By guest blogger Susan Bamberger
Thank you all for your detailed and well thought comments on the first installment of this case study! At the end of the history, we should have some idea of what might be going on. Performing a detailed interview will help to create hypotheses that we can test in the physical examination.
Giving some thought to pathoanatomical causes, it is possible the he may have a tendonosis of the psoas. It is also possible that he has a mechanical impingement of the hip joint. He may also have a structural defect such as a labral tear. The symptoms could be coming from the lumbar spine or the hip, SIJ, knee or foot. It is also possible that he has a stress fracture. Each of these pathoanatomical possibilities are managed in different ways. How do you discern which to treat?
While the pathoanatomical possibilities are there, we do not have the ability to look inside and determine the exact cause. The most accurate information we have in front of us in this visit is the patient’s pain presentation and its behavior of symptoms. We can look at the behavior of symptoms and assess for change in these symptoms through the course of testing. This will become the most effective guide in developing a plan of care.
My assessment utilizes Mechanical Diagnosis and Therapy (MDT) which is used to target the problem based on symptom presentation and behavior. More common in the spine, MDT has proven to be reliable, valid and prognostic in multiple studies conducted over the last 40 years. However, the principles of assessment can easily be utilized in any joint of the body, including the hip.
As I begin to plan the physical exam I must consider all of the factors contributing to his recovery:
- The pain is a 5/10 on a 0-10 scale, 0 being no pain and 10 being the worst pain ever imagined.
- It comes on as soon as he begins running and it ramps up immediately. However, it goes away within a few minutes after stopping his run.
- He does not notice the pain otherwise- he sleeps well, and does not feel the pain when going up and down stairs.
He has been trying to run every few days, without any noticeable change. Any objective baselines I find must be related to the exact pain he experiences when running. However, he was not prepared to run on this visit, so another baseline will need to be used.
To get a solid baseline, I may need to be pretty aggressive in my examination on day one. However, in order for trust to be established, I decided not to try and provoke his symptoms, but rather to educate him in the assessment process and the need for him to participate in the analysis.
The location of symptoms indicates the pain could be coming from the hip or the lumbar spine. The behavior of symptoms does not exclude the hip or lumbar spine. So a screen of the lumbar spine was necessary before exploring the hip in detail.
The physical exam reveals an athletic man in no apparent distress. Left hip passive range of motion into flexion, abduction internal and extension rotation were tested in supine. IR and ER were tested supine in 90 degrees flexion. Extension was tested in side lying. Flexion ROM is approx 100 degrees and painful. Abduction is approx 25 degrees and painful. There is a minimal loss of internal and external rotation, with pain greater into external than internal rotation. Extension lacks approximately 5 degrees to end range.
Resisted motions are strong and painless in all directions except flexion and adduction, which are weak and painful. These tests were performed in supine. Resisted flexion in supine, in particular, produced his primary pain. This was the baseline to refer back to when I perform my mechanical testing later.
While special tests ( Hip scour, compression) could be performed, none were performed on visit one. The patient had been referred from his orthopedist, who was confident there was not an operable structural issue, and there was nothing yet in the history that indicated surgical referral. At this time, special tests did not have a practical use. If there was not a consistent response to the repeated motions, at that time special tests may be indicated for further clarification.
Screening for the lumbar spine did not reveal any significant lumbar component. This was done by first checking for lumbar range of motion in standing, flexion, extension and side gliding were within normal limits. To determine if the lumbar spine was involved, 15 progressively loaded lumbar extension mobilizations were performed in prone, and then his primary baseline ( resisted hip flexion in supine) was retested for change. There was no change, indicating it was necessary to move to the hip for further testing.
The next step is the repeated movement examination, a key component of the MDT assessment process. Responses to symptomatic, mechanical and functional baselines give us the information needed to classify his condition and devise a directed and effective treatment plan. Repeated movements can be performed dynamically, with sustained positions or with resistance. If the baselines demonstrate an immediate and lasting change, the classification is derangement and the prognosis is excellent.
Repeated hip extension in half kneeling was the first movement chosen. Given the irritability of the symptoms, half kneeling would provide a great deal of force, and is a good start to providing movement that will provide immediate and lasting results. The direction of extension was chosen as this is often the direction most frequently seen for patients with hip derangements. The position of half kneeling was chosen as a relatively aggressive position, knowing that since an aggressive force was needed to produce the symptoms, that an aggressive force would be needed to reduce the symptoms.
The patient had 0/10 pain at the start of the repeated motions exam. There was some pain at the end of the range of the first repetition, in the same location as his primary pain. This pain progressively improved with subsequent movement, as did his ability to move further.
In retesting his primary baseline (5/10 pain with resisted hip flexion in supine), 10 repetitions of dynamic hip extension in half kneeling reduced his pain to 4/10, and 10 more reduced it further to a 2/10. His ROM in all planes were restored to symmetrical and within functional limits.
With an immediate and lasting change in range of motion and pain, the repeated motions exam confirmed a classification of derangement, indicating an excellent prognosis. As his pain decreased, his strength also improved, indicating the weakness with resisted hip flexion was more likely related to pain inhibition than true strength loss.
Since we have not actually tested running, we cannot conclude that this movement alone will resolve his primary pain. However, since we were able to find a baseline that reproduced his primary pain, and it changed with the repeated motions exam we have something to start his treatment plan.
The patient was sent home with instructions to assess the effects of this test over the next few days. He was instructed to discontinue any other stretches he was performing, and to perform just this one exercise until he came into the clinic again. This would help to determine the effect of this one stretch alone. Specifically, he was instructed to do hip extension in half kneeling, 10-15 times, 4-5 times throughout the day. In a few days, he was instructed to test running, to see if a few days of the repeated hip extension in half kneeling produced any positive results for running. Pt understood the mechanical issue, and experienced the immediate results during our assessment. He was eager to take a role in the analysis of his symptoms.
Four days later, the patient presented to the clinic with a journal describing his pain behavior and exercises. There was a consistent effect with the exercise: immediate discomfort, then a loosening of the range of motion and a lessening of pain with each subsequent repetition.
He had tried running two days, and was encouraged as he could now run 10 minutes before experiencing pain. In addition, the pain was not as intense- it was a 2/10 instead of a 5/10 as before. He ran to the clinic for this visit, and was experiencing a 2/10 pain towards the end of his run to the clinic. He demonstrated the exercises, and was performing them correctly.
The patient is better, but is it enough to continue with the current plan of care?
What would you like to add to his home program at this time?
What would you do on this visit?
What other treatments would you want to apply, and why?