How does lumbar radiculopathy cause tenderness to palpation at the greater trochanter, which worsens with direct pressure?

Lumbar Radiculopathy and Greater Trochanter Pain: Understanding the Connection

Lumbar radiculopathy does not directly cause tenderness to palpation at the greater trochanter that worsens with pressure. This presentation suggests a different diagnosis, most likely greater trochanteric pain syndrome or another hip pathology rather than true radicular pain from nerve root compression.

Differentiating Radicular Pain from Trochanteric Pain

• Lumbar radiculopathy produces sharp, shooting or lancinating pain that typically follows a narrow band down the length of the leg in a specific dermatomal distribution 1
• True radicular pain from nerve root compression is caused by irritation of the sensory root or dorsal root ganglion of a spinal nerve, resulting in ectopic nerve impulses perceived in the distribution of the affected nerve 1
• Pain that worsens with direct pressure over the greater trochanter is more consistent with a local inflammatory or mechanical condition affecting the hip region rather than radiculopathy 2

Clinical Characteristics of Lumbar Radiculopathy

• Radiculopathy presents with objective sensory and/or motor dysfunction as a result of conduction block, often with specific dermatomal sensory loss, motor weakness in the corresponding myotome, and/or reflex changes 1, 3
• The pathophysiology involves compression sensitizing the nerve root to mechanical stimulation, stretching, and a chemically mediated inflammatory reaction 1
• The most commonly involved nerve roots are L3, L4, L5, and S1, each producing distinct symptoms and neurological findings 3

Greater Trochanteric Pain vs. Radicular Pain

• Greater trochanteric pain that worsens with direct palpation suggests a local pathology such as:

  • Greater trochanteric pain syndrome (formerly trochanteric bursitis)
  • Tendinopathy of the gluteal muscles
  • Referred pain from hip joint pathology 2

• In contrast, lumbar radiculopathy typically:

  • Follows dermatomal patterns
  • May be exacerbated by activities that increase intradiscal pressure (coughing, sneezing)
  • Often includes positive nerve tension signs (straight leg raise test) 4
  • Presents with neurological deficits corresponding to the affected nerve root 3

Diagnostic Approach

• MRI of the lumbar spine without IV contrast is the preferred imaging modality for evaluating suspected radiculopathy to identify nerve root compression 2
• For patients with greater trochanteric pain, evaluation of the hip region itself would be more appropriate than focusing solely on the lumbar spine 2
• Electrodiagnostic studies can help confirm the diagnosis of radiculopathy and distinguish it from other conditions 3, 4

Clinical Implications

• Misattributing greater trochanteric pain to lumbar radiculopathy could lead to inappropriate treatment targeting the spine rather than the actual source of pain 5
• Treatment approaches differ significantly:
  • Radiculopathy may respond to epidural steroid injections, neural mobilization, and specific spine-focused interventions 5
  • Greater trochanteric pain typically responds to local treatments such as physical therapy, corticosteroid injections at the greater trochanter, and addressing biomechanical factors 2

Common Pitfalls to Avoid

• Assuming all leg pain is radicular in nature without careful clinical correlation 4
• Relying solely on imaging findings without clinical correlation, as disc abnormalities are common in asymptomatic individuals 2
• Failing to consider overlapping or multiple pain generators in patients with complex presentations 2

In summary, tenderness to palpation at the greater trochanter that worsens with pressure is not a typical feature of lumbar radiculopathy and suggests an alternative diagnosis that should be specifically evaluated and treated.