Page 34 - IDF Journal 2023

IDF – Study Weekend IDF News – Spring 2023
Underdiagnosed Myofascial Pain Syndromes with Low Back Pain and Sciatica
Dr Tzvetanka Ivanova-Stoilova
Background and real-world life: As clinicians, we come across patients suffering from severe pain in the lower back, abdomen, flank and leg which is unexplained by imaging investigations.
These patients might have had consultations with specialists
in orthopaedics, rheumatology, gastroenterology, urology, gynaecology, and been discharged with ‘no organic pathology’ or ‘non-specific pain’.
Further to that, these patients may not respond to conventional treatment and are therefore referred to pain clinics for ‘symptom management’.
By the time patients present to a pain clinic they might have developed morbidity, disability, as well as reactive psychological and worsened psychiatric conditions.
In my clinical practice 17% (32/187 patients) with low back and hip pain and 11.6% (94/811 patients) of lower trunk and anterior thigh have no clinical diagnosis, apart from ‘medically unexplained pain’.
The pain phenotypes in these patients are very interesting and are a unique combination of
1. musculoskeletal pain - deep, dull, intense, activity related
2. neuropathic pain - changed skin sensitivity, spontaneous, stabbing, burning, exploding
3. visceral pain – abdominal, rectal and deep vaginal
Therefore, the generators of the
patient’s pains could be the myofascial compartments of the trunk, lower back and buttock, which are in close vicinity to the lumbar and
sacral plexi.
There are two major myofascial pain syndromes to investigate: the iliopsoas and the piriformis syndromes.
Iliopsoas syndrome (snapping hip syndrome)
By the time patients present to a pain clinic they might have developed morbidity, disability, as well as reactive psychological and worsened psychiatric conditions.
Anatomy and physiology: The iliopsoas muscle is large and complex, consists
of psoas and iliac parts, situated para spinally, and attaches between L2 and the lesser trochanter of the hip. It flexes of the hip and is responsible for erect gait. It is in close vicinity to the lumbar plexus, the renal bed, aorta, abdominal structures, mid lumbar spine, hip, groin, and anterior thigh.
Diagnosis: This is clinical. The patient’s symptoms may have started after falling on the side, L3/L4 discectomy, kidney surgery, repair of abdominal aneurism, bowel surgery, overextension injury to
the hip, or be present in patients with autonomic diabetic neuropathy. It is of note that occasionally the symptoms may present years after trauma to the muscle.
The patient may report lumbago, severe limitations in spinal mobility, groin and anterior thigh pain down to the knee only, or abdominal pain. The patient may have difficulties climbing upstairs, getting up from sitting down position and may walk with a stooped gait, bent over the affected side.
Clinical examination: Tendon reflexes of lower limbs are present, there is a negative femoral stretch, tender femoral triangle, and tender flank on bimanual palpation.
Figure 1: Iliopsoas muscle is cut (red arrow) to reveal lumbar plexus, kidney is retracted (blue arrow)
Figure 2: Pain symptom projection in iliopsoas syndrome
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