Freud’s tingling thighs

Where do Freud’s thighs fit in?
Sigmund Freud was diagnosed with a meralgia paraesthetica (MP) and hence the link. MP, the well described ‘entrapment’ of the lateral femoral cutaneous nerve of the thigh (see the image below) was one of the first described nerve entrapments back in 1878 by Bernhardt. We can learn a lot about the behavior of a peripheral nerve problem from MP.

Back to Freud’s thighs… his self observations in 1895 were translated by Schiller. At the time of writing he had a MP, occasionally bilateral, for 7 years in a zone similar to the image. Freud complained of a ‘furry sensation” and ‘alien skin’. He also mentioned that the rubbing of his undies caused a ‘disagreeable sensation’ and that if he ‘pinched the skin on the painful side it was worse than on the other’. It is tempting to suggest that Freud may have had a bit of central sensitisation as well (allodynia, long duration, bilateral sensations, more cold reactive than heat). It feels quite strange trying to diagnose a problem in Sigmund Freud!

What causes Meralgia Paraesthetica?
Up to 100 causes have been suggested, so it is best to keep it to a case by case discussion. The usual problems which contribute to peripheral neurogenic troubles such as diabetes, thyroidism, alcoholism, are in the literature, but problems in this nerve are likely to have mechanical contributions as well. It emerges from L2-3, travels around the iliac crest and then contends with the inguinal ligament a few centimeters below the anterior superior iliac spine. Here it can turn nearly 90 degrees to enter the fascial planes of the thigh (Mumenthaler and Schliack 1991).

Diagnosis of Meralgia Paraesthetica
The nerve is purely sensory, so there should be no motor changes, such as the reflex changes or weakness in the hip flexors and knee extensors which may be characteristic of a root lesion. (Freud checked this out as well). These days, with our new knowledge of injury to peripheral nerves (Nee and Butler 2006) a term such as ‘entrapment’ may not be that helpful. The nerve may not be stuck, but still sensitized anywhere along its pathway. Symptoms may not necessarily be in the entire zone, but be ‘zings and zaps’ in part of the zone, especially when the hip is in extension.

What do you do for it?
There are no large clinical trials on the management of Meralgia Paraesthetia, but the syndrome needs a good application of modern neurobiology and neurodynamics to provide ideal management. The advice in the literature is usually to leave it, or if bad enough, attempt surgery. Education and appropriate movement rarely get a mention in the literature where the advice is usually to wait or try surgery.

Education should help
This must be a worrying syndrome. Everyone thinks of the horrible neural diseases with a few tingles and groin area pain may be a bit more worrying than most. Freud has three patients with MP describing them as “healthy anxious people who consulted me for the very reason that they were taking the harmless affection for something grave”. Threat reducing education could include “this should go, we understand it, it’s not a serious disease, informing that anxiety can excite the nerve, and there are things you can do for it yourself.” Get rid of the term “entrapment”. It’s scary! An “excited nerve” may be more relevant to many cases. A good examination as Freud did, is also helpful to reduce anxiety.

Secondly, get moving
All the sitting that people do these days, bunching up the front of the hip – the nerve probably just needs a good airing in many people. How long has it been since your hips have been in extension? The test for the nerve is hip extension, adduction, knee flexion (Butler 2000). This is not new. Mumenthaler and Schliack described a similar test in 1991.

Some targeted manual therapy to structures around the nerve. Sites of ectopic (mid-axon) discharge could be anywhere along the nerve. Known candidates could be within the psoas, thigh fascial structures, where the nerve exits just medial to the anterior superior iliac crest and where the nerve has its origins at L2-3.  Removal of tight belts, some weight loss and the completion of pregnancy may help in some cases. Most writers agree that surgery should be the last resort. 

Butler, D. S. (2000). The Sensitive Nervous System. Adelaide, Noigroup.
Mumenthaler, M. and H. Schliack (1991). Peripheral Nerve Lesions. New York, Thieme.
Nee, R. J. and D. Butler, S. (2006). “Management of peripheral neuropathic pain: integrating neurobiology, neurodynamics and clinical evidence.” Physical Therapy in Sport 7: 36-49.

Your turn
In the name of tingling thighs, we want to give away a copy of The Sensitive Nervous System to the one who sends in the best poem on Freud’s tingling thighs.

Last month’s notes on being individual
We had two favourite contributors from last months newsletter on individualised assessment and treatment. Thanks Manuel and Helen – you will both receive a Graded Motor Imagery pack.

Read Manuel and Helen’s stories here…

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One Response to “Freud’s tingling thighs”

  1. What Causes Meralgia Paresthetica? | MERALGIA PARESTHETICA Says:

    […] Freud’s tingling thighs | NOI Notes – Sigmund Freud was diagnosed with a meralgia paraesthetica (MP) and hence the link. MP, the well described entrapment’ of the lateral femoral cutaneous nerve of the thigh (see the image below) was one of the first described nerve entrapments back in 1878 by Bernhardt. We can learn a lot about the behavior of a peripheral nerve problem from MP. […]

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