(8th January 2011)
Hi everyone!
I am a Singaporean physiotherapy student and i need some help with a patient i have been seeing informally for a while. i am unsure of source of the inguinal hip pain she is presenting with and how should i approach it.
53/F Housewife & part-time kindergarten teacher, Singaporean (recently since 2 months ago, works from 7am to 3pm with a lunch break)

History:
History of sudden delibitating lower back pain (12 years ago)in lumbar segments that were worse with going down stairs and 'certain provocative movements', poorly diagnosed by GP as slipped disc, no investigations done, prescribed beserol - muscle relaxant and adviced to rest and given core exercises (leg lifts, supine LL cycling) which were not adhered to, GP adviced pt against doing sit-ups. Pt progressively has frequent onset of LBP (once every 2 months on average) from thence on, aggravated by lifting acitivities (carrying toddlers, grocery shopping, laundry, hyperextension of back in standing), stress/anger, anxiety/fear. Back pain remains diffused over lumbar segments and alternates in relative severity between left and right sides of spine.
Pt finds relief by lying supine with both knees brought up to her chest and held there for about 5 minutes or more depending on severity.
History of fall when pt was 18 y.o., fell on her tailbone and did not seek treatment, pain in coccyx area when pt sits in cushioned chairs i.e. sofas, movie theatre seats, progressively improved

Patient gave birth to 4 full-term babies via cesarian from 1986-1996, no occurrence of slipped disc but reported that 'baby sat on her nerves and provoked nervy pain in both hip joints throughout pregnancy until child was given birth to'.

Patient is not on any current medication, does not participate in regular exercise. Is on her feet at least 12 hours a day doing housework and teaching in the kindergarten. Has poor motivation to continue doing any form of exercise ie. takes up line-dancing and quits after 1 session. Complains of stress during day and constant pressing need to fufill daily chores. Plays computer games daily for an average of 2 hours a day at night to de-stress. Sleeps an average of 6 hours daily on a firm mattress, alternating between supine and side-lying. No sudden loss of weight, although pt reports having fevers and flu on average of once a month due to weather and fatigue

Current presentations:
Pain-
P1: Same lower back pain R>L in lumbar region aggravated by carrying toddlers who struggle in her arms (first few days of school) for the past 3 days and having to do paperwork on tables and chairs meant for children (undersized) in the kindergarten resulting in a crouched position. Pain is nagging and lasts for the rest of the day after it is triggered. Pt is able to walk with an antalgic gait (weight-bear more on L) with the pain and carry on with houshold chores but needs to take rests (lying supine) of about 1 hr after work before commencing housework. Pt also reports avoiding certain movements of her neck, shoulder and trunk to prevent aggrating the existing LBP.
P2: (this is the one im most confused about) Recently developed deep, sharp and localized bilateral anterior hip pain in the medial inguinal region (L>R) with prolonged hip flexion in sitting >/= 80deg for more than half an hour in the last year, limiting hip extension from sit-to-stand. Pain in inguinal region occasionally spreads down anterior thigh no more than 2 inchs from inguinal line. Pt hobbles in a flexed hip posture for about 30 steps after which her pain disappears gradually. This pain also causes her to feel weakness in the LL. The relationship between the onset of P1 and P2 is usually independent of each other although currently the pt is experiencing both pains. No treatment seeked for any of these pain due to financial difficulty as expressed by the pt. No night pain, no morning stiffness.

Objective assessment done:
Observation- no swelling, no redness, no warmth on any of the affected regions. Pt c/o pain on lying on L hip with hip flexion in 80deg, avoids lying prone due to back pain. Small quads muscle bulk, generally slim limbs except for obvious paunch 'due to multiple cesarian operation'. Pt actively trying to lose belly fats by commercial methods ie. slimming pills
Posture- slight anterior pelvic tilt in standing. R foot placed in external rotation (45deg), normal Q-angle, mild flat feet
ROM-
AROM of hip: within functional length (WFL) and no pain
AROM of trunk: rotation L>R
PROM of hip: R - 10 deg internal rotation, 45 deg external rotation, 0-5 deg extension, 110deg flexion with pain, L - 10 deg internal rotation with pain in inguinal region, 40 deg external rotation, 0-5deg extension, 110 deg flexion with more pain than R, less pain with distraction added. all ROM presents with firm end-feel except of soft-end feel in flexion due to soft tissue approximation.
MMT-
Hip: flexion 5, adduction 4, abduction 4, extension 4 (R=L)
Accessory movement-
Compression of hip joint: pain reproduced on L side
P/A, A/P glides of hip joint: more lax in L hip, no symptoms reproduced
Special tests-
Quadrant test: positive on both sides, L>R in hyperflexion internal rotation and adduction
Gait-
normal gait pattern with lordotic posture and external rotation of feet as seen in stance phase. mild trendelenburg gait is observed indicating right hip abductor weakness.

Analysis:
Increased carrying activity as an aggravating factor for the LBP plus pt's lordotic posture does suggest a case of PID (prolapsed invertebral disc) of the lumbar region however pt did not report any numbness or paraesthesia so far therefore an investigation is required to confirm the diagnosis.
With the anterior pelvic tilt and limited hip extension, the inguinal pain could be a result of compression of the anterior hip joint structures involving joint capsule, labrum, nerves and vasculature and adaptive shortening of the hip flexors due to poor biomechanics.

Treatment so far:
Hip flexor stretches in lunge position, squats (with attention to correct alignment), lumbar support to be worn during work and when there is pain for the time being, adviced to take up exercise regime of brisk walking daily for at least half and hour at an exertional level of working up a sweat preferably after dinner or after work as a means of transport home. Taught patient how to actively put pelvis into posterior tilt in supine and to do it with knees bent as a ROM exercise daily.
Besides the use of the lumbar support, this pt did not adhere well to the exercises prescribed and continues to c/o of the pains which have been progressing.

Questions:
How i can improve my treatment approach?
How can i find out which structures are causing the inguinal pain?
Also, should i advice this pt to go for an x-ray to confirm her slip disc?

To all who took time to read this lengthy case study: thanks a million! Hope someone could shed some light for me as i have not been able to find any threads on anterior hip pain of this nature.

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