Physio Charlie - hip

New website!!

noreply@blogspirit.com (PhysioCharlie) — Mon, 09 Mar 2009 19:22:00 +0100

I have a new website!!

http://physiocharlie.vpweb.co.uk

Hip pain

noreply@blogspirit.com (PhysioCharlie) — Mon, 19 Jan 2009 10:24:10 +0100

I found this discussion about Hip pathology on the CSP web:

http://ptjournal.org/cgi/reprint/86/1/110

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1724872&blobtype=pdf

help, i'm currently seeing a patient who has a 2yr history of anterior hip pain, he has been reviewed by orthopaedics and had MRI + arthrogram, which came back negative the consultant felt that his hip symptoms were related to a psoas tendinopathy.

the patient is a rugby player (2nd row) who initially felt the pain prior to a game in the changing room there wasnt any trauma and as the patient started to warm up he couldnt due to pain. Since then he has had a number of physio appointments,where he under went stretching, soft tissue mobilisation etc. He was thought to have a psoas bursa which was injected X4 (with no improvement) prior to referral to the consultant.

The consultant then referred him back to physio for local treatment of the tendinopathy, but has offered debridement of the psoas if treatment doesnt work.

On assesment, Lumbar movements are normal although he does have some amount of pivoting at L1/2, unilateral palpation of these also slightly increased the pain in his hip, so neurodynamics were tested PKB increased pain (? due to neural tension or due to hip extension).

Hip assessment he has limited PROM with pain increase too much at around 100 degrees, MR/LR both painful, Ext painful, ADD painful, MS caused pain on all movements, PSOAS bursa test was positive, Minimal pain resisted trunk flexion to rule of abdo origin. palpation gives pain on adductor origin, flexor origin and generally very painful around the anterior area of his hip

my initial thought were ?psoas bursa but Rx of that hasnt worked, then perhaps a chronic adductor/flexor related pain so treatment has been aimed at these with minimal to no success treatment has included soft tissue work, eccentric loading relative rest hip stability exercises. to progress i decided to try Rx Lumbar segments to see if any improvement could be made from there (min/no improvement).

I am at a loss where to take treatment next, the patient as you cna imagine is fed up with the pain and is very willing to persevere, i am unsure of the psoas tendinopathy diagnosis due to my own objective findings, any help would be useful to decide where to aim my treatments next, may be some pain relieving modalities etc?

Many thanks

Hi
Have you cleared SIJ. I treat a lot of rugby players and find they often have SIJ dysfunction, especially 2nd row players, who jump and land alot.

Title:	hip pain
Added by:	gtwinning
Posted:	05 December 2008 13:38

what you are probably finding is that everything is sore as a compensation to the initial injury. Have a look at his abdominals. I have seen similar with a rectus tear. Can he do a sit up or is it pain provoking. Look at symphysis pubis dysfunction. Its hard and these are a struggle to get to the origin. Alomost ignore what is tender and try and get to his original pain location. Everything else should settle as it is offloaded. Is the pain mecahnical?? isolate the provoking movement.

I would start from scratch again, and slowing eliminate origins with the investigations he has had. If you are still ineffective then find someone with experience in high level rugby. In Gloucestershire I use one if the EIS sports doctors as he deals with Gloucester and Worcester teams. I haven't had a patient he hasn't cured!!!!

Title:	Re: Hip pain
Added by:	wriggles66
Posted:	05 December 2008 13:41

What eccentric loading work have you done and how much/for how long?

Title:	Hip pain
Added by:	ZASKAR
Posted:	05 December 2008 13:43

I have had a number of dodgy hips where I haven't been able to sort them out. I have gone for acupuncture and to be honest tend to go for it a lot sooner these days, unless its something obvious. Elecro-acupuncture is particularly good as it has greater influence over hormone release. Looks like you have tried quite a lot already. Thats how i would approach it if not already tried. Hope that helps!

Ade

Title:	hip pain
Added by:	rachel.brophy@hotmail.com
Posted:	05 December 2008 14:43

I would agree with gtwinning, with anterior hip pain you need to clarify whether it is a
1. Capsular pattern - internal rotation ROM v's external rotation ROM and pain pattern
2. SIJ pattern - observed levels, ASLR, stork, prone extension, knee fall out i.e. kinetic tests to identify weak pelvic muscles unilaterally and/or malalignement
3. Muscle pattern - Iliospoas v's Rectus Femoral - Thomas test and resisted tests, palpation of psoas abdominally

He is likely to have a pelvic muscle/SIJ asymmetry causing this unilateral pain. Once this imbalance has been worked on any specific muscle problem/joint problem can then be treated with specific strengthening or MWM's of his hip rotation as needed. I would be interested what you find. Many second rows have this problem of differing degrees.

Title:	Second Rows
Added by:	Sinkers
Posted:	05 December 2008 15:45

I agree with all the above.
Ask him if he packs down right or left side of the scrum and which hip is it in relation to his foot position in the scrum.
he may technically be contributiing to this pathology

best wishes,
John

Title:	Hip Pain
Added by:	paulntfisher
Posted:	05 December 2008 18:59

Unfortunately the scans he has had are not full proof (if any are) I would try to get him into see of the hip specialists especially to rule out a labral tear.... they are quite common in rugby players.

He will also need a CT to rule out cam/pincer lesions Damian Griffin based in Coventry is exellent....

