INTRODUCTION
Femoral nerve entrapment is a complex condition that has been the subject of much recent study. It is characterized by pain, dysesthesia, muscular weakness, and specific provoking movements.1 The femoral nerve, a mixed motor and sensory nerve formed from the L2–L4 nerve roots, is the largest branch of the lumbar plexus.2 It can be injured in various ways and has several areas of potential entrapment.2
The clinical presentation of femoral nerve entrapment can include numbness and paresthesia in the iliac fossa, inguinal region, anterior thigh, medial calf, foot, and great toe.2 Patients may experience ipsilateral knee weakness or buckling with walking, which may result in frequent falls.2 Severe femoral neuropathy can produce weakness and wasting of the quadriceps muscle.2
Entrapment neuropathies of the lower limb, including femoral nerve entrapment, are often misunderstood and underdiagnosed.1They are commonly mistaken for lumbar plexopathies, radiculopathies, and musculotendinous diseases, which appear even more frequently and have overlapping clinical presentations.1 A comprehensive anamnesis, physical examination, and electrodiagnostic studies should help clarify the diagnosis.1
If the diagnosis remains unclear or a secondary cause of entrapment is suspected, magnetic resonance neurography (MRI) or ultrasonography should be conducted to clarify the etiology, rule out other diseases, and confirm the diagnosis.1 Early diagnosis of nerve damage is crucial to prevent muscle atrophy.1
The objec tive of this case study is to describe the diagnosis and management of a patient with femoral nerve entrapment.
CASE REPORT
A 24-year-old sought care for pain in her lower extremity. On the initial visit, an exam and history were performed and revealed the patient was experiencing left inguinal pain (lateral 1/3rd of the inguinal ligament) that occurred 2 months prior. The patient believed it was due to performing an abdominal exercise of knee raises. It had become progressively worse and was provoked by abdominal exercises. She felt that hip adjustments and manual therapy did help her temporarily. The pain description was “feels arthritis-like, two bones rubbing together.” The pain was rated as a 0/10 at rest and a 6/10 with activity.
Management & Outcome
Examination findings included pain upon left hip flexion and extension. Palpation of the left inguinal ligament reproduced her myofascial pain and tenderness that was deep to the ligament. Muscle Reflexes and Sensations (MRS) were within normal limits. The following orthopedic exams were positive for reproducing her anterior left hip pain: Ely’s Sign, Gaenslen’s, Nachlas Test, Patrick’s, and Yeoman’s. The diagnosis of left hip flexor contracture with chronic shortening of the iliopsoas was made. The conservative chiropractic care initially included adjustments to the lumbar and pelvic regions however after the injury progressed to rehabilitation exercise as described below. Therapeutic exercises to relax and lengthen the hip flexors were recommended, along with strengthening of the left gluteus medius. Passive modalities included laser therapy and TENs unit application.
The patient began a course of care that included manual therapy of the left hip flexors, and chiropractic adjustment. The patient responded well to care for 2-3 visits; however, the relief was temporary. The initial improvement included a decrease in pain and increased range of motion (ROM). On her 4th visit, she exacerbated her hip pain by performing rope climbs. This spawned a re-evaluation which revealed inguinal ligament involvement on the left. This was addressed using light drops on the area where she felt sore but better post-treatment. The next morning, she felt significantly better until she went up some stairs and the pain in the left hip became severe. She rated the pain as an 8/10 at rest and a 10/10 with activity. The pain was severe. She used crutches/wheelchairs to get around but was bedridden most of the day due to the pain. An x-ray was taken to rule out underlying pathology (negative). The laser was used palliatively. The patient returned the next day still using crutches to ambulate. A TENs unit helped to decrease some of her pain but she began having numbness of the superior portion of the right gluteal muscle. An MRI of the pelvis without contrast was taken and appeared within normal limits.
Outcomes
Examination and Diagnosis: The examination revealed a positive Femoral Nerve Tension.2 Test, Ely’s sign, Internal Femoral Hip Rotation (FADIR) (Kuhlman & Domb, 2009) prone lumbar stability test, and Janda Hip Abduction, indicating reduced hip ROM and decreased reflexive lumbar stability. The diagnosis was femoral nerve entrapment.
