Dig Deeper to Find the Driver

A few years ago, I was convinced my left hip pain was due to osteoarthritis. When my hip locked up after a 14 mile run, my manual therapist husband differentially diagnosed the pain as discogenic. Partly in denial and partly wanting to know the extent of the “damage,” I got an x-ray of my left hip, which was completely normal, and a lumbar MRI, which wasn't pretty. The source of my hip pain was a disc bulge at L3-4 and L4-5 with a Schmorl's node at L5-S1 to boot. Instead of riding the train of thought that we treat what hurts, therapists need to disembark and look further for the source, as suggested in the course, “Finding the Driver in Pelvic Pain.”

A case report published in the International Journal of Sports Physical Therapy by Livingston, Deprey, and Hensley (2015) documents the discovery of a deeper problem than the referring diagnosis of greater trochanteric pain syndrome. A 29 year old female had to stop running because of lateral hip pain that began 3 months after increasing the intensity and frequency of her running and low impact plyometrics. She had pain in sitting and while running. During the evaluation, she demonstrated a positive Trendelenburg, weak and painless hip abductors, and a positive single leg hop test on concrete. When the pain was not elicited with single leg hop on a foam surface, the patient was referred back to the physician for magnetic resonance imaging. The patient was later diagnosed with an acetabular stress fracture. The therapist’s thorough examination helped prevent possible avascular necrosis or a more traumatic fracture of the pelvis.

In a 2013 issue of the same journal, Podschum et al. presents a case report on deciphering the diagnosis in a female runner with deep gluteal pain with pelvic involvement. A 45 year old female marathon runner reported pulling her hamstring and complained of left ischial tuberosity pain with aching into the gluteal and pubic ramus regions that eventually forced her to stop running. She had pain in sitting and could not tolerate speed work. She had a history of low back and pelvic floor pain, with an MRI showing osteitis pubis, a lateral L3-4 bulge, and facet hypertrophy at L4-5. The physical therapist ruled out lumbar disc lesion, radiculopathy, sacroiliac joint dysfunction, and hip labral tear with special tests. Initial treatment focused on the differential diagnoses of hamstring syndrome and ischiogluteal bursitis based on subjective complaints and objective findings. After 4 visits, her deep ache shifted to the inferior pubic ramus in sitting as the ischial tuberosity pain diminished. A trained therapist then conducted a thorough pelvic floor exam. Pelvic floor hypertonic dysfunction was diagnosed and took over the “driver’s seat” as the focus for the rest of the treatment of this patient. Symptoms resolved and the patient returned to running marathons without any of her initial presenting symptoms.

If we let specific pain complaints guide our treatment, we will run out of steam with the lack of progress. Finding the true source of symptoms is critical in physical therapy. Sometimes so much is going on with our patients we have to sort through the weeds before we can access the actual road to recovery. The lumbar spine, hips, and pelvic floor create an intricate map of U-turns and two-way streets, so we need to deepen our understanding of how to navigate the regions. Only then will be able to confidently diagnose the “driver” and let the other areas call “shotgun.”

References:
Livingston, J. I., Deprey, S. M., & Hensley, C. P. (2015). DIFFERENTIAL DIAGNOSTIC PROCESS AND CLINICAL DECISION MAKING IN A YOUNG ADULT FEMALE WITH LATERAL HIP PAIN: A CASE REPORT. International Journal of Sports Physical Therapy, 10(5), 712–722.
Podschun, L., Hanney, W. J., Kolber, M. J., Garcia, A., & Rothschild, C. E. (2013). DIFFERENTIAL DIAGNOSIS OF DEEP GLUTEAL PAIN IN A FEMALE RUNNER WITH PELVIC INVOLVEMENT: A CASE REPORT. International Journal of Sports Physical Therapy, 8(4), 462–471.