This guest cease presentation is from Dr. Marc Heller, who has been practicing for 44 years in Ashland, OR.

A 57 year old female presented to our practice with severe low back pain with pain radiation into the right buttock and right anterior groin. Her pain had apparently begun 4 weeks earlier after changing her workout routine. She sought care in our office from other providers at weekly intervals for much of the previous 4 weeks. Treatments consisted of manual therapy and low force manipulation of the spine. During that time, her low back pain and right buttock pain had improved but the radiating pain into the right flank and groin persisted. Her providers hypothesized that an L3 nerve was involved and she was referred to me. In review of treatment records of my colleagues, these details were interesting to me.

“10/7/24
Sciatic pain and lower back pain came on so severely over the weekend she could not
walk or even get up off of the floor after trying to get out of bed in the morning. Nothing
seemed to help and the pain is very intense in the buttock and into the groin and lateral
leg
 
10-12-24
She complains of continuing right anterior groin pain and right buttock/lumbar pain. She
describes the pain as sharp and stabbing.”
 
Patient was first seen by me in early November, 2024. 
Exam included tension testing for the sciatic (SLR) and femoral (femoral nerve tension test) and motor exam for those peripheral nerves which were all WNL. Orthopedic exam of the right hip was negative and no movement restrictions there were noted. My thinking was that the common causes of anterior hip pain including arthralgia and radicular processes had been ruled out.
 
Asking myself what else could contribute to this, I considered that the pain might be arising from the small peripheral nerves coursing around the lateral abdomen into the groin. The primary suspects there would be the iliohypogastric and ilioinguinal nerves.
 
Let me back up, and continue with my exam process.
 
Sometimes I get my left brain to shut up, and follow my hands. I’ve been a chiropractor for 44 years, and a massage therapist for 5 years before that.
 
I have extensively studied the French osteopathic system, Visceral Manipulation, for several
years, and am very enamored of the subtle palpation skills that Jean Pierre Barral, DO uses when applied to the abdomen and viscera.
 
I palpated the right abdomen woman and I seemed to be able to feel through the abdominal tissues to the back of the abdomen.

(Notes on Barral’s palpation recommendations: Barral suggests abdominal palpation using a broad, flat contact with the flat hand while sensing through the fingers rather than a more pointed palpation using the fingertips. Using this gentle introduction of the manual contact, Barral describes a process of “local listening”, in which the practitioner allows the hand to be attracted intuitively to areas of interest.)
 
Using a manual process of Engage, Listen, Follow (described here) with the patient in supine position I was drawn to an area lateral to the right psoas that seemed to feel restricted in movement and tissue consistency. Thinking from a NeuroCentric Approach (NCA) perspective, I remembered the anatomy of the nerves in that area that arise from the spine at T12-L2. Among those nerves are the 2 nerves mentioned earlier that correspond to the area of presenting symptoms in this patient. Using myofascial release techniques I’ve learned and applied for 40 years in practice, I spent time in this area of altered tissue consistency until it softened. The patient reported feeling less pain afterward and was encouraged to return for follow up in a few days.
 
Two days later, she told me she had felt much better after I performed the abdominal release.
So, on this next visit I opted to continue using NCA and considered the “downstream” neurology in the area of the right lateral abdomen and into the anterior hip and groin. I palpated a couple of tender spots, just below the right ASIS and marked these tender spots with tape, so I could accurately go back after treatment. These were areas corresponding to the patient’s complaints of radiating pain. My thinking was that these tender points could be areas of restricted movement of cutaneous nerves, possibly the anterior and lateral femoral cutaneous nerves in that area.
 
Continuing my palpatory exam into the anterior abdomen, I found an area of altered tissue consistency near midline and another just medial to the ASIS. Again, utilizing the ELF manual approach I am familiar with I spent time in these areas until they softened. As I worked I considered the possibility that these areas might correspond to interface points of the genitofemoral, ilioinguinal and iliohypogastric nerves. At the end of the day, these thoughts of the creation of the narrative to explain the observed findings can be helpful to both doctor and patient. However, it’s helpful to keep an eye on a clinical audit process and functional improvements within the treatment. In this case, I returned to the areas of palpatory tenderness I had marked with tape. The patient and I were pleased to find them non-painful.
 
She texted me later, and said she felt the best she had felt in a long time. 2 days later, she was back to doing a 2.5 hour intense workout,
   
Hindsight:
 
This patient had seen the other docs in my office, multiple times in previous weeks but was still experiencing pain
in buttock and groin, and difficulty sleeping. Their approach was, as Phillip Snell would say, “meat based”, focusing on soft tissue and joint issues.
 
I am using Phillip Snell’s NeuroCentric Approach primarily here, incorporating palpation skills
I learned from Visceral Manipulation. I think she had a small nerve issue, that
responded to my light touch releases. I hypothesize that my main effect was the initial releasing
of the iliohypogastric and ilioinguinal nerves, in their anterior exit from the upper lumbar spine. I did not
work directly on her posterior spine or on her right buttock, but the abdominal manual
release work seemed to dramatically relieve her low back and buttock pain. The relief has
persisted, 2 weeks later.
 
Marc Heller, DC

AUTHOR BIO:

Marc Heller, DC has maintained a clinical chiropractic practice for over 40 years in Ashland, OR. His column, Low Force Methodology, has been a regular contribution to Dynamic Chiropractic Online for many years. For another similar case write up from Dr. Heller, check out this link.

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