Ballet dancer with unknown pain at hip

Heya

I'm a first year physiotherapy student so I apologise if my terminologies are a little weird but I would really appreciate your help.

A dancer I know has a pain at their hip/groinal area.
She has been to many Doctors and Physiotherapists to try to diagnose what is wrong with her but they still do not know exactly what is going on.
She has had 5 steroid injections into her groin in an attempt to rectify the situation.

She does not appear to have any joint pain at the hip and her MRI is clear indicating nothing structurally wrong with the joint itself.
However she does have some pain when actively testing the adductor muscles in her lower limb.
She describes the pain as continuous even when she is relaxing. It is described as a "throbbing" pain.
It is aggravated by walking and is not eased by either hot or cold modalities.
My thoughts are that she might have damaged her Pubofemoral ligament or Pectineal muscle or adductor group of muscles.

Her goal is to go back to professional ballet as soon as possible.

ROM at knee is normal.
ROM at hip is reduced until the hip joint audibly pops, at which point normal ROM is available.

If you guys could help me with this, it will be much appreciated. Mainly due to the fact that I have been thinking about this for a while now and it is not making sense to me.

Best Regards

Mark

Sounds like the starting place is a good assessment of the pelvis. Have a look at the levels of the ASIS, PSIS, Pubic Symphysis, Flare of either inominate from a central axis (use the naval as a guestimate of midline in the absense of any lateral shift). Then look at whether any of this changes between sitting, standing and supine.

Next look at apparent leg length and also internal and external rotation of the hips and compare sides in supine and with the hip and knee at 90 degrees. Note and difference in all of the above and get back to us.

As you are recently graduated perhaps have someone about during the exam as you will have to palpate in some rather personal regions of the girls body (just to be safe) and explain clearly what and why you are doing things.

Get back to us on the results and don't at any cost let he have another injection. My ex. did the same, tore of a hamstring insertion and ruined her professional ballet career.

Once we work out more clearly what's going on then we can investigate potential reasons why. :D

Hi.

Perhaps she may have ***overactive*** deep hip external rotators causing anterior translation of the femoral head in the acetabulum. This would put increased pressure on the anterior hip joint structures and possibly be casuing the "pop" via tendons flicking.

***This is different to having "tight" muscles***

She may also have overactive psoas causing a similar problem.

THe pain in the adductor region may be from using her "anterior oblique" sling to try stabilise her lumbpelvic hip region. You may find her contralateral external oblique muscles overactive on that side.

Try an ASLR Test - Active Straight Leg Raise - and test to see if there are any compressions at the level of the ASIS or PSIS or Pubic Symphysis that may help.

Also, there are tests that you can do to see if there ligamentous injuries in the SIJ/Pubic Symph etc but in the absence of an obvious event causing injury, it is unlikely (although not impossible).

The above information can be sourced (including treatment) from Diane Lee's "The Pelvic Girdle - 3rd Edition". I am a fan and would recommend this book to anyone who is interest in low back pain...

Thanks

MRI is clear of hipjoint I assume. A popping sound is audible and afterwards the movement is full range.
-Take a look at the syndesmosis of the pubis, MRI? Is the pelvis well aligned? (popping)
-Does patient complain about backpain? (might refer to joint from level T11-L1)
-Is the patient hyper mobile? (instability of pelvis/spine)
-What about Tensor facia lata? (can give a popping feeling and pain on lateral side of thigh, test by e.g. knee flex/ext)
Since your patient is a ballet dancer and female the likelyhood of an instability is great. Pelvis instability can easily be tested and X-rayed (before popping!)
good luck

hi!
how old is the ballet dancer....why not check for inguinal ligament strain....
sana

Hi

I apologise for not coming back sooner but I have been far too busy. Thank you all so much for giving me information on this matter. However, I am only a first year physiotherapy student, so I do not know some of the methods of assessment you have recommended to me. Please note I do not intend to treat her, but am interested in what the problem is so that I can help direct her to an appropriate member of the MDT. However, I can answer some of your questions.

Apparent leg length is the same for both limbs.
She is hypermobile.
Tensor Fascia Lata test is negative. There is no pain.
The Dancer is 21 years old.
Recently, she has told me that she has no pain at her hip. She wanted to go straight back into training for September but I suggested to leave it for a few weeks, which she has agreed to.

Are there any specialist Physiotherapists I can get her to contact so that she can sort this problem once and for all? I really appreciate your help in this matter. Sorry for any confusion I may have caused you.

Thank you

Mark

What country are you in? I look after a professional neoclassical ballet company at the Royal Opera House in London, UK. And my partner is a dancer and choreographer and we specialise in dance as well as pilates and gyrotonic rehabilitation and training.

I could also suggest someone in Sydney.

Hi there

We are both in the UK. I really appreciate this.

Mark

OK, well we are in London in Harley street if you client is interested. You could look on our website at www.performancephysio.net for contact details etc. 8o

Laberal tear? can be small and hard to see with mri, try ct scan. other wise try piriformis release, pressure pointing on the medial part of the lateral hamstring, fimoris, as well at the more proximal lateral side of the gastrocs.