Slip disc and chronic anterior hip pain

(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.

Dear Beazus

We should thank you for the detailed assessment you've done, its not everyday (myself inclusive) we take the time to give some detailed information...

It is rare for you to have bilateral anterior compression syndrome in the hips except you have some form of congenital anatomic disposition. If your lady is complaining of that and your assessments are pointing towards some form of capsular sign...then I would query whether this woman has a systemic problem...that is taking a slow time to progress...there is a history generally of poor health flu every month (that is unusual for the average allegedly healthy person)...

I know you said she isnt complaining of stiffness and night pains arent a feature....the other thing I would consider is vascular issues....

you breezed through the back assessment so there is very limited information there...

I know you have mentioned that this pains appear mechanical...but are any of them constant? are the constant and then are aggravated by activity...
whats the patients general health like or her own perception of her general health...
what investigations have been done?

I know you said that there is no stiffness, however painful hyperextension may suggest some developement of stiffness which is not reported as stiffness--whats the general range of spinal motion generally? actively and passively...

My suggestion
send this lady back to her G.P/rheumatoogist for tests to rule out a systemic problem, R.A, A.S, Fibromyalgia...possibly an MRI of the lumbopelvic/hip...I know you said finiancial constraints are there, however I do not think your input will be enough to help this lady...

Do you think you would get anywhere with this lady realistically? she is not compliant with your exercise program anyway...she sounds like she is under a lot of stress, my personal opinion is there is a systemic problem that is very slowly progressing...
even if it isnt, at least that has been ruled out...

Just a little reflection, I have seen cases of spondylolisthesis with bilateral lowerlimb presentation...often sharp burning sensation...

My initial thought still stands but I think you need to examine the back properly....

thank you Dr. Damien.
The hip problem seems to be significantly L>R wherein the R hip only occasionally acts up together with the L hip.
You mentioned that you would consider vascular issues... pardon my ignorance but what kinds of vascular issues would you be looking at in such a scenario? Necrosis? Just a simple case of vascular compression?
As for the back assessment, I avoided testing her back ROM too much because she was already presenting with high irritability and severity of the back pain at that moment. But yes, i will definitely come back with a thorough back assessment when i next assess her.
My pt's pains are not constant though its irritability levels are increasing as her condition seems to worsen. I think I might have phrased it wrongly - her 'aggravating factors' for her LBP:- lifting activities, stress, anger, fear/anxiety - are actually the provoking factors or mechanism of injury. Similarly, sitting in more than 80deg for more than half hour brings on the inguinal pain L>>R. After the onset of her pain(s), the same provocative factors for each pain respectively are her aggravating factors... am I confusing things? :S
After all has been said, your suggestion of a slowly progressing systemic problem does seem like a possibility. I have in mind SLE (lupus), early onset of arthritis.
I will also strongly recommend a lumbar/hip x-ray for starters (not as much a financial strain as an MRI) and refer back to GP to rule out those systemic issues you mentioned.
I feel that priority should be given to the chronic LBP and this might provide some clues to the inguinal pain.

Once again, thank you for your suggestions. Will keep everyone posted on the progress.

Do let us know the results of any x-ray investigations as I to agree that you might want to rule out a larger grade spondylolithesis :)

Dear beazus

How are you? My feeling is the physical examination has not matched up with the sujective assessment yet. From your physical examination, the mind points towards a systemic problem. By vascular issues, I mean compressions of lowerlimb vessels with certain positions akin as you would find in some cyclist who complain of leg pain. I have seen this, and it turned out to be caused by narrowing of vessels flowing from the abdomen to the lowerlimbs...

Again, this reasoning is coming from the physical examinations you have done...it is hard to say unless one sees this lady physically

If I take away your physical examnation and just look at the presentation you describe only, it really looks like a spondylolisthesis... the markers are
1) bilateral inguinal and radiating thigh pain- (I have seen this before)
2) feeling of weakness in the lowerlimbs
3) inability to extend, avoiding prone
4) dffuse pain pattern generally in the lumbar area could suggest several problems,from visceral, inflamatory spine problems, dural matter problems...it can be seen in spondylolisthesis if it has become a larger grade shift as physiobob means...because of irritation of more central structures

you are right, a simple xray should help confirm or refute this hypothesis and yes, you are definitely on point giving more focus on the back...I have suggested an MRI because you could have this same presentation in a large disc herniation, something a simple xray is unlikely to pick up

I would suggest suspending any physiotherapy input until you have the results of even if it is just your xray referral...if it is a spondylolisthesis, those exercises you have given can aggravate the condition

Good luck and keep us posted, it is good to know the actual diagnosis

I just wanted to congratulate beazus on making such a good effort to document this case - thoughtful, orderly and informative. I won't comment on the content as you have got some good feedback already.

What a joy it would be if other students and therapists took the trouble when seeking feedback and advice

...the only thing one has to watch is the ethical and legal ramifications. In our country due to our goverments Health inormation Privacy Code we have to be very careful what information we post - it is quite restrictive and very easy to land ourselves in hot water. The key thing for us is if the patient, or a member of the public who knew the patient could possibly identify who the patient was then that would be a breach of the code.