Femoral Nerve Radiculopathy
1. Introduction
Femoral nerve radiculopathy mainly has impact on the femoral nerve, with either sensory or motor functional changes. This is similar to the sciatic nerve which many people are familiar with. In the main context the sciatic nerve is responsible for the back of the leg and the femoral nerve the front of the leg (1).
Away from the central nervous system (brain and spinal cord) is a network of different nerve types that make up the peripheral nervous system, of which the femoral nerve is one of the largest. Different types of nerves are responsible for different functions such as:
- Sensory nerve – responsible for sensory input such as pain, temperature and touch.
- Motor nerves – responsible for controlling muscles.
- Autonomic nerves – control involuntary actions such as breathing, blood pressure, metabolism, food digestion, heart regulation, thyroid and hormone secretions.
The femoral nerve stems from nerve roots at different levels of the spinal cord (L2, L3 and L4). This is the upper part of your lower back. It passes down through the rear abdominal wall through the pelvis, supplying the muscles at the front of the thigh. It is responsible for bending the hip and straightening the knee. It also receives messages from the skin when there is pressure on the thigh or inner calf.
Individuals with leg pain related to their back pain is a common presentation of lower back pain with approximately two-thirds of those seeking treatment reporting leg pain; however, this is usually more common in the back of the leg (6).
Frequently Asked Questions
- This is where the nerve that supplies the front of the leg is irritated and causes pain.
- Femoral nerve radiculopathy is an irritation to the femoral nerve, predominantly causing neural symptoms into the thigh and upper leg, occasionally the lower leg and inside of the foot (1).
- Overall, this is one of the less common causes of back pain with referred leg pain symptoms (3).
- No.
- With the right rehabilitation approach femoral nerve radiculopathies can recover well during the first 2-3 months.
- If left untreated the prognosis may not always be as positive.
- Those with a lumbar disc injury or lower back pain.
- Overstretching of the nerve which is more common in athletes.
- Direct trauma to the nerve or pelvic region (4).
- Sedentary individuals and prolonged periods of inactivity.
- Pain, numbness and altered sensation into the front of the thigh, or into the inside knee joint, lower leg and foot.
- Loss of balance or co-ordination due to hip weakness.
- Weakness in bending the hip or straightening the knee.
- Lifestyle change and activity modification.
- Home exercise plan and progression tailored to the individual by a physiotherapist.
- Avoidance of aggravating factors.
- Heat therapy/acupuncture/hands-on treatment.
- GP may prescribe medication that helps to reduce the irritation of the nerve known as ‘neuropathic pain relief’.
- This will depend upon several factors including, but not limited to, medical/lifestyle factors, stage of injury, your ability to follow your rehabilitation plan, etc.
- Initial recovery is usually within 2 to 3 months and full recovery usually within 3 to 6 months.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Pain, numbness and altered sensation in the front of the thigh, sometimes into the inside knee joint, leg and foot.
- Loss of balance or co-ordination due to hip weakness.
- Weakness in bending hip or straightening the knee.
3. Causes
The most common underlying cause of radiculopathy is irritation of a particular nerve, which can actually occur at any point along the nerve itself, but most often is a result of a compressive force.
The intervertebral discs in the lower back are flat and round, and about half an inch thick; they act as a shock absorber when you walk or run. They have a soft jelly-like centre and a thick fibrous cartilage ring around the outside. A shift in pressure on the disc can push the jelly like centre against the outer part causing it to ‘bulge’.
It is important to note that disc bulging is likely to occur in individuals without pain as well, with a prevalence of 30% in 20–30-year-olds and 84% in 80-year-olds. Obviously, a greater prevalence in the older generation, but this shows it can occur in young populations too and is not necessarily a sign of ‘old age’ (7).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing femoral radiculopathy. It does not mean everyone with these risk factors will develop symptoms.
- Lumbar disc issues and lower back pain – referred pain symptoms into the front of the thigh.
- Athletes over-stretching the nerve through injury – typically those that require greater flexibility, i.e. gymnasts, martial arts, football players.
- Obesity/diabetes/metabolic disorders/autoimmune disorders/vascular disorders.
- Sedentary lifestyle and prolonged periods of inactivity.
5. Prevalence
There is a wide variation in reported prevalence; estimates show some higher levels in those with reported lower back pain compared to those without. It is also dependent upon several factors including, but not limited to, co-morbidities (additional health conditions), stage of injury, adherence to rehabilitation, etc.
6. Assessment & Diagnosis
Your physiotherapist will take a detailed history of your symptoms, followed by a thorough clinical examination to establish a diagnosis. A fast and accurate diagnosis will mean that the most effective treatment and management plan can be implemented straight away, helping to achieve optimal outcomes.
Assessment will include subjective questioning as to how your condition is affecting you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Regular reassessment will ascertain if you are making progress towards your goals and will allow adjustments to your treatment to be made.
7. Self-Management
Your physiotherapist will educate you on your condition and will offer strategies that will help you manage your symptoms and support recovery. This may include activity modification, advice on suitable exercises, avoiding aggravating activities and methods to ease symptoms. Neuropathic pain medications and anti-inflammatories may also be prescribed by your doctor to help ease your symptoms, helping you to return to a level of function which is manageable. Liaison with your GP may be required to discuss this. They may also recommend using heat therapy which may help to relieve symptoms and make you more comfortable.
