Right hip pain

[sakerwalla]

35 yr female marathon runner, hurt her right hip while on the 21st mile while running, heard a pop and pain but continued to run till the finish. Incident occured in Feb 08. MRI is negative. Main c/o is pain and unable to run. O/E tenderness/tightness over right piriformis, pain with flex/add/ER of hip(GMed), standing left iliac crest is slightly lower, lying down right lower extremity is shorter and coming to long sitting position the leg telescopes and equalizes the leg discrepancy. Already tried SIJ mobilization/manipulation, Piriformis/GMed stretching and SI MET correction techniques. It has helped some and now can walk on Treadmill at 4.0mph for 10-15 mins without pain. But limb length discrepancy remains and pain is still around 3-4/10. Also advised to use a SI belt.
What is happening over here? Any input is appreciated.

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[sharileedahl]

Reading this, my gut is saying SIJ isn't the issue (i.e no true fixation).
With the supine-to-sit test, if there is an apparent LLD (leg length discrepancy) in supine but not in sitting, my thought would be that there is some sort of myofascial restriction that is causing the LLD to appear. The fact that the apparent LLD disappears when they come in to sitting would say to me that the SIJ itself is rotating as it should.
What other SIJ tests have you done....list them all with their findings and maybe we'll see a pattern that will help. (i.e. both mobility / kinetic testing and stress (pain provocation) testing).
HOWEVER...has she noted any difference when wearing the SIJ belt (either related to pain or function)?

When she heard a pop in her "hip" what do you mean by hip? i.e.....do you mean the actual hip joint or do you mean in the gluts?

What were the findings of all your resisted muscle testing?
Other than pain with F/Add/ER, is there any other positions that she has significant tightness either bilateral or compared to the left?

Since she still ran another 21 miles after the initial injury, it would have been very inflamed so would expect a little more time for things to calm down. However since this happened in February, she should be past the point of pain related to inflamation. Findings may be there at the SIJ but again, my gut is saying the it's the compensatory factors related to an initial muscle strain that's making it look that way (but of course, I'm not the one looking at her!! )

[sakerwalla]

Thank you for the reply.
Standing flexion test was negative for SI Dysfunction. Resisted hip extenson and abduction was weak on right 4/5 no pain. Stretching of piriformis revealed tightness and pain. ITB-- NO tightness. lumbar spine ROM full and painless. I have done lot of soft tissue mobs for piriformis and GMed and it helped. I have seen her for 9 sessions.

[sharileedahl]

Just going to "talk out loud" here for a minute for the purpose of problem solving...don't think I have a strong opinion as to what is going on yet.... Let me know what you think....

1. IF THE POP WAS IN THE HIP (i.e. the hip joint)
Could it be possible that the ITB "flicked" over the greater trochanter? Could the pain be related to irritation of the ITB / trochanteric bursa / muscular attachments in the area... Resultant muscle tightness could be due to compensatory factors?
I suppose you don't know what her running technique BEFORE the injury (unless you saw her before that race). If she was somewhat weak throughout her gluts / core and had trendelenburg type of gait while running it could be possible even if her ITB isn't "tight".
Questions: Where was the pop? Any tenderness over the greater trochanter? Any discomfort with testing ITB length (Ober's)?

2. IF THE POP WAS IN THE GLUTEAL AREA
Potentially could be a tear in a muscle however I guess I wouldn't suspect it unless she had a previous injury / was running with pain in the first place / was running with a healing injury.... (I say this because I would suspect a tear in any of the muscles in this area would take a large force (trauma) or a sudden eccentric force (jump / sprinting) rather than repetive motion at a slower pace (ie. marathon).....but again - this is just a suspicion...could be wrong)

3. IF THE POP WAS AT THE SIJ
Again, my gut is saying this is unlikely but again...I'm not the one looking at her. Did you stress test the SIJ and the pubic symphysis?
Question: Does the SIJ belt help (ie. does it allow her to walk further; is her pain less...)? If it does, it doesn't necessarily mean there is instability and / or dysfunction at the SIJ...it could mean that it is just assisting by backing up some of the "core muscles".

Anyway....since it has been 5 months since the original injury maybe the initial injury doesn't matter as much at this point (unless of course there is some instability at the SIJ / pubic symphysis)

I think I would, similar to you, be dealing with the myofascial tightness to try to normalize the tension in the area. Along with this it would be important for the client to be doing stretching (QL, quads, gluts, hams, iliopsoas) and strengthening (gluts, overall core) daily to sort out any muscle imbalance. With her walking, ensure she is maintaining good technique and not fatiguing in to a trendelenburg gait (although watch her and see if her gait changes once her pain comes on).

What does she do for the rest of her day...i.e. at home / work? Is there anything else that could be playing in to this?

Interested in hearing your thoughts.....

[sakerwalla]

Thank you again for the reply.
Ober's test was negative. NO tenderness OVER the greater trochanter, however, some tenderness over the posteriorsuperior aspect of GT.
POP was in the Hip area as she described it.
I checked her running technique. I found it was good.
She is a Nurse, traveling position.
SI belt did help her with running on the treadmill. She ran on the road(without the belt) again past weekend and after 1.5 miles her hip started bothering her but not to the same extent as before. She stopped as I had instructed her and did brisk walking and went for another mile. Maybe she is just deconditioned from not doing the running for 5 months. She has good core stability and hamstrings flexibility.
Another interesting finding was when she outstretches her both arms at 90 degrees flexion, her right arm is slightly shorter in length. She mentions her right side is weird from before.
She was off for a month so close to home. Now she is back to traveling but I will get in touch with email and see how she is doing. She did order the SI belt.

[alophysio]

Hi sakerwalla,

Your last post did it for me...it sounds like a thorax dysfunction causing myofascial referred pain.

The 'pop' doesn't sound that serious.

She was nearly finished in the race - she only had 5 more miles to go so was 80% through the race - fatigue is likely and she probably went into a habitual motor pattern and likely overused her obliques to help her breathing or stability (i don't think her core stability is that good if the belt helps her BTW )

The thorax experts are definitely LJ and Diane Lee, LJ esp in the rehab side of things.

Good luck with her - the SIJ is likely to be secondary to the thorax giving way.

BTW, thanks for the good posts sharileedahl!

[sharileedahl]

That's a good point (alophysio) ... didn't think of that.
Related to that, there has been some good recent research re. breathing patterns in relation to pain. If the patient changes their breathing pattern (i.e. change in ratio between inspiration and expiration), it has been shown to have significant effects on pain patterns and recovery from injury. May be useful to look at it in addition to everything else.

(Just want to add.....sorry, I got my miles and kilometers mixed up! I was thinking she was 21km in to a 42km marathon rather than 21miles into a 26mile marathon! I've been thinking to myself...."Holy crap! This woman is a MACHINE!!!" )

[sakerwalla]

Thank you Alophysio and Sharileedahl. You both have made good points.