What causes groin pain ?

It's a question that comes up periodically and since there is no easy answer that I can give to patient during a routine appointment slot, I decided to put my thoughts in writing so I can refer patients to it as a conversation starter.

The groin is a small piece of the body's real estate, that we tend to think of as private, but that can really control your life if it starts acting up.

It's a body area that is the intersection of several structures that can be pain producing, and you need a little bit of attentive detective work to determine the source of the problem.

The main structures that can be involved in producing groin pain:

– referred pain from the middle lumbar area, especially L2 and L3 segments. These would be things like a lumbar disc herniation causing pain to radiate along these dermatomes, or significant bony spurs. The lower lumbar segments such as L4 5 and L5 S1 definitely take the lines shares in terms of referred this pain, so that sometimes we tend to forget that mid lumbar areas can also be a source of referred pain. Patients with groin pain referred from these mid lumbar segments tend to have pain that is aggravated by lumbar movement.

– Referred pain from myofascial structures in the deep hip flexors, especially if involving some peripheral compression of the anterior peripheral nerves that exit that those levels: the femoral nerve, the ilio inguinal nerve, and the lateral femoral continues nerve. This pain can be really tricky to assess, since it will not readily show up on advanced imaging like MRI. During physical examination, deep lateral palpation of those structures can usually be pretty revealing, and the fact that very often activities involving hip flexion can be very triggering.

– The hip joint, or more precisely the acetabular femoral joint (AF joint) . This is the ball and socket joint between the socket in the pelvis (acetabulum) , and the femoral head. This is not usually a joint that is subject to primary misalignments due to its ball and socket nature, although it certainly can, but is subject to articular cartilage degeneration, and tearing and catching of the cartilage rim also known as the labrum. There are specific orthopedic testing that can help isolate the AF joint is the source of the problem, and in addition pain from imaging as well as advanced imaging like MRI can be very diagnostic of the problem starting in that structure. From a history standpoint, patient will often report the sensation of catching or clicking, and pain triggered by hip movement rather than lumbar movement.

– The sacroiliac joint. The sacroiliac is a rather large vertical/horizontal articulation at the base of the sacrum, and the anterior portion of the sacroiliac joint can refer pain to the groin. This would happen with misalignment of the sacroiliac joint internally, that will be often associated with deep pain in the buttocks, difficulty with flexibility in the affected side of the pelvis, and standing with a toe out position on the affected side.

So groin pain can come from many different sources, but it should not be a mystery and a good physical examination can usually point the patient and the treating doctor into the right direction.

Autism spectrum disorders and altered gut microbiome: new scientific diagnostic methods

https://www.nature.com/articles/s41564-024-01739-1?utm_source=klaviyo&utm_medium=email&utm_campaign=%28Email%20-%20Chris%20Kresser%20General%20News%29%20Chris%27s%20Friday%20Favorites&utm_term=new%20study&utm_content=new%20study&_kx=ZpXBDTeEF9QJhwDqQXXrImrT_HpFsBz1ZlYMbsx_Vq0.my75y6

With children going back to school this week, I was reminded of this article I first read earlier in the summer. Children with autism spectrum disorder (ASD) makeup and increasing percentage of our school population, with some debate about the real increasing incidence versus better diagnosis inflating the ranks.

Equally the subject of vigorous debate, is the cause of autism. Or more accurately, the causes, since it appears to be a multifactorial trigger that may be different in various affected individual.

This particular article focused on assessing the microbiome of neuro- typical children versus children with ASD. The integrative health community has long argued that neuro- divergent children almost always will exhibit significant functional G.I. markers abnormalities, which are likely the source of some retrograde brain functioning alteration. That same community has also argued that neuro- divergent children can see improvement in their brain functioning if we can improve their microbiota. This particular research article did not address that question, but clearly confirmed with advanced diagnostic techniques that is the children do indeed have some substantially and statistically significant differences in their digestive ecology. However it's pretty safe to operate on the hypothesis that G.I. intervention that will improve microbiota composition will indeed have a secondary positive effect on the function of the central nervous system. It's especially exciting for chiropractors in the integrative health community, since chiropractic adjustments alone have been shown to improve gut -brain axis signaling, further enhancing the effectiveness of any nutritional intervention.

