Subjective History: 35 y/o female presents with hip and back pain.  She had no injury or accident but has been dealing with back pain for 5-6 years.  She sought care from surgeon who ordered MRI (5-6 yrs ago) that showed DDD but that she was too young for surgery and has to deal with the pain.  In Feb 2014, her right hip “gave out” on you on her way to work one morning.  The sensation was a pinching in the groin that hurt on every step.  It hurt so bad that she went to ER who then referred her to Dr. *&$^(.  She has had multiple x-rays, bone scan and then MRI of hip showing a torn labrum in April 2014.  She wound up losing her job after 14 yrs due to not being released to go to work.  She had another consult in Sept 2014 with a surgeon for hip, but was told to lose weight and she was not a candidate for surgery.  She started another job (that involved 8 hrs of standing) shortly thereafter but after one week, she could hardly stand due to right hip pain arising again and numbness in right leg.  She then sought care from her PCP, Dr. *^%*, who referred her for CT scan (for back) and then to Dr. *$&^.  She had a consultation and then referred to PT.  She was told she would have injections.

Onset

Date of Onset: Back pain and numbness in right leg for past 5-6 years. Right hip pain started Feb 2014. In 2010, she had to have ambulance get her from her house due to her back giving out and right leg “stuck” resulting in her having to be put asleep to get the right leg extended again. Onset Due To: Unknown. Recent Symptom Trend: Condition worsening.
Symptoms
Primary Symptoms: She c/o numbness down right leg from hip posteriorly to 5th digit. Provokes symptoms: Any movements. Hurts with standing/walking/sitting and doesn’t matter what type of chair. Relieves symptoms: trying to stretch (nothing specifically) and sometimes medication.

Pain Rating:

Currently: 6.5/10, Best: 3.5/10 (between stretching and medication), Worse: 10/10 (see above but also occurs weekly).

Sleep Disturbance: She barely sleeps. She tosses and turns all night only getting 4-5 hours. This has been going on for years.

Vocational
Current Status: Not working. Has lost 2 jobs in last few years due to functional limitations.

Objective
FABQ (work): 19, FABQ (physical activity): 22.

Oswestry: 56%

Observation: Unable to stand without dysfunctional pattern and using B UE for support.

Observation: Single leg stance 5″ on left limb, 1″ on right limb.

Palpation

Hypersensitivity along entire lumbar spine from L1-S4 mostly centrally > laterally ~3 fingerbreadths from SP

Lumbar Spine Flexion: 
Very restricted to patella bil and pain low back (all AROM equally painful in same location in LB)
Lumbar Extension:
Very restricted
Only ~5 degrees. (all AROM equally painful in same location in LB)
Lumbar L Side Bending: 
Very restricted
Only ~10 degrees. (all AROM equally painful in same location in LB)
Lumbar R Side Bending:
Very restricted
Only ~10 degrees ((all AROM equally painful in same location in LB))

Reflex Tests
Achilles Tendon Reflex (S1)
Absent (0) on right, 1+ on Left
Patellar Tendon Reflex (L4)
Diminished (1+) bilaterally

Neurodynamic Tests
SLR
Positive
~40 deg SLR for LB but not leg symptoms on LEFT, and ~20 deg SLR for LB but not leg symptoms on RIGHT (+ crossover)

Lower Extremity Dermatomes (to sharp prick):
L1: Inguinal Region: Intact

L2: Upper Thigh: Intact

L3: Mid Thigh: Intact

L4: Patella, medial leg, medial malleolus: Intact

L5: Dorsum of foot, 3rd metatarsophalangeal joint: Intact

S1: Lateral aspect of calcaneus, lateral aspect of posterior leg: Diminished
Absent to lateral aspect of foot from calcaneus to MCP of 5th digit.

S2:Medial aspect of posterior leg: Intact

Lower Extremity Myotome Strength

L2: hip flexion: 4/5
Generally weaker on right side
L3:Knee extension: 4/5
Generally weaker on right side
L4: Ankle Dorsiflexion: 4/5
Generally weaker on right side
L5: Great Toe Extension: 4/5
Generally weaker on right side
S1: Ankle Plantarflexion: 3-/5
Unable to perform single calf raise on RIGHT, 18 reps on LEFT
S2: Knee Flexion: 4/5
Generally weaker on right side

With the information provided, how would you proceed? What other objective/subjective information do you need?  Is this individual appropriate for PT services?