Patient Care Plan or Treatment: The care plan included chiropractic adjustments using the drop, manual therapy for the left hip flexors, and passive modalities such as laser therapy and TENs unit application. Exercises to lengthen the hip flexor and strengthen the glutes included femoral nerve flossing, crocodile breathing, tall kneeling diaphragmatic breathing, bilateral half-kneeling kettlebell heartbeat halos, and lateral band-assisted reactive neuromuscular training knee extensions.
Outcomes: Post-treatment, the foot’s internal rotation decreased to 20 degrees after the first treatment and to 0 degrees after the second treatment. The patient was able to walk 30 yards unassisted with no pain. The overall response to treatment included a 25% reduction in pain, measured using a numerical pain scale, and improved activities of daily living.
DISCUSSION
The chiropractic drop technique, is a common method used in chiropractic care. This technique utilizes a specialized segmented treatment table with a drop mechanism to help diagnose and adjust spinal alignment problems. The table is adjusted according to the patient’s weight. The chiropractor applies a high-speed thrust using minimal force and the pneumatically driven table then “drops” slightly to lower the section corresponding to the spinal region being adjusted.3 This facilitates the adjustment and carries the joint through its normal range of motion, allowing full correction of the segment while applying less force than would be needed without the special drop table.
Another beneficial technique for patient care is nerve flossing. Nerve flossing, also known as neural mobilization, is a therapeutic technique used in physical therapy to improve nerve movement and reduce pain. A systematic review published in Pain Medicine found that neural mobilization techniques are effective in managing musculoskeletal neck disorders with nerve-related symptoms and these techniques can improve overall pain intensity when incorporated into physiotherapy treatment.4 Another case report published in the Bulletin of the Faculty of Physical Therapy highlighted the use of neurodynamic techniques, a form of nerve flossing, in treating entrapment neuropathy of the infrapatellar branch of the saphenous nerve post-knee arthroplasty.5 The study suggested that soft tissue mobilizations followed by neurodynamic techniques can improve neural mobility and functional outcomes. Thus, nerve flossing is a valuable tool in the management of various nerve-related conditions. However, it’s important to consult with a healthcare professional for personalized advice.
Soft tissue mobilizations refer to manual techniques used to improve tissue extensibility and range of motion, often through massage or similar methods.
Belly Breathing
Belly breathing, or diaphragmatic breathing, is a simple yet powerful way to take deeper, fuller breaths. Instead of breathing shallowly into your chest, this technique uses the diaphragm to draw air deeper into your lungs. When you inhale, your belly rises as your diaphragm moves downward, making room for your lungs to expand. As you exhale, your abdominal muscles contract and your belly flattens, pushing the air out. This method helps you breathe more efficiently, engaging the diaphragm rather than relying on the chest and rib muscles, which is common with shallow breathing.6
Femoral Nerve Flossing Technique
To perform femoral nerve flossing, the patient is instructed to lay prone and take 10 belly breaths, focusing on breathing low into the abdomen to raise the back off the table.7 This helps rehab the faulty breathing pattern and decreases pain through relaxation. The patient is then passively guided through 15 clinician-guided femoral nerve flosses. This is followed by higher-level functional exercises such as bilateral half-kneeling positions to re-establish core motor control. Cues are given to enhance stability and balance while maintaining proper breathing and relaxation.
Higher-Level Functional Exercises
The exercises used included bilateral half-kneeling kettlebell heartbeats and halos to re-establish core motor control, followed by lateral band-assisted reactive neuromuscular training knee extensions to establish neuro-reflexive correction of the internal hip rotation. This systematic approach aimed to improve lower limb strength and neuromuscular control.
Half-Kneeling Kettlebell Heartbeats: This exercise, performed from a half-kneeling position, challenges the core by requiring stability as the kettlebell is moved away from the chest and back. This movement not only activates the shoulders and chest but also enhances postural control by engaging the glutes and abdominal muscles. It is often used to improve Core control during movement.
Half-Kneeling Kettlebell Halos: These are particularly effective for improving shoulder mobility and increasing core engagement. The half-kneeling stance adds a stability challenge, as you have to resist rotational forces while moving the kettlebell around your head. This variation strengthens the core and helps improve coordination and balance.8
Reactive Neuromuscular Training (RNT) for knee extensions is a method used to improve motor control and stability by addressing faulty motor patterns through external resistance. In this technique, resistance is applied in a way that exaggerates improper movement, forcing the body to recruit the correct muscles to maintain proper alignment and control.
