COHF 009: 40-year-old female who was referred to a physio rehab by a friend because she had complaints of the following issues: Sudden onset of pain in the right groin, radiating to the right front thigh, and marked limping for one month.
Today, Episode Nine. We’re gonna be discussing a 40-year-old female who was referred to a physio rehab by a friend because she had complaints of the following issues: Sudden onset of pain in the right groin, radiating to the right front thigh, and marked limping for one month. No associated history of fall or trauma. Was out on a vacation while walking one morning, and the pain started. Right leg felt heavy because of lack of strength. Pain was pulling in nature. At rest, the intensity of pain was 0 out of 10; on activity, it was 5 out of 10. Had to give up regular walks completely due to severe pain. Attempt to sit with crossed legs gives sudden shooting pain in the groin, due to restriction of the motion as well.
Aggravating factors are walking for 15 minutes, rotary movement of the hip, jerky movements of the hip or knee, crossed leg sitting, and squatting. Relieving factors were rest. Some lifestyle issues: She’s an architect by profession, a very fitness conscious person. She does yoga three times a week, weight training in the gym the other three days. She loves walking every day.
On evaluation, she was thin or lean built with slightly prominent hip bones. She had sway back posture. On palpation, it was tender in the groin area and on the right hip joint. The right hip joint contour is slightly more bulging. Inward rotation of the hip was painful. Outward rotation of the hip, restricted and painful. Lower limb strength reduced, the right was weaker than the left. Difficulty in balancing on the right leg when standing, squatting painful, and waddles when she walks.
Let’s Hear From The Council!
Given already that we know that she likes to get out and walk a lot. The first point with the biomechanical analysis is I’ll probably have a look at her gait to see if there are any abnormalities there, both having a look, treadmill based analysis, making sure you’re having a look from the front and from the side, but also using force plates to see how much force she’s putting through on the ground contact on each leg during her gait, too. I’m also thinking to have a look at some of those movements that she’d be performing in the gym, so maybe some squats and some lunges, and try to quantify that as well, using our movement assessment tool, a video analysis, and the force plates. So I’ve got some objective data that I’ll be able to use in her management plan.
Usually, first treatment is just trying to get everything under control, trying to get to a relaxed state. And usually, the second treatment, that’s when we kinda find where the main issue is. And about that time, that’s kinda when we go in with the deep tissue, we go in with the trigger pointwork. We do some effleurage and petrissage, a little bit to relax it, as well. But we’re trying to look and see if it’s not more in a hypertonicity or adhesions that are causing it. We are making sure that we are treating the groin area because that’s where she’s feeling it more. It might be a little bit, even when it comes to the pelvic joint. We might need to shotgun in a little bit and do some craniosacral work, just to see, maybe it was a little off, depending on the activities that this person’s been doing in the past.
I’m gonna establish the pathways projections and systems that appear to be involved in the pain experience. In doing so, I’m gonna avoid making any assumptions about the complaint and as a therapist and trainer, put myself in a position where I can respond accurately to what the client’s nervous system is showing me at that moment in time with regards to the symptoms and what they’re experiencing. I unavoidably do the Sherlock Holmes thing, trying to work out the exact driver of pain and where it originated and all that kind of thing, but I’ve pretty much decided to accept that while I can make some decent educated guesses, it is ultimately a guess, and I can’t just know everything that’s going on in a person’s brain and body. What I will try and do is establish, is the pain more mechanical or chemical or is it both? With this presentation, I’m certainly suspicious of mechanically mediated pain. And so, I’m gonna establish all of the motions that create pain as well as any that relieve the pain. In this case, the swayback posture may be increasing compression of the lower lumbar nerve roots, which could be affecting the obturator nerve, and the waddling gate as it was described sounds like a Trendelenburg, which is suggesting weakness of the glute medius.
Then, we’d want to begin to take from that if we do see anything abnormally, or if not, gothrough and collect 3D gait analysis to see if there’s any distinct deviations, any range of motion problems that present themselves. Again, with the swayback and the Trendelenburg gait, it’s gonna tell us if there’s definitely like David mentioned issues going on at the hip. If the hip is weak, especially glute medius, then the adductors kind of pull in causing some strain there. And then if this person again was in some type of different environment terrain, those muscles may not have been able to withstand the stimulus of the stress that was presented from changes in their normal walking pattern. I would also then through the evaluation look at foot mechanics. Is there different from the right to left? We’re looking at the forefoot and the medial arch. Are they supinated? Are they pronated? Again, all these things are gonna change the way they spend time on the ground and the contact times.
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Dr. Mark Wade: Council President, Posture Expert, & Global Health Leader, bringing insight together with the council on health, wellness, physical rehabilitation, neurology and exercise fitness strategies for health care professionals.