Specific chiropractic adjustments versus random manual mobilization: why it really matters

https://www.researchgate.net/publication/377361433_A_randomized_controlled_trial_comparing_different_sites_of_high-velocity_low_amplitude_thrust_on_sensorimotor_integration_parameters

Over the last 30 years of practice I have often found myself answering the same question many times over. 1 of those questions is why I seem to only be adjusting only one side and only one very specific spot, when patients may have had previous experiences with chiropractors or other manual therapist that showed a much broader contact, and adjusting multiple areas of the spine on both sides. With the addition of Dr. Steve as my esteemed colleague and associate, I realize I'm not the only one answering that question. Dr. Steve and I have very similar approaches and background in manual adjusting, (more specifically we both had most of our training in the Gonstead technique and system), which means that on occasion we will both bemoan the drift of our profession away from specific and systematic manual adjustments based on a system of analysis that aims at isolating the main segment(s) of spinal dysfunction that should be adjusted, while leaving the rest alone.

There are good scientific rationales behind that approach: the spine is a very dynamic system of action and reaction based in gravity. What happens in one area of the spine will often lead to broad compensations in a different area, and it takes some clinical investigation to make sure you address the root cause rather than waste your time (and your body's limited healing energy) on areas of compensation.

There is also good and pretty solid research to validate the specific approach. I was thrilled to come across this wonderful paper by our colleagues from down under in New Zealand (especially Dr. Heidi Haavik who has been a workhorse of basic science chiropractic research for well over a decade). The nuts and bolts of the study was to measure the brain-based motor response of an adjustment in a randomly selected area of the spine across the test subjects, versus a specific spinal segment determined by chiropractic analysis including static palpation, palpatory tenderness, abnormal motion segment etc.). The results were statistically incredibly different between the 2 interventions.

The moral of the story is that chiropractic care is most likely to give you longer-lasting neurologically integrated results if your provider spends time to specifically isolating the main problem area and adjusting it according to best biomechanical correction principles.

How frequent is spinal pain in children?

https://www.sciencedirect.com/science/article/abs/pii/S1413355524000042

I continue to listen to a series of research podcasts, catching up from 2015 and on. All I can say is that we have some amazing colleagues doing serious research and enlightening our day to day practices.

This particular piece of research caught my attention because I've been thinking about children a lot recently. We have a crop of new babies coming in to the office, the children are back in school dragging heavy backpacks and happily crashing into each other in their fall sports.

Over the last 30 years of practice I feel that at times I have been fighting an uphill battle in the area of chiropractic pediatrics, trying to convince many parents and the community at large that children do develop spinal problems fairly early, fairly frequently, and that we are currently operating by a false narrative that back pain is not something that happens to children but rather to adults, and that if a child is complaining about pain, it is usually a psychological reason behind it. Up until recently we've not really had much research data to back this up.

This brand-new study (January 2024), from Brazil, indicates that a whopping 30% of adolescents may complain of spinal pain that could be at times disabling. What's most interesting looking through the fine print of the paper is that the pain pattern is really quite similar than adults already. (Objective factors, risk factors etc.) these numbers fly in the face of our current cultural understanding of spinal pain in children, much less our healthcare intervention resources. Having had the pleasure and privilege of working with individuals from birth to natural death over 30 years, I can say without a doubt that I have been shocked by the types of finding I've seen in rather young children over the year. But ultimately, as time goes by, I see the continuum of presentation between my adult patients and the history of their 1st trauma much more clearly now. When I see the children taking tumbles on the playground, falling down the stairs, and wrestling with the siblings I realize that none of us adults could do this and still get out of bed the next day. To be fair children's neuromusculoskeletal systems are more pliable and a little more resilient than ours, but they do not magically survive some of these injuries without some potential long-term residuals that will manifest episodically into adulthood.

I am most excited about another 10 year longitudinal initiative started in Denmark, currently underway. It will start screening a very large swath of schoolchildren starting in preschool and through high school, looking at a variety of metrics from pain to motor control to balance to visual efficiency. I think were going to get a wealth of data as to how children develop pain over time and what the risk factors are in their history, as well as what early signs in their other developmental milestones may be useful to flag them for early intervention. Those little people are genuinely our most precious resource and it's time we stop writing off their back pain as just something in their heads.

Revisiting the best Vit D supplementation for the winter months

It feels a little paradoxical to be adding this blog while the temperature is scheduled to hit the mid 80s today, however the weather forecast is calling for a temperature cliff at the end of the week, and my Windows automatic photo update posted a beautiful snowy landscape upon firing my machine this morning. I take that as a sign from the universe that it's time to talk about a topic that will very soon affect us all.