For knee extensions, RNT can be used with a resistance band placed around the ankle pulling in a specific direction. This causes the body to correct the knee’s position during movement by activating stabilizing muscles, such as the glutes and core, thereby improving knee control, proprioception, and neuromuscular coordination. This approach is beneficial for athletes recovering from injury or those aiming to correct movement dysfunctions during exercises and daily life.9
Step-by-Step Treatment Plan
Belly breathing exercises: 10 belly breaths
Femoral nerve flossing: 15 repetitions10
Higher-level functional exercises:
Bilateral half-kneeling kettlebell heartbeats and halos: 2 sets of 10 reps each
Lateral band-assisted reactive neuromuscular training knee extensions: 2 sets of 15 reps each
The pain measurement scale used for the 25% reduction in pain was a numerical rating scale (NRS), and this was observed after the first treatment.*
Overall Response to Treatment
The patient experienced a significant reduction in pain, improved range of motion, and increased ability to perform daily activities. The systematic approach of combining breathing exercises, nerve flossing, and higher-level functional exercises was effective in managing femoral nerve entrapment.
Neurodevelopmental demand: This term refers to the body’s requirement for coordinated, integrated functioning of the nervous and musculoskeletal systems. The exercises were designed to increase this demand by challenging the patient’s balance, stability, and motor control.
Kettlebell Heartbeats and Halos: Kettlebell heartbeats involve holding a kettlebell close to the chest and extending the arms outward and back in a controlled manner, while halos involve rotating the kettlebell around the head to improve shoulder mobility and core stability.
Reflexive Correction: This technique involves performing exercises that stimulate automatic, reflexive stabilization of the body. The goal is to improve neuromuscular control and reduce dysfunctional movement patterns.
Mechanism of Injury and Role of Breathing and Core Firing
The exact mechanism of injury is unclear, but it is hypothesized that paradoxical breathing and insufficient core firing contributed to the femoral nerve entrapment. Paradoxical breathing, where the abdomen moves inward during inhalation instead of outward, can lead to increased tension in the hip flexors and subsequent nerve irritation. Improving breathing patterns and core stability can help reduce this tension and alleviate symptoms.
Comparison with Literature
The results of this case study align with findings from other studies that emphasize the importance of a comprehensive, individualized approach to managing nerve entrapment conditions. The combination of manual therapy, nerve flossing, and functional exercises is supported by literature as effective in improving pain and functional outcomes in patients with similar conditions.
Several studies emphasize that nerve flossing is effective in managing nerve entrapment syndromes. For example, a study published in Pain Medicine found that neural mobilization, including nerve flossing, improved pain intensity and functionality in patients with nerve-related conditions, such as carpal tunnel syndrome and sciatica.4 This aligns with the case study’s success in reducing femoral nerve irritation through the use of nerve flossing techniques.
Similarly, manual therapy has been shown to have significant benefits in managing nerve entrapment. A case study from the Bulletin of the Faculty of Physical Therapy discussed how manual therapy, combined with nerve flossing, improved symptoms of infrapatellar nerve entrapment following knee surgery.5 This supports the approach used in the case study, where manual therapy played a pivotal role in reducing pain and improving mobility.
The functional exercises, such as those described in the case study (e.g., kettlebell heartbeats and nerve flossing), are also backed by research. Studies on rehabilitation for lower limb neuropathies, such as femoral nerve entrapment, highlight the importance of exercises that engage the core and promote dynamic stability to support long-term recovery.2 Such exercises improve neuromuscular control, reduce the risk of recurrence, and enhance functional outcomes, which corresponds with the positive results observed in the case.
The combination of manual therapy, nerve flossing, and functional exercises reflects evidence-based practices supported by current literature, providing a well-rounded approach to managing nerve entrapment conditions effectively.
CONCLUSION
This report study demonstrates the successful management of femoral nerve entrapment using a combination of chiropractic adjustments, nerve flossing, and targeted exercises. The detailed care plan provided can serve as a guide for other practitioners in treating similar cases, emphasizing the importance of thorough evaluation and individualized treatment strategies.
