HELP ?Groin Pain

[physiouk]

Hi

Just looking for a bit of advice r.e. a patient i have been seeing.

He is a 40yr old male who was involved in an RTA on 29/02/08. His vehicle was hit on the passenger wheel arch whilst stationary with him in the passengers seat (restrained by seatbelt). He has told me he had no immediate pain but after waiting in the car for 2hrs for a recovery vehicle to arrive he noticed stiffness in his lower back and left groin. These are his current problems.
He states his lower back is a dull ache sensation of 7/10 on VAS with intermittent radiation into his right buttock. His groin pain is also a dull ache but does experience intermittent episodes of shooting pain along the path of the inguinal ligament.
He also complains of intermittent numbness in his anterior left thigh and a dull ache which covers the same area and extends into the anterior aspect of his lower leg. He has never complained of pins and needles.
His pain is made worse when walking and after sitting for prolonged periods. He is a driving instructor and feels that his pain in his left groin is worse when he is driving as he has to sit in an upright position whereas when he is in the passenger seat and teaching, his seat is pushed right back with his legs fully extended and the seat reclined slightly in order to see his pupil.
He has difficulty sleeping at night and must sleep with his left leg hanging out the side of the bed.
I must also add in here that he had a previous RTA in May 2007 which left him with similar injuries. After 4months of physiotherapy his pain reduced and he was able to function and lead a 'normal' life with minimal pain. The doctor advised him that he had a strain of his rectus femoris tendon which was the reason for his pain.
However this recent accident has flaired up all his previous injuries and has left him with a large amount of pain. He has also been diagnosed with OA in his left hip and has had an ultrasound over his left testicle to ensure this has nothing to do with his pain...this showed no problems. He has also been investigated for hernias but no positive results. He has had no further scans on his back or groin area.
All lumbar spine movements are reduced to half with an increase in pain in his lower back. Hip flexion is also reduced to half with an increase in groin pain. He has three quarters lateral rotation with pain in groin and full medial rotation with pain throughout movement. Increase in groin pain on resisted hip flexion, extension and adduction. Patient states he feels he does not have the strength in his left leg to adduct it and often complains that he cannot actively cross his left leg over his right (not due to pain but due to weakness).
On palpation he has tenderness and spasm in lumbar spine paraspinal muscles. Palpation of the attachment point of the inguinal ligament and adductor muscles is extremely painful and recreates the patients pain. It also causes reproduction of the numbness in his left leg when pressure is placed over the groin area.

Lumbar mobilisations, deep frictions, massage, strengthening and stretching exercises are having limited effect so far.

If anyone can give me some advice it would be much appreciated. Not sure if i have put down enough information so please ask any question and I will try answer them!
Thanks!!

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[eils]

Hello Physiouk
Have you done a full neurological exam - Power, sensation, reflexes ? It just sounds like a L3/4 dermatomal pattern and then most of the adductor muscles are supplied by the obturator nerve (L2/3/4). Maybe a neurodynamic test also - Straight leg raise or prone knee bend. Has he had any investigations for the lumbar region after the accident?
Very best of luck

[morwenna]

The back and groin pain may or may not be related. An MRArthrogram of his hip might show damage eg a labral tear, or rupture of lig teres? He may be experiencing impingement syndrome of the hip?

[jesspt]

How about specific ortho provocation tests for the hip? FABER test? Gensalen's test? Scouring test? If these are positive for reproduction of groin pain, could be labral, or some OA-related pain. I'd recommend gentle hip mobs, such as long-axis distraction, and anterior-posterior glides.

Have you tested repeated movements ofthe lumbar spine?

With no symptoms distal to the knee, and a relatively recent onset of LBP, he would likely respond to lumbar manipulation.

[junior_physiotherapist]

Well, inaddition to above try to assess if ur patints suffering a referred pain(visceral) pain ,as if he had/have a tendernss on grion ,burning sensation at urination, no more drinking water,constant pain,blood at urine (what ever amount),
back pain at costvertebral area goes to anterio aspects of abdomin!

[Yarok]

hi


looks like referral problem with inuinal ligament ie trigger points

check pelvic balance ( sacro IJ ),
check ililumbar lig,
obviously lower th and hole lumbar spine.
thanks