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According to the most recent ChiroUp Clinical Outcomes and Patient Satisfaction Synopsis of more than 630,000 unique presentations, lumbosacral pain is the most common complaint in chiropractic practices.

Fortunately, most low back and buttock pain presentations are straightforward diagnoses that respond quickly and favorably to chiropractic management. But… 😏those elusive few presentations that fail our care are the ones that keep us awake at night.

Lucky for you, ChiroUp is on a mission to help you sleep well as an Expert Clinician armed with the latest skills to confidently resolve problems. So this blog will cover one of the most overlooked causes of lumbosacral and buttock pain, as noted last month in the Journal of General and Family Medicine (1):

“Cluneal nerve entrapment syndrome is often overlooked and misdiagnosed.”

And if a PCP can recognize an unusual mechanical LBP diagnosis, you should be a master at managing it; in the next 3 minutes, you’ll learn the essential cluneal neuropathy clinical skills to help ensure you won’t overlook or misdiagnose this condition ever again.

What Is Cluneal Neuropathy?

Quick answer: Irritation or entrapment of the superior cluneal nerves

Cluneal neuropathy describes entrapment of the superior cluneal nerves at the iliac crest. The cluneal nerve originates from the thoracolumbar dorsal rami then diverges inferiorly into branches that surface through osteofibrous tunnels over the iliac crest, approximately 4 and 8 cm from midline.

Entrapment often occurs at the osteofibrous orifice where the nerves penetrate the thoracolumbar fascia before innervating the cutaneous regions of the iliac crest and buttock. (5-8) These distal entrapments can increase neurodynamic tension on the dorsal nerve root, thereby generating ischemia and hyperexcitability. (7,8) Compression or irritation results in radiating pain or paresthesia into the lumbosacral spine, hip, or buttock.

How Does Cluleal Neuropathy Differ From Maigne Syndrome?

Quick answer: Peripheral vs proximal nerve irritation

Any reference to cluneal nerve entrapment would be incomplete without a discussion of Maigne syndrome; however, those diagnoses are not synonymous. Maigne syndrome involves irritation of the dorsal root near the spine, while cluneal nerve entrapment is a more peripheral neuropathy. The relationship could be likened to cervical radiculopathy and carpal tunnel syndrome, respectively. And the conditions frequently co-exist as double crush partners. Check out ChiroUp to learn how.

Who Gets Cluneal Neuropathy?

Short answer: A S#!t ton more patients than you would expect

Cluneal nerve irritation (including Maigne syndrome) may be a causative or contributory factor in up to 40% of LBP cases. (5,40,41) That prospect increases as symptoms extend over the posterior iliac crest. (2) Cluneal nerve entrapment can affect any age group but is most common in the 55-70-year-old population, and seems to have a slight preference for females. (40)

What Are The Symptoms Of Cluneal Neuropathy?

Short answer: It looks and smells like typical mechanical lumbosacral dysfunction

The most common manifestation of superior cluneal nerve irritation is low back pain that mirrors the presentation of lumbosacral or sacroiliac joint dysfunction. (3,9) Symptoms including pain, numbness, or paresthesia characteristically refer to the lumbosacral region, iliac crest, or groin. (7,9-12) Symptoms are typically described as chronic, constant, and unilateral, although the problem could present on both sides concurrently. (3,40).

Cluneal nerve entrapment can be exacerbated by transitional movements, like arising from a seated position, rolling in bed, squatting, lateral bending, and trunk rotation. (8,40) Prolonged walking is also a known trigger for cluneal nerve irritation. (8,12,14)

What Tests Can Help Diagnose Cluneal Neuropathy?

Short answer: Poke, pinch, or tap the nerve

In cases of peripheral cluneal nerve entrapment, patients will often report palpatory tenderness at the primary site of entrapment on the posterior iliac crest, approximately 3–4 cm (medial branch) or 7–8 cm (intermediate/ middle branch) from the midline. (8,12,40) Pinching or skin rolling may demonstrate hyperalgesia over the flank and iliac crest. (10,14,17)

A thickening of tissue over the posterior rim of the iliac crest has been reported in some cases. (28) Tapping a reflex hammer over the entrapped nerve may reproduce symptoms, including a shock-like sensation (Tinel’s sign) (28)

How Do I Treat Cluneal Neuropathy?

Short answer: Cluneal nerve release, manipulation, and rehab

Cluneal nerve entrapment and Maigne syndrome can be frustrating conditions to manage for both patients and clinicians. (3,28) The long-term treatment goals include restoring biomechanical function at the thoracolumbar junction and reestablishing normal peripheral neurodynamics.

Modalities

Electrical stimulation and ice might help decrease pain and inflammation in the early stages. (18)

Manipulation

Dr. Maigne identified “painful minor intervertebral dysfunction” as a common finding in his namesake condition. (3) Not surprisingly, spinal manipulation of the thoracolumbar junction appears to provide benefit. (13,16,35). Manipulation and mobilization should also address any other joint restrictions throughout the kinetic chain, particularly in the lumbar, sacral, thoracic, and costovertebral regions. Some experts advocate for the use of a foam roller to further enhance mobility at home. (36)

Cluneal Nerve Release

Excessive fascial tightness can generate traction ischemia and hyperexcitability of the dorsal nerve root. (33) Myofascial release may help improve fascial movement and pliability in patients with chronic back pain. (34) Myofascial release should focus on the thoracolumbar aponeurosis and distribution of the cluneal nerve (16,18) IASTM could be a management consideration. (16)

Rehab

Flexibility exercises should target the thoracolumbar erectors and iliopsoas, particularly if the patient has adopted a compensatory flexed posture. Stretching could include a standing hip flexor stretch, half-kneeling psoas stretch, and progressive latissimus stretches. Spinal elongation self-correction may also be useful. (45) A progression of pelvic tilt exercises has been advocated for the care of Maigne syndrome. (18)

Early stability rehab could begin with a prone plank and advance to progressive variations. (45) Active rehabilitation should focus on building strength in the hip and core stabilizers. (9,16) Long-term resolution necessitates the restoration of normal breathing mechanics and correction of any other contributory functional deficits.

How Do I Motivate Cluneal Neuropathy Patients to Follow My Treatment Plan and Actively Participate?

Short answer: Four clicks

We’re glad you asked because we made this one crazy simple. Watch this 1-minute video to learn how.

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Essential Skills To Resolve Cluneal Neuropathy