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100 m a s s a g e & b o d y w o r k n o v e m b e r / d e c e m b e r 2 0 1 6 Entrapment of the superior cluneal nerve fibers can occur as they pierce the thick thoracolumbar fascia, or they could also be compressed against the bony edge of the superior iliac crest. The thoracolumbar fascia is a dense fibrous tissue, so it can be difficult to increase elasticity or pliability of the fascia where the nerves pierce through it. The region just under the lip of the iliac crest is a common location for the aggregation of small fatty lipomas. They feel like small peas under the skin when you are massaging this area. They don't appear to involve significant tissue pathology, but they can sometimes be painful. One possible explanation for their pain could be pressure on adjacent superior cluneal nerve fibers. Because the cluneal nerves are so superficial, you are easily affecting them any time you work in the gluteal region. However, working tissues of the low-back region extensively can help free mobility of the superior cluneal nerves in some cases. Static compression or broad contact sweeping techniques may also help free up cluneal nerves in the gluteal region (Image 5). Last year, Massage & Bodywork magazine devoted an entire issue ( July/ August 2015) to treatment of the gluteal region. Many of the techniques described in that issue could be helpful in freeing up mobility and reducing compression on the cluneal nerves. LATERAL FEMORAL CUTANEOUS NERVE A frequently overlooked cause of lateral hip and lateral thigh pain is entrapment of the lateral femoral cutaneous nerve (LFCN). This condition also goes by the name of meralgia paresthetica. The LFCN supplies sensation to the skin on the lateral thigh and hip region. The nerve originates from the L2 and L3 lumbar nerve roots and then courses around the inner aspect of the iliac crest. It then descends beneath the inguinal ligament. It takes a very sharp bend just as it passes the inguinal ligament, Similarly, pain that might be caused by entrapment of the medial cluneal nerves is likely to be felt in the buttock, but could also be felt in the lower leg. The medial cluneal nerve fibers pass just adjacent to the long sacroiliac ligament, and this is one location where they are vulnerable to compression (Image 3). Irritation or entrapment of the medial cluneal nerve by the long posterior sacroiliac ligament is often mistaken for sacroiliac joint dysfunction. 3 Identifying specific tissue causes of sacroiliac joint pain can be very difficult, and one reason may be involvement of nerve pain in small nerves like the medial cluneal nerve that are not easily identified. The superior cluneal nerve is the division most susceptible to compression injury and is a likely cause of back or gluteal pain. Noting the anatomical path of the superior cluneal nerve, it is easy to see how it could be involved in these conditions (Image 4). It arises from the posterior rami of the 1st through 3rd lumbar vertebrae. It angles diagonally from the lumbar spine, and then its branches pierce the thoracolumbar fascia and course across the upper margin of the iliac crest. 3 4 5 Long sacroiliac ligament. Mediclip image © (1998) Williams & Wilkins. All rights reserved. Superior cluneal nerves. Image is from 3D4Medical's Essential Anatomy 5 application. Static compression can free up cluneal nerves. Image is from 3D4Medical's Essential Anatomy 5 application. Long sacroiliac ligament Superior cluneal nerves