跑者膝髋痛可能源自上腰椎：鉴别与诊断线索

The post Hip, Knee, or L3: Leg Pain from the Upper Lumbar Spine in Runners appeared first on iRunFar.

Among all types of runners, few complaints are more stubborn — or more often mislabeled — than chronic, run-specific knee, anterior thigh, and hip pain.

We foam roll the quadriceps, tape the knee, stretch the hip flexors, and blame the last long descent or most recent ultramarathon. Yet when the pain is severe, poorly explained by training load, and unresponsive to standard orthopedic care, the source may not be the leg at all.

Instead, it may be referred pathology from the mid-lumbar nerves in the back — those coming from the L1, L2, and L3 vertebrae. This cause is easy to miss because the lower back itself often isn’t painful. Severe, sudden, and random (non-traumatic, no-mechanism) knee and hip pain, or leg instability, could actually be the upper lumbar spine acting up.

Lower Lumbar Dysfunction

Many of us runners and medical professionals are easily fooled by upper lumbar spine dysfunctions, as most conventional lower lumbar pain is pretty straightforward, with pain and often stiffness that begins locally in the lumbar spine. If advanced, lumbar radicular symptoms refer pain down the leg.

Usually, this pain referral is felt in the back of the thigh and is often referred to as sciatica. If severe, it can refer to the lower leg and foot. In addition to pain, it can also cause more classic nerve symptoms — tingling and numbness — as well as neurological weakness in parts of the leg.

This sort of low back pain with referred leg pain nearly always involves the lower lumbar spine, the bottom three bones that comprise the lumbosacral spine: L4, L5, and the sacrum (S1 segment).

Of low back pain etiologies, 80% or more of lumbar pain cases originate in the lower lumbar region.

I theorize the lower lumbar spine is more susceptible to strain because it is closer to the hip. With running, especially if the hip and, secondarily, the pelvis are moving inefficiently or insufficiently, the lower lumbar spine may move excessively and inefficiently, resulting in strain.

Upper Lumbar Dysfunction

But what happens when the upper lumbar segments — L1, L2, and L3 — are irritated?

Let’s first look at the sensation and muscles innervated by the lower versus upper lumbar spine. Lower lumbar dysfunction can lead to pain and paresthesia in the back of the thigh, the front and back of the lower leg, and the front and back of the foot and ankle. It can also cause weakness in the hip, hamstring, lower leg, and foot.

Meanwhile, issues with the upper lumbar region can result in pain and paresthesia in the front and inner thigh; front, back, and outer hip; and front, outer, and back of the knee. It can also lead to weakness in the anterior and lateral hip, knee, and a general sense of instability through the hip, such as being unable to bear weight.

When the upper- and mid-lumbar spine is stiff, misaligned, or simply not moving right, it can express itself as significant hip and knee pain and weakness, including both stabbing and burning pain throughout the front and outside of the hip.

Upper lumbar spine dysfunction may often create severe leg pain referral with little or no focal upper lumbar pain.

Difficulty in Diagnosing Referred Leg Pain from the Lumbar Spine

Many runners present with severe and focused hip, anterior thigh, and knee pain — often without any low back co-symptom — making it nearly impossible for even the savvy sports medicine specialist to consider that it could be referred spine pain.

Since knee and hip joint pathology are so ubiquitous in experienced runners, it’s easy to jump to conclusions about the cause of the pain and, even worse, get quick — and often false-positive — confirmation of joint pathology from a simple X-ray, or even an MRI, of the knee and hip.

I have treated multiple athletes who have undergone serious hip and knee surgery to repair areas diagnosed by imaging, yet fail to recover. The reason is that the pain was referred from the spine.

Diagnosing Lumbar Spine Dysfunction

There are several clues that knee and hip pain is actually referred upper lumbar dysfunction:

Fast-Onset Leg Pain Occurs Without Explanation

Neurogenic pain, which originates from injury, irritation, or dysfunction of a nerve or part of the nervous system, can come on quickly. Conversely, degenerative, arthritic pain is nearly always slow and insidious. Thus, when someone is otherwise fine, then suddenly feels acute-onset knee or hip pain without a mechanism — in other words, they didn’t do a “couch-to-Mount Everest” hike, or lift a small car off a child — that is a strong clue that the pain generator is spinal-neurogenic, not orthopedic.

Severe and Random Leg Pain is Poorly Correlated With Activity

Neurogenic pain is often severe at rest, and certain spinal- and nerve-tensioning positions can be painful, especially while sitting or lying down. Conversely, doing a lot of even strenuous activity can feel fine. That is antithetical to orthopedic pain. True hip and knee joint pain is mostly non-existent at rest.

Spinal Position and Movement Affect Leg Pain

If hip and knee pain can be triggered, or relieved, by movements and positions of the spine, it’s likely a sign of spinal and neurogenic pain. Conversely, with joint position and loading held constant, true hip and knee joint pain will never modulate. For example, pain from an inflamed knee while sitting will not change with spinal flexion or extension.

Leg Treatment Strategies Don’t Affect Leg Pain

Spinal and neurogenic pain is unlikely to respond to standard orthopedic treatment plans, including mobility, strength, alignment, rest, ice, heat, or local anti-inflammatories. It’s worth noting that systemic anti-inflammatories, particularly compounds like prednisone, may be extremely helpful, as irritated spinal joints and nerves respond favorably to corticosteroids.

Leg Imaging is Boring or Mediocre

If X-ray and MRI data show mild to moderate degenerative changes in the joint, these findings correlate to gradual, chronic stresses. Especially if leg pain is acute and severe, such gradual degenerative imaging findings correlate very poorly with these symptoms.

Lumbar Imaging Reveals Relevant Upper Lumbar Pathology

This is the biggie. If you have leg pain that meets the above criteria, it’s time to consider lumbar spine imaging.

Common Runner Leg Pains That Could be Caused by Upper Lumbar Referral

The following pain conditions could be caused, or amplified by, neurogenic pain from the upper lumbar spine:

• Anterior, lateral, or medial knee pain. Posterior knee pain is the territory of the sciatic nerve, innervated by lower-lumbar segments
• Anterior (hip crease) and lateral (trochanteric bursitis) hip pain
• Quad or lateral thigh pain, including the IT band
• Medial thigh pain, or a groin strain

Consider the Upper Lumbar Spine For Stubborn Hip and Knee Pain

For most of us, lower lumbar pathology and its symptoms are more common and familiar, and upper lumbar pathology hits different. It’s important to recognize what the upper- and mid-lumbar segments do and how referred pain from these segments feels different.

Next month, we’ll dive into:

• Testing for potential upper lumbar nerve pain
• A look at a case study of a runner with chronic hip, thigh, and knee pain, solved with upper lumbar treatment

Until then, if you or a runner you care for begins to have severe, unexplained, and unresponsive hip and knee pain, consult with a physio, chiropractor, or other skilled orthopedist to consider the upper low back!

Call for Comments

• Have you dealt with leg pain that could potentially be an upper lumbar issue?
• Have you received treatment for upper lumbar dysfunction?

Hip, Knee, or L3: Leg Pain from the Upper Lumbar Spine in Runners by Joe Uhan.