Meralgia Paresthetica

Meralgia Paresthetica (MP) is a type of peripheral nerve entrapment affecting the lateral femoral cutaneous nerve (LFCN) as it passes through the inguinal ligament or fascia lata. It is a sensory mononeuropathy that causes burning pain, numbness or paraesthesia on the lateral thigh. MP is most common in individuals aged 40-60 years, with recent trends showing clusters of cases following the COVID-19 pandemic.

 

Pathway and Entrapment of the Lateral Femoral Cutaneous Nerve

The lateral femoral cutaneous nerve (LFCN) originates primarily from the L2 and L3 spinal nerves. It follows a specific pathway:

Pathway of LFCN:

• The nerve emerges from the lumbar plexus, running over the psoas major and iliacus muscles.
• It then travels toward the anterior superior iliac spine (ASIS) and passes near the lateral inguinal ligament before entering the thigh.

Common Compression Sites:

The LFCN is often compressed at the inguinal ligament, where it transitions from the pelvis to the thigh. Variations in its course can influence compression risk. These include:

• Transligamentous variant: The nerve passes through the inguinal ligament.
• Subligamentous variant: The nerve runs underneath the ligament.
• Muscular or bony entrapment: The nerve may pass through the sartorius muscle or travel over the ASIS, potentially increasing susceptibility to entrapment.

 

Risk Factors

• Advanced age, high BMI, diabetes mellitus.
• Obesity and tight clothing (e.g., "jeans disease").
• Significant weight loss, reducing fat protection around the nerve.
• Pregnancy, similar to carpal tunnel syndrome.
• Other nerve compression syndromes (13.6% of 140 patients in a case series had multiple nerve issues).

 

Causes of Meralgia Paresthetica

 

Clinical Presentation of Meralgia Paresthetica

• Burning or stabbing pain in the ventrolateral thigh, sometimes extending near the knee.
• Well-defined sensory disturbance – patients can often precisely locate the affected area.
• Persistent symptoms may lead to permanent hyposensitivity and reduced hair growth in the area.
• No motor deficits – the LFCN is purely sensory.
• Patient sleeps in supine position with the leg extended (Meralgia Paresthetica Nocturna).
• Sitting or hip flexion can help reduce symptoms.
• Pain upon compression near where the LFCN emerges under the inguinal ligament.
• Tingling, numbness or burning pain in the anterolateral thigh.
• Increased sensitivity (hyperesthesia) or decreased sensation (hypoesthesia) in the affected area.
• No Muscle Weakness
• Symptoms may worsen with hip extension or direct pressure over the inguinal ligament.

 

Diagnosing Meralgia Paresthetica

As a physiotherapist, diagnosing Meralgia Paresthetica involves a comprehensive assessment focusing on history, physical examination and differential diagnosis.

 

 

Differential Diagnoses

• Lumbar Radiculopathy (L2-L3 Nerve Root Compression)
• Femoral Nerve Entrapment
• Trochanteric Bursitis
• Hip Osteoarthritis
• Labral Tear of the Hip
• Iliotibial Band Syndrome
• Lateral Cutaneous Branch of the Subcostal Nerve Entrapment
• Diabetic Neuropathy
• Pelvic or Abdominal Mass (e.g., Tumor, Hematoma, Pregnancy-related Compression)
• Inguinal or Femoral Hernia

 

Physiotherapy Management of Meralgia Paresthetica (MP)

The main goal of physiotherapy in Meralgia Paresthetica (MP) is to reduce nerve irritation, alleviate symptoms, restore mobility and prevent recurrence. Since MP is a compression neuropathy of the lateral femoral cutaneous nerve (LFCN), physiotherapy focuses on nerve decompression, postural correction, soft tissue mobility and patient education.

1. Patient Education and Lifestyle Modifications

Managing external factors that contribute to Lateral Femoral Cutaneous Nerve (LFCN) compression is essential.

• Avoid Tight Clothing – Encourage patients to avoid tight belts, corsets, or jeans that compress the inguinal ligament.
• Weight Management – Obesity increases intra-abdominal pressure, worsening nerve compression. Weight loss may help reduce symptoms.
• Modify Daily Activities – Limit prolonged standing or walking and adjust sleeping posture (e.g., avoid lying supine with legs extended).
• Ergonomic Adjustments – Optimize sitting posture by using lumbar cushions or ergonomic chairs to prevent excessive anterior pelvic tilt.

