Sciatica that is along the top and/or inside of the thigh is relatively rare, and normally originates from the upper lumbar spine. Care has to be taken to rule out hip arthritis, which can cause pain along the same area. Basic management includes obtaining a baseline of strength and sensation for areas affected by the involved nerve roots. Generally, sciatica of a longer duration, with symptoms that are further from the back, or with more severe signs – weakness, reflex loss, or numbness – is tougher to treat and has a lower chance of resolving with therapy.
Problem
He “tweaked his back” leaning, twisting and picking up his daughter, causing pain in the groin and thigh. It resolved in a couple of weeks. However, while working in his garage several weeks later, pain gradually came on over a 20-minute period and was so severe that he had to go to the emergency room for pain control. He saw his primary care physician that Monday and was immediately referred for therapy.
Examination
He was having trouble walking without a limp, and demonstrated muscular weakness consistent with compression of his L3 nerve root. Isolated movement of the hip (without moving his back) did not cause him any pain or discomfort, but several directions and types of back motion caused increased pain that left him worse overall. He eventually found that lying on his stomach, with his chest supported on pillows, gave him some relief, and left him better as a result.
Treatment and Outcome
Over the next 10 days, he was seen 5 times for progressive manual therapy, traction (decompression), and core stabilization exercises. His symptoms did not improve, and neither did his weakness. After two weeks of intensive examination and treatment, it was clear he his condition was not going to improve with therapy, and he was referred to a neurosurgeon for evaluation, with follow-on referral to pain management as appropriate.
Many times patients in this situation experience complete, or near complete resolution of signs and symptoms with only one, or sometimes two, epidural steroid injections.