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13 comments

  1. Hey Harrison,

    Challenging case and I have to say I’ve been there… You have clinical findings that suggest some significant neuro issues yet physician(s) say no medical intervention warranted based on imaging and their exam. She sounds like she is definitely “sensitized” as they say in the chronic pain verbiage. This supported by your palpation assessment and painful ROM all directions, positive SLR, etc She also has some historical findings that fit this chronic pain profile.. The loss of job, likely financial worries because of that, multiple medical providers with no help to date, etc. Did you do a fear avoidance or catasrophization outcome measure to gauge this? Also did you try the jendrassik maneuver to see if that Achilles reflex is truly absent? With the S1 weakness, is it truly weak or that she is not wanted to do a a heel raise because of fear/pain which would be consistent with her poor single leg balance test? With all the physician consults and being passed back and forth to different specialists and having various imaging studies, you would figure a S1 encroachment would have been picked up if she was a true candidate for surgical intervention. That being said, you have S1 pattern symptoms that you don’t want to ignore…I would say keep her under your care to watch over her so to speak so she doesn’t feel like she is victim to another healthcare provider that passes her along. The pain science perspective, popularized by Adrian Louw, David butler, and lorimer mosely is definitely something to explore to help her understand what pain is but more importantly what it is not. I would choose carefully on the words you choose to explain your examination findings as they can induce fear (I posted on that here: https://goldricksteve.wordpress.com/2014/11/17/we-ought-to-watch-our-tongue/). Hope that helps.

    1. Steve,
      Thanks for the comments and feedback. This is absolutely a challenging case.
      In regards to weakness/DTR impairment; I feel this is a true finding compared to the rest of the physical exam. It does seem as if she is ploying with me in regards to motivation and actual effort with the physical exam, but the consistent findings of dermatome/myotome/DTRs show the encroachment.

      It is very difficult to get anything done with this individual as you can imagine. Believe it or not, dry needling to the lumbar spine helped tremendously the first visit taking away pain for first time in 6-7 yrs (lasted about 3 days). However, did not get as strong of a response the 2nd visit. Still cannot perform other manual interventions due to inability to tolerate manual pressure, even very light (hence reason I went for DN and she did not have an allodynic response…sometimes you would put DN on contraindication list if hypersensitive but in this case, it was effective).

      H

  2. Id be interested to know seated hip IR/ER passively, if there are frontal plane add/abd asymetries r/l and via passive gleno-hum IR at 90 to find thoracic asymetries r/l?

    The case sounds fimiliar to me, feel like ive had a couple people who present with a similar pattern recently but obviously id like to know those test outcomes before making more assumptions.

    The pts ive had like this had a pain on the right side that wouldnt turn “off” because their structure mimicked right stance while their weight bearing (like your left leg 5-1 ratio) told their brain they were in left stance. Hence the conflict, and the unending spasm yet surgically/image-wise they couldnt jusify an operation.

    There are a couple ways to go about treating this but without those tests im just blowing smoke… It just sounded oddly fimiliar and i could be wrong, but if you find extra hip IR on the left (the rt should be more than normal, but less than the left), more rt abduction vs left and less left adduction, oh also, right HG IR should be less than the left IR indicating the Tsp is “stuck” in rt stance to.

    Good luck, id love to know how this progresses

    1. Thanks for the response. I’ll take a peak more at GH ROM but hip ROM was about 12-18 degrees on both sides in seated (flexion). Interesting enough, ER was painful in prone on the right side but not the left.

      Hv

  3. If she has not tried aquatic therapy yet, I would request an order and get her in the pool. Twice a week for 2-4 weeks to get her moving in a pain free state. Good luck, sounds like she is ready to feel better!

  4. As I think about this case again it looks like you did do the FABQ and the scores weren’t too bad.. I’m eager to hear about how the rest of this case turned out..

  5. I think this could be one of those cases that is simply ” it is what it is”. She needs a labral repair. 90% of the hip labral pts I have seen do well with surgery, This seems pretty straightforward, Occams razor and all that.

    Jeffre

      1. Harrison,

        Sure it can. Just had a pharm tech that works at the hospital pull me aside for a quick consult. Complained of low back and hip pain that some times went to her knee. Ran her through a quick Directional preference routine with NC in sx. Looked at her hip. Reproducible familiar pain with FAIR test/movement. Pt stated “That’s it!”. She was initially upset telling me about her problem because she had already saw a MD and 2 PTs. And she was worried/upset because she was afraid to lose her job as she had to stand all day and that’s what made it hurt the most. Anyway, told her it was probably from her hip not her back and you could see the relief come over her. Told her to follow up with her MD and ask for an MRI. Haven’t seen her yet so I am interested in what she decides to do now that she does not think its her back and she won’t be paralyzed.

        Jeffre

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