutaneous branches. I chose to manipulate L3-L4 because I wanted to mobilize the segments that correlate with the femoral nerve. Additionally this was the region she had pain as well. As we know, there are several benefits of manipulation, one of which is the neurological reset or jump-starting the nervous system.
In addition to a lumbar gapping manipulation, I chose to manipulate the hip and knee to restore normal joints mechanics and allow for improved muscle activation surrounding the hip. In hindsight, I do not believe the neural mobilization was necessary because the patient's symptoms were already relieved by manipulation and the psychometric properties of this technique are unknown.
I want to conclude by reminding the audience that the patient's movement pattern changed following manual therapy. I had expected to see a decrease in pain and negative neural tension testing, but I was amazed to see an improved single leg step down. By relieving pressure along the nervous system, there was an immediate improvement in function.
Do not underestimate the power of manual therapy in the presence of neural tension!
The Student Physical Therapist
On this page we're going to bring you some interesting cases that we come across. Not only do we hope to show you some of the clinical reasoning behind our decisions, but we'd like to hear from you!