The topic of vitamin D levels in health and disease has waned a little bit in popularity since its peak of research around 2010, although it did enjoy a resurgence during the Covid pandemic. The research has really been all over the map for laypeople, and even at times confusing for healthcare professionals, until you dig a little bit deeper into the details of the study such as the type of biomarker measured, the target population, etc.

I recently polished up on the latest research and recommendation from a couple of pretty good trusted nutritional sources to see what a commonsense consensus would be. Here are my highlighted suggestions:

1st of all, vitamin D metabolism is extremely variable among different people so generic recommendations about intake are only going to go so far. Ideally you should get your vitamin D level tested. It's typically lowest in the spring, and highest at the end of the summer. This is assuming that humans follow an ancestral pattern of having outdoors skin exposure for vitamin D manufacturing for the summer, which is not always true of our modern lifestyle and individual lives. I recommend getting it tested at both of these peaks. Testing can be done through a variety of manners, including traditional testing through primary care, through Labcorp/Quest direct, or through home kits using blood spot finger prick method. (It's beyond this blog to talk about resources, but patients can contact the office and schedule a consult for that separately).

Vitamin D absorption is impacted by digestive issues especially along the biliary tree since vitamin D is a fat-soluble vitamin, as well as medications that impact lipid absorption and metabolism (especially certain cholesterol medications). Vitamin D need is also increased by certain illnesses. So you really need to look at your own individual factors when trying to eyeball your needs.

As far as ideal blood levels, you'll see different schools of thoughts. Some outfits recommending very high levels of vitamin D3 above 50 and sometimes close to 80, and some people making much lower recommendations. Looking at the more recent research I think the average population does best between 30 and 50. This would be in line with what we have historically known of traditional human population with levels never exceeding 46 with whole foods diet and outdoor sun exposure. However there are subpopulation of peoples with special health needs, especially autoimmune, that may do better with a therapeutic goal above 50. However those people should always be working with a healthcare professional to ensure that those high levels of vitamin D are not causing secondary problems.

Vitamin D is part of a group of fat-soluble vitamins that are finally regulated as a whole, and depend on each other for the proper management of calcium deposition in bone and soft tissues. Probably the strongest recommendation update I am pushing forward now would be to not routinely supplement vitamin D alone, but rather look at a minimum combination of vitamin D3/K2/A in the right ratios. This will prevent some unwanted effects of over dominant vitamin D3 among fat-soluble vitamin, which could negatively impact the deposition of calcium into soft tissues rather than bone. This is especially true in patients with cardiovascular disease and osteoporosis, and with patients who have to limits the intake of dairy products (which tends to provide the vitamin K2). Professional brands of nutritional supplements have started reformulating their fat-soluble vitamins along those lines with several good options both in gel caps and liquid forms.

THE MONSTER LURKING IN THE BACKPACK

Although it seems impossible it's already that time of year... I'm seeing mountains of pens, highlighters, folders, and backpacks lining up the entrance shelves of my local general store. The munchkins are already on week 2 of the great school year !

Parents may be tempted to skip over this blog entry because we've become numb to the fact that backpacks can be a problem. We really shouldn't be. There's so much at stake for long-term spinal health and stability that will be irreversible if we don't pay attention to it at this stage. The research article below from 2018 took some interesting measurements that actually quantify the mechanical stress load on the developing spine. The results are not encouraging. However picking a backpack with the right features and occasionally dropping it on the scale before letting you munchkin out of the door can help you mitigate the worst of the problem.

Here is a bit of basic math that illustrates the extent of the problem. According to the authors of the article, the multiplication factor of the weight of the backpack on the actual spinal structure such as a developing disc is anywhere between seven and 11. In plain English, if you have a backpack of 10 pounds, the actual load on the spine is anywhere between 70 and 110 pounds, and a backpack of 20 pounds anywhere from 120 to 220lbs. This is really quite astounding but explains why so many kids will come home saying they're sore everywhere in their back and shoulders. This is even more of a problem if your child has to walk any distances with their backpacks, either from classroom to classroom, walking to and from school, and to and from the school bus.