 

2. Pain Management

a. Electrotherapy Modalities

• TENS (Transcutaneous Electrical Nerve Stimulation)
• Therapeutic Ultrasound 

b. Cryotherapy (Cold Therapy)

Ice packs applied to the inguinal region or lateral thigh for 10–15 minutes, 3–4 times daily. It helps reduce inflammation, numb pain, and decrease nerve irritation.

c. Manual Therapy

Myofascial Release over the hip flexors, inguinal region, and tensor fasciae lata (TFL) to reduce tension. Soft Tissue Mobilization is also performed to relieve nerve entrapment caused by tight fascia and soft tissue adhesions.

Example:

Performs deep tissue release around the inguinal ligament and TFL with sustained pressure and slow strokes.

3. Stretching and Mobility Exercises

These exercises focus on reducing nerve tension and improving pelvic mobility to prevent compression.

1. Hip Flexor Stretch (Reduces Compression at the Inguinal Ligament)

2. Tensor Fasciae Lata (TFL) & IT Band Stretch

3. Lumbar and Pelvic Mobility Exercises 

• Cat-Cow Stretch – Improves spinal flexibility, reducing lumbar lordosis.
• Pelvic Tilts (Supine Position) – Helps correct postural imbalances and pelvic positioning.

4. Strengthening Exercises

Strengthening the core and hip muscles helps improve pelvic stability, reducing excessive anterior pelvic tilt and nerve compression.

1. Core Strengthening (Prevents Excessive Anterior Pelvic Tilt)

• Pelvic Bridges – Lie on the back, knees bent, lift hips toward the ceiling.
• Dead Bugs – Lie on back, alternate extending opposite arm and leg.
• Plank Holds (Modified if Necessary) – Engage core while maintaining a neutral spine.

2. Hip & Gluteal Strengthening

• Side-Lying Clamshells – Strengthens hip external rotators and improves pelvic stability.
• Hip Abduction Exercises (With Resistance Bands) – Strengthens gluteus medius to support lateral hip stability.
• Glute Bridges – Targets posterior chain muscles, preventing anterior pelvic tilt.

5. Neurodynamic Techniques (Nerve Gliding Exercises)

These techniques help mobilize the LFCN, reducing irritation and restoring function.

Lateral Femoral Cutaneous Nerve Glide

The patient should lie on their side with the affected side facing up. In this position, they should gently extend the hip while keeping the knee flexed to minimize excessive strain on the nerve. The movement should be slow and controlled, ensuring that no additional discomfort is caused. The position should be held for 3–5 seconds before returning to neutral. This exercise should be repeated 10–15 times per session, 2–3 times daily, to effectively mobilize the lateral femoral cutaneous nerve and reduce irritation.

6. Postural and Gait Correction

• Postural Retraining – Corrects excessive anterior pelvic tilt, preventing LFCN compression.
• Gait Modification – Adjusts walking mechanics to reduce stress on the hip and pelvis.

7. Functional Training and Activity Modification

• Gradual Return to Activities – Encourage patients to resume daily and sports activities slowly, monitoring symptoms.
• Sport-Specific Drills – Assess nerve compression risks in athletes and modify hip movement patterns.

8. Progression and Follow-Up

In the acute stage, focus on pain relief and nerve decompression with cryotherapy and manual therapy while avoiding aggravating positions. The subacute stage introduces gentle stretching, mobility work, and light strengthening for the core and hips. In the chronic stage, restore full function with functional training and postural correction to prevent recurrence.

Additional Treatment Options

Kinesio Taping (Kalichman et al.)

Application Method:

• Y-shaped strip: Placed above the lateral inguinal ligament, covering the symptomatic area.
• I-shaped strip: Placed along the inguinal ligament with light tension.

It was effective in symptom relief when applied correctly.

Electroacupuncture (Alexander Study)

The findings showed significant pain reduction, with more than 50% decrease in pain after three months of treatment. Additionally, there was a 92% reduction in daytime pain and a 94% reduction in nighttime pain, indicating the effectiveness of the intervention in providing sustained symptom relief.

Muscle Energy Technique (MET)

• Position 1:

Hip extended until reaching the restrictive barrier.

• Position 2:

Hip flexed at 75° with adduction until restriction is MET.

Conservative management is the first-line treatment for Meralgia Paresthetica, including lifestyle modifications, physiotherapy and medications. Nerve infiltrations and minimally invasive treatments (e.g., radiofrequency ablation) may provide temporary relief in resistant cases.