Case Reports

Case Study: Chronic Hip Right Pain and Dysfunction

Fit 46-year-old nulliparus office worker (half desk time half in the car and meetings 50hrs per week) presents with two years of constant distressing hip pain and dysfunction she has had on and off for decades. Using manual and exercise therapy over a 3-month period the patient doubled her hip range of motion and reduced the pain to discomfort.

Subjective Data

History:

Patient says that lately the pain has become intolerable but normally puts up with it. Likes to exercise at gym and walking a few km but both becoming hard to do with the pain. Has problems putting on shoes. She has had recurrent hip issues for decades.

Chronic hip dysfunction that is affecting patient’s ability to keep fit, control weight and starting to affect ADL’s. Needs diagnosis of hip problem and management plan.

Chief complaint

Onset:

Two years ago, but on and off for whole life. This time started in the R buttock.

Location/Radiation:

Right groin, right buttock, associated ipsilateral and to a lesser extent contralateral knee pain.

Duration:

Mostly constant hip discomfort requiring PRN NSAID most days.

Timing:

Exercise helps sometimes, does not wake at night but worse in the am.

Character:

Throbbing, shooting, stabbing

Aggravating:

Walking, sitting, putting on shoes.

Alleviating:

Massage fortnightly ish for the past couple of years, rest, and movement.

Severity:

Current VAS 7/ 10

Past history:

When probed she admitted always had problems sitting cross-legged on the floor as a child and the hip problems had recurred for decades. Slow weight gain over years.

Medications/Co-morbidities:

Graves disease (hyperthyroidism) - managed by specialist and GP on oral med’s, considering surgery, mild exophthalmos noted, self-monitors for tachycardia

Marina from GP, for perimenopause, longish monthly cycle, cramping sometimes.

Celiac Disease successfully controlled with exclusion diet.

PRN Anti-inflammatory and analgesia

Allergies: None stated / gluten intolerant

Social History: Married, around 2 OHO drinks per day, high-pressure job around 40-60 hrs per week, busy but not too stressed.

Family History: No children

System review: as per med’s/co morbidities - no other complains.

Vital signs: monitored by self and GP, No fever to

General health and physique: general health good, fit looking tall woman BMI 27

Objective Data

Examination:

Patrick test P +++ L +

Hip ROM very limited – Flexion R 15, L 40 extension R 5 L 10 Internal rotation R 0 L External rotation R 5 L 10 Abduction R 0 L 10 Adduction R 0 L 5

Non-tender R groin, no palpable R inguinal nodes

Tender R lateral buttocks, R adductors

Investigations: needs XR but refuses to have one despite encouragement

Assessment

Impression: Long standing hip problems probably from childhood that is managed through conservative measures but worsening lately. Needs but refuses hip XR to assess condition of the joint, sinister differentials and possible need for surgical assessment now or in the future if unresponsive to further conservative interventions. There is adequate engagement with medical providers for known co-morbidities and blood tests providing opportunity to be vigilant. As she describes this condition throughout her whole life the risk of sinister pathology is low. That said the hip dysfunction is likely to progress with the aging process and it is somewhat frustrating that XR investigation is refused.

Differentials: Hip DJD, Perthes disease, hip dysplasia

Plan

Goal: general reduced pain and increased ROM, ability to put on shoes and walk further more easily. Wants to lose 5-10 kg.

Interventions:

Series of sessions to mobilize the hip, exercises to strengthen associated musculature and maintain/increase hip ROM. Continued reminder that XR would be helpful in determining the condition of the join and help set realistic goals and management going forward.

Follow up/Outcomes

Main complaint:

Pain responded promptly to soft tissue work and mobilization with reported lowing use of PRN analgesia. High compliance to home exercises and stretches. A total of 14 treatments were given between January and September focusing on hip ROM and associated soft. Standing hip ROM in flexion 100 degrees with minimal discomfort. Can nearly reach to tie R shoelaces seated. Knee-ache now more noticeable than hip pain when going downstairs. Quad strength and soft tissue work given.

Further Investigations:

Should really have imaging on hips and possibly knees going forward however patient does not want to at this time. Encourage the possibility of surgical assessment in the long term.

Associated Complaints:

Medications: encourage regular check-ups with GP for thyroid, peri menopause / HRT and CVD risk factors.

Diet/Weight: Encourage a bright colourful plate appropriate to celiac disease with negative energy balance.

Exercises/Stress management: Continue current exercise program of gym and walking with opportunity for relaxation.

Case Study - chronic right hamstring pain following avulsion repair 2 ago

Subjective Data

Fit 48-year-old female empty-nester (retired photographer) injures her R hamstring in yoga 2 years ago. Proximal avulsion is surgically repaired 11 months later with two screws. Completes rehab but complains of pain in the proximal hamstring aggravated by sitting. December 2017 requests removal of screws but specialist says it may make the pain worse. Lyrica helped with the pain, but she came off this as she felt it was affecting her mental state and now using a tens machine daily. Returned to tennis but cannot achieve full forward bend in yoga. Has taken up jiu jitsu recently that she says seems to help.

Patient points to medial R ischium and describes feeling the screws. She describes recurrent LBP for a decade with buttock radiation an says that MRI a few years ago showed degenerative change and discopathy.

Denys reproductive dysfunction or pain.

Annoyed and frustrated by the pain and limitation of flexibility.

Meloxicam PRN (NSIAD), Turmeric 1g daily (NSAID/prebiotic)

Regular check-ups with GP, normal BMI, normotensive, fit and active, social drinker, in happy new relationship.

Healthy looking with athletic build and flat abdomen.

4-5 x / week (yoga, jiu jitsu, tennis)

Objective Data

Examination

Adams negative, standing toe touch limited by hamstring tightness 15cm.

Lumbar ROM, normal with some mild pinching at end of rotation and in extension + sidebend (Kemp’s) bilaterally.

SLR R 55deg (+ve for similar discomfort) L 90deg

Investigations states a Lumbar MRI a few years ago revealed discopathy and DJD.

Exquisitely tender R proximal hamstring attachment medially along teno-muscular junction. No palpable foreign bodies (screws).

R Gluts tender consistent with mild R greater trochanter pain syndrome

Assessment

Impression - probable adhesions associated with post-surgical hamstring avulsion with mild posterior trochanter pain syndrome.

Differentials - Low back / sensitivity to surgical screws

Plan

Patient wants reduce pain and increase flexibility.

Intervention - apply specific soft tissue work to painful areas, strengthen buttock and core (home clamshell, add Pilates, hamstring stretch), re-evaluate.

Post - reduction in discomfort, standing toe touch 2cm (down from 15)

1 week follow up by phone - considerable improvement in ischial discomfort stating, "You did a great job."