Meralgia Paraesthetica

By Jonathan Blood Smyth_

Meralgia paraesthetica is a pain syndrome and one of many different ones potentially presenting to a physiotherapist or doctor for diagnosis and treatment. The typical symptoms are numbness, pins and needles and pain in the lateral and anterior parts of the thigh. In the 19th century this condition was described and the link made with problems to do with the lateral femoral cutaneous nerve, a purely sensory nerve. This nerve only deals with sensations and has no role with muscular action but transmits sensations from the thigh areas supplied by it. The incidence of this problem is not particularly clear but it could be under recognised.

There are many musculoskeletal conditions which could send pain to this general area and which can be confused with this neural problem, including trochanteric bursitis, spinal referred pain and spinal nerve compression. The commonest reason for this condition is abnormal pressure on the nerve in specific parts of its track where it is vulnerable. This has been linked to wearing an over tight belt and to being generally overweight. The syndrome may also be brought on by surgery near the area such as bone graft, hip replacement and quadriceps.

The compression points somewhere along the nerve’s course can occur at various anatomical locations, including the point of emergence from the psoas muscle, the close relationship with the inguinal ligament, where it is running close to the bony prominences at the front of the pelvis and finally where it comes out of the fascia lata, a wide connective tissue sheet at the side of the thigh. The classification of nerve injury starts with the mildest result from compression which is a neurapraxia where the myelin insulation can be lost.

The nerve axon itself is not affected in this injury and this is the nerve injury which recovers well and most quickly, taking a very short time up or to several months to resolve. A more severe injury, where the axon is disrupted, is known as axonotmesis and results in the whole nerve axon degenerating along its length. It then has to regrow at its very slow speed, meaning this kind of injury can take a long period to resolve even though it may do so in the long term. If a nerve is so badly injured that its ends are not in contact any longer then the chances of recovery without surgical intervention are very low.

The history of the patient during the examination will include any mention of previous injuries or accidents which could be relevant. Examining the patient directly will turn up changes in the sensibility in the anterior and lateral parts of the thigh with typical reports of pins and needles, lowered sensibility, numbness and burning pain. The problem usually comes on from a low level of discomfort and changes slowly with pain normally not found beyond the knee. The nature of the pain is often the typical sharp and burning type but can also be less clear aching. Symptoms vary in location in the thigh to some extent.

Initial treatment is aimed at finding out what the likely compressive problems is and to correct that, for instance wearing tight clothing, a tight belt or something heavy around the waist. Overweight patients can be encouraged to lose weight as this may be enough on its own to improve or abolish the symptoms. If the patient adopts any particularly risky postures in the course of their work or activities this should also be addressed. Local injections with anaesthetic drugs or with corticosteroids may be useful to interrupt the pain or reduce any possible local inflammation.

The lateral cutaneous nerve of the thigh can vary considerably in its anatomical course so any injections and surgery have to take account of these potential variations. Once the compression has been released the nerve tends to recover spontaneously. Injections can be considered if activity modification does not help, and surgery if all else fails with techniques including neurolysis which is nerve destruction by chemical injection or by other means. The nerve can also be cut or can be decompressed at the various potential compressive sites in the pelvis and thigh. Reports on groups of patients undergoing surgery have generally shown positive results.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about physiotherapy, physiotherapy, physiotherapists in Leeds, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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