Curtis, P., Gibbons, G., & Price, J. (2000). Fibro-fatty nodules and low back pain. J Fam Pract, 49(4), 345-348.

BACKGROUND

Massage practitioners spend more time than anyone else in the health care system doing detailed palpation, especially in the low back region. It is not at all uncommon to encounter subcutaneous fatty lipomas in the area of the upper iliac crest. These small bubble-like nodules are usually pain free and pose no significant problems. However, sometimes there may be nodules in this region that are more serious. This article is a report on two cases where deeper and larger fibro-fatty nodules contributed to back, abdominal, and hip pain.

The first case involved a patient who had a chronic case of trochanteric bursitis. She had been repeatedly treated with anti-inflammatory injections directly into the bursa. While these injections did provide some temporary pain relief, they did not have any lasting effect.

It was suggested that a more detailed palpatory examination be performed to identify if anything else might be causing her pain. After a more specific palpatory examination she was found to have a long, rubbery fibro-fatty nodule just above the iliac crest on each side. On one side it measured about 3 cm by 1 cm, and on the other side it was about 6 cm by 1 cm. Repeated deep palpation of these fibro-fatty nodules reproduced the lateral hip pain that she had been experiencing.

She was treated with repeated injections into the fibro-fatty nodule. Each injection contained a specific measure of anti-inflammatory medication. After the repeat injections there was immediate and complete relief of the symptoms.

In the second case the patient presented with significant abdominal and anterior thigh pain that had been steadily increasing over the course of several months. She had been tested for numerous abdominal pathologies and no specific cause of her pain could be identified. One of the clinicians she was working with then suggested that she have a more thorough palpatory examination.

After further evaluation it was found that she had significant tenderness in the sacroiliac region. In addition she had a fibro-fatty nodule about 3 cm long that was over the top of her iliac crest about 4 inches lateral to the spinous processes. Repeated pressure on this nodule reproduced the abdominal and anterior thigh pain she had been experiencing.

She was treated with a multiple injection technique similar to that described with the first patient. This treatment also provided immediate and long lasting relief of the pain she had been experiencing.

DISCUSSION

Finding subcutaneous fat nodules in the upper iliac crest region is quite common for massage therapists. In this study it was estimated that these fibro-fatty nodules might be present in as much as 15% of the population. It is likely that some of the benign fatty lipomas that are felt just under the skin may eventually develop into some of these more serious fibro-fatty nodules described in this article.

The exact mechanism by which these nodules cause pain is uncertain. Because there does not appear to be any specific structural or neurological link from the nodule to the region of pain, it is likely that the pain sensations are from referred pain. The authors of this study suggest that the origin of pain may be in the innervated synovial capsule surrounding the nodule.

Single injections of the nodule were not effective in treating the nodules. Nor was repeated injection with saline solution any less effective than repeated injections with the anti-inflammatory medication. This suggests that it is the repeated injection and not the actual medication that was the therapeutic procedure. The repeated injections appear to relieve pressure inside the nodule indicating that increased pressure inside the nodule may be the cause of the pain.

Since massage practitioners are often in a position to find these fibro-fatty nodules, it is beneficial to be aware of this problem. If increased intranodular pressure were a reason for aggravation of the problem, further pressure during massage would be contraindicated. However, the deep palpation done during massage could be very helpful in locating and identifying the nodule as the source of pain sensations either locally or in some remote region.

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