8. Rehabilitation
A thorough examination and comprehensive treatment programme should also assess for, and direct treatment of, abnormal movement patterns that affect the lower back, hip and pelvis. Rehabilitation will focus on restoring normal pain-free movement and reducing any restrictions. Neural gliding is a manual therapy technique that attempts to improve neurodynamic between relative movements of the nerve and surrounding structures. This requires specific knowledge, acquired from your physiotherapist, of the nerve pathway and movement that applies tension of the irritable nerve. Soft tissue mobilisation can address goals of increasing range of movement, reducing pain, decreasing swelling, increasing flexibility and improving muscle performance (8).
Stretching, whether performed independently by a patient or performed by a physiotherapist, attempts to relieve nerve compression by lengthening shortened muscle / tendon structures. However, aggressive stretching can be irritating to the nerve and must be controlled in a slow and progressive manner.
Strengthening exercises can also be performed to facilitate proper load transfer between the lumbar spine, pelvis, hip and lower extremity when deficiencies of these relationships have been identified. Some low-level Pilates techniques may be used to initiate strengthening activity with a steady progression to more of an all-round strength and conditioning programme, depending on the individual’s specific rehabilitation goals.
9. Femoral Nerve Radiculopathy
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This plan aims to restore/maintain movement in the spine due to the fact this is the most commonplace for symptoms to originate. This should not exceed any more than 3/10 on your perceived pain scale.
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- 910
At this stage, the exercises progress to ensuring that there is no tightness in the nerve itself and then on strengthening the muscles around the lower back and pelvis region. This should not exceed any more than 3/10 on your perceived pain scale.
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- 910
This moves on from the intermediate exercises with more progressive and challenging exercises, particularly in strength. The exercises also move towards more functional positions to help ensure a return to normal daily activities. This should not exceed any more than 3/10 on your perceived pain scale.
- 0
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- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and to establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
11. Other Treatment Options
Although the majority of patients with this condition will return to normal through a physiotherapy led rehabilitation programme and treatment, some may require further assistance. Due to the fact that the majority of radiculopathy originate from the spine, it is likely that you would see a spinal orthopaedic consultant for an opinion if conservative treatment was not successful. This may then lead to spinal epidural injections or surgery but these cases are rare.
References
- Drake, R. L., Vogl, W., Mitchell, A. W. M., & Gray, H. (2015). Gray’s anatomy for students.
- Berry, J. A., Elia, C., Saini, H. S., & Miulli, D. E. (2019). A Review of Lumbar Radiculopathy, Diagnosis, and Treatment. Cureus, 11, e5934. Https://doi.org/10.7759/cureus.5934
- Alexander CE, Varacallo M. (2020). Lumbosacral Radiculopathy. Stat Pearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK43037/.
- Lorei, M.P. and Hershman, E.B. (1993). Peripheral nerve injuries in athletes. Sports Medicine, 16, 130-147.
- Moore, A.E. and Stringer, M.D. (2011). Iatrogenic femoral nerve injury: a systematic review. Surgical and radiologic anatomy, 33, 649-658.
- Kongsted A, Kent P, Albert H, Jensen TS, Manniche C. (2012). Patients with low back pain differ from those who also have leg pain or signs of nerve root involvement – a cross sectional study. BMC Musculoskeletal Disorder. Http://dx.doi.org/10.1186/1471- 2474-13-236.
- Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology. 36, 811–816. Https://doi.org/10.3174/ajnr.A4173.
- Martin R, Martin HD, Kivlan BR. (2017). Nerve entrapment in the hip region: current concepts review. Int J Sports Phys Ther. 12, 1163-1173. 10.26603/ijspt20171163.
Other Conditions in
Lower Back, Hips & Pelvis, Upper Legs, Knees, Neurological
Spondylolysis
An injury due to a stress fracture through part of a vertebra known as the pars interarticularis of the lumbar vertebrae (lower back).
Spondylolisthesis
A term to describe a slight change in position (usually further forward) of one vertebra relative to the vertebrae below.
Sacroiliac Joint Dysfunction
Pain originating from the sacroiliac joint at the base of your back where the spine joins the pelvis.
Mechanical Back Pain
Lower back pain caused by structures in the back, such as joints, bones and soft tissues.
Lumbar Spinal Stenosis
Narrowing of the spaces though which lower back spinal nerves travel which can result in weakness, pain and reduced function.
Lumbar Disc Injury
Lumbar discs sit between each of the bones of the spine. Problems can occur when these discs become irritated.
Low Back Pain and Sciatica
Sciatica is a symptom describing pain and/or pins and needles down the back of the leg.
Greater Trochanteric Pain Syndrome
A condition affecting the tendons that insert into outside of the hip. A common cause of pain felt around the hip and pelvis.
Femoroacetabular Impingement
A condition that results in pain in the groin, hip and down the front of the thigh.
Deep Gluteal/Piriformis Syndrome
A presentation where the sciatic nerve is irritated in the buttock and can cause sciatica symptoms in the leg.
Cauda Equina Syndrome
A rare but serious condition as a result of compression of the nerves at the base of your spine.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Ankylosing Spondylitis
A rare condition that can cause joint stiffness and pain, often worse at night and when resting.