Hi, Fouche.

My answer will be based on the assumption that you have applied "direct" pressure to the L4 segment and by that partially or fully reproduced the patients hip pain. If this is false, please provide information on what different method you used to identify the L4 segment as a component of the hip pain.

My initial choice of technique would be a postero-anterior mobilization technique to the area which reproduced the patients pain the most. I would also try to locate which direction this pressure reproduced the sym's. For example, you often will find different symptom response if you do a cephalad or a caudad directed mobilization. And equally so with a medially or laterally directed technique. Play around, pick the level/direction that reproduces the most. Apply the technique (goes for all techniques in general) accordingly to the patients severity and irritability (and nature) and always make sure the patient is treated within his/hers acceptable limits.

The next thing is patient position. This has been an eye-opener for my part as I've many times gotten really good results on reassessment when I "nailed" all components - for me the main component has been patient position while technique is applied. In which activity/test position does the patient reproduce the sym's? Is it while the hip is extended/flexed, up/down steps, leaning forward/backward/sideways/rotation/combined, etc. Now, try to replicate that position. You've now got two choices - either replicate something like that position on the plinth - e.g. flex the plinth, put patient prone to replicate standing forward flexion, or extend, rotate, etc... Then apply the mobilization in that position. Your other choice is to simply add the mobilization technique in the specific position the patient gets his/hers pain. E.g. in standing with affected leg just about to take a step up/down and so on. Hope I was able to describe that adequately... If the patient is in too much pain (likely not with a hip "bursitis") lie the patient in normal front position, find the direction as I talked about and go on.

Another thing to consider, or I should probably say, one thing that I considered before, was how much pressure should I give, at what rate? There's good indication from very recent research that the effect of these kind of spinal mobilizations are not significantly different if you give 50, 150 or 200 Newtons of pressure or a rate of 0.5 Hz, 1 Hz or 2 Hz (1 Hz = 1 push per sek) or even static pressure of 200 Newtons. These results were based on 1 minutes applied 3 times with 30 sek apart. 200 Newtons is about 19 kg I think, and is not much, most people would apply more, everything up to 45 kg. The point being, it doesn't really matter how you apply it... Just do something. More importantly, observe how the patient responds when you apply them and adjust thereafter.

Always remember to reassess!!! That's just one technique, would be nice if some other people also gave some input on other neat stuff to do.

Good luck!