You only have two real decent strategies to mitigate the issues: first select a backpack that has good padding, wide padded shoulder straps, a waist strap, and all adjustable straps in the waist band, shoulder straps, and possible chest strap. Arguably you will probably get some pushback from you kid about the look they want versus the functionality you want as a parent. Second, grab your kids backpack every so often when they come home from school and put it on your home scale. Wait until a couple months into the school year to do that because the amount of things they have to carry will change, and you'll have a more authentic idea of how much they're hauling around by the time activities and sports roll around. When you start seeing numbers that amount to the same weight as your child, it is time to ruthlessly review which contents get to stay and which ones get to go. Also remember to reach out to the teachers and share your conundrum. Some will be willing to be practical and adjust their homework to tasks that do not involve the dragging of larger textbooks home

https://pubmed.ncbi.nlm.nih.gov/30204924/

Chiropractic care in patients with Parkinson's and Alzheimer's disease

https://www.researchgate.net/publication/380154147_The_Effects_of_Chiropractic_Spinal_Adjustment_on_EEG_in_Adults_with_Alzheimer's_and_Parkinson's_Disease_A_Pilot_Randomised_Cross-over_Trial

This research article caught my attention recently, as I have been dealing with loved ones in various stages of neurodegenerative progressive diseases (Alzheimer's disease especially). It's a small pilot study testing the effect on brain waves from a single chiropractic adjustment on a sample population of patients with diagnosed Alzheimer's and Parkinson's disease. Both of those diseases share common neurodegenerative pathological mechanisms. It also brought some bittersweet memories of a loved one who passed away a decade ago from Huntington's disease, another albeit genetically transmitted form of neurodegeneration. I was attending neurology appointment for this patient with a well-known Huntington specialist who was also a medical neurogenetic researcher. When she found out I was a chiropractor, she was really excited. She was noticing that a lot of her patients who were receiving chiropractic care seem to have slower progression of diseases, and she was very interested in seeing some formal research in that area. That type of research is notoriously difficult to conduct much less fund, so I was quite elated to find out that our colleague Dr. Heidi Haavik from down under in New Zealand had managed to line up a pilot study, hopefully opening the door to a larger scale research.

This particular pilot study showed some rather surprising effect on brain waves of patients with neurodegenerative diseases following a single chiropractic adjustment, showing some improvement in the normal electrical excitability and conductivity in some key areas of the brain. Anyone who's ever dealt with patients with those terrible diseases know that maintaining quality of life and cognitive function as long as possible is usually important, and that any available tools in the toolbox should be available to those patients and their families. I look forward to see what the next 5 years of research in that area brings about and how it may impact our ability to more routinely treat, and hopefully help, these lovely folks.

Can I have a pinched blood vessel ?

Patients will often precede a question with the disclaimer “ this may be a dumb question, but I am wondering if….”. This disclaimer almost always guarantees that they are usually pretty astute in their observation and closing in on some matter of importance.

The latest “dumb question” that came up this week was interesting: could my symptoms be caused by a pinched blood vessel ?  The patient had some pins and needles sensations in the front of the shoulder, they had noticed that the skin on the front of the arm was a little darker and a little colder than on the other side. Good logic led them to wonder if there was decreased blood flow in the affected area.

The surprising answer to that question is not only: yes !, but the fact that most instances of pinched nerves probably have some degree of pinched vascular structures that go along with the pinched nerve. And there is a very simple reason for that: if you go back to basic anatomy, nerves, arteries and veins very often travel as a trio before splitting off prior to their final destination. Anyone who has done college level anatomy will recall the acronym NAV, standing for  nerve, artery and vein, describing the bundles of the three structures lumped together. And anyone who has done anatomy cadaver dissection recalls how difficult it was to separate the three structures from each other and tell them apart.

From a practical and clinical standpoint, there is a lot of overlap in the symptoms of nerve and vascular compression. Both can cause pain, and both can cause abnormal sensation like numbness and tingling, making it difficult to differentiate them based on symptoms alone. Physical examination can be helpful, but also somewhat limited. Mild vascular compression can cause subtle swelling, changes in color and temperature, but those can be difficult to differentiate from inflammation related edema, and most body areas have collateral circulation that can take over when there is mild vascular compression from one source. 

In day to day chiropractic practice, we tend not to aim our treatment to relieve mild vascular compression independent from relieving nerve compression, which is probably why we talk about this topic infrequently. Relieving nerve compression is the main goal, and vascular structures will basically benefit from that approach. Nerve tissue and vascular tissues have distinct features that makes nerves more vulnerable in NAV bundles: they lack collateral back up, and they are not as adaptable to move out of the way of compressive forces. But that is not to say that some patients will show up with unusually strong vascular compression symptoms that need to be taken into account when setting up a treatment plan, for example limiting the use cold pack therapy and compression