Labral tears can be sorted fairly easily....

hope that helps

Title:	Hip impingement
Added by:	timpowell
Posted:	05 December 2008 21:07

I agree with the previous post that this could a hip impingement issue, although one would expect the arthrogram to show some issues if labral tear present. If there is nothing on the scan to suggest a psoas tendinopathy keep that orthopaedic surgeon away from this guy, as the debridement option sounds very much 'finger in the wind'.

The management of hip impingement is a very controversial issue and there is no consensus of Damian Griffin method of arthroscopic surgery versus Mark Norton who uses a Ganz Osteotomy. Either way try and find a hip surgeon who understands young adult hip pathology.

If you have had a good go at treating this guy don't bother with muscle imbalance etc etc - this guy needs a diagnosis as he will be questioning whether he will play again after 2 years.

Title:	making sense of the mra
Added by:	lauraengland1
Posted:	06 December 2008 08:37

i agree; a MRA will show up labral as well as a cam or pincer impingement as well as give an idea as to the condition of the joint around the femoral head. the diagnosis hasn't been made from the MRA as to a structural lesion requiring surgical input... so as far as us physio's go- we need to do what we do best and assess his symptoms. in agreement with the below posting there is usually a combination of SIJ/ Lumbar spine facet joint stiffness, anterior rotation of the pelvis and psoas tightness/ inhibition.Active SLR looking at eccentric control will really help to differentiate out the SIJ/ pelvic element (modifying squish test ) looking at abdominal control, lumbar lordosis and looking at the trochanteric movement in the last 30 degrees for psoas; i've found this a really useful test that kills several birds with one stone. as far as psoas bursitis it is a relatively rare diagnosis and usually a red herring as pain provocation tests are usually positive with any of teh above diagnoses.
also just quickly make sure diagnoses such as adducter lesions, gilmores groin have been excluded

Title:	hip pain
Added by:	JosetteF
Posted:	06 December 2008 13:10

Have you looked for anterior displacement of the femoral head? uneven weight bearing? bottom gripper (look for divots )
Incidentally just to update all who have mentioned ilio-psoas; psoas bursitis; - Mark Comerford presented an evening lecture in February showing evidence that there is no bursa in Psoas Major and that its revised role looks more like this:
Lumbar spine: stability role through axial compression
Hip: stability role by holding the head of femur centred in the acetabulum
SI Joint: fascial connections to sacrum and innominate aiding force closure
Posterior rotation of innominates maintains close pack positioning

This brings the discussion back to what people like rachel.brophy and some others have pointed out: Looking at pelvic dysfunction - force/loading /muscle imbalance
adaptive patterns of movement. One can hypothesise that the anterior translation (if evident) may be resultant from inhibition of Psoas due to overactivity of Piriformis/ischio-coccygeus among others/ poor training techniques especially the loaded squats favoured by rugby players and their instructors

Title:	hip pain
Added by:	joeybea
Posted:	07 December 2008 12:24

To follow up on JosetteF's advice, it is well worth checking whether the hip is 'seating' during squat and sit to stand movements (scrumming) etc.
This involves palpation of the femoral head during these functional tasks and compare Right ato Left. Tight glutes, not allowing the 'seating' and overstretched anterior capsular/ muscular tissue are two things to look out for. Referring to Sahrmann or Diane Lee's work on pelvic dysfunction is a great place to start.

Title:	Hip pain
Added by:	TJCSmith
Posted:	07 December 2008 18:56

Any clues in the from the subjective history prior to this e.g. change in loading patterns that may have lead to the injury developing over time?

I would have to disagree with Paul Fisher that 'labral lesions can be sorted fairly easily'. They are far more complex than labral lesions in the shoulder due to the important role in stability of the hip joint and reducing contact stress on the articular surface by distributing load. I realise the labrum in the shoulder performs the same role but due to the weight bearing function of the hip I think it is a more complex problem. You may want to have a look at this article - http://ptjournal.org/cgi/content/full/86/1/110

What has this guy been doing in the interim? You have not mentioned what he is capable of functionally now two years on from the original symptoms beginning. Has he actually made a reasonable attempt at letting the condition settle so that appropriate rehab can work? We must create a window of opportunity to help someone through appropriate off-loading first.

You may also like to have a look at this article - http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1724872&blobtype=pdf
It may help guide your assessment and diagnosis.

Title:	RE: hip pain
Added by:	djb
Posted:	09 December 2008 10:27

It sounds as though there must be a structural component to this. As such, whilst he may have numerous findings that we as physios can address, we are unlikely to provide significant lasting benefit.

I attended the Sports Hip Surgery Conference last month. The radiologist there talked about these scans that may show a pathology, but requires a radiologist/orthopod who has a clear understanding of inpingement/labral pathologies to interpret them. CT 3D reconstruction would help, but needs to be by the correct team.

Damian Griffin/Richard Villa/Darren Fern/Mark Norton. These guys know when the dfifferent approaches discussed in earlier comments are appropriate and suggest you get him in with one of them.

Had similar prob myself and tried various physio approaches prior to diagnosis. If the hip specialists rule out cam/pincer probs etc, then try physio tricks. (i had a scope and repair by Damian Griffin - very impressed.)

Title:	Hip pain
Added by:	paulntfisher
Posted:	09 December 2008 15:43

I accept that "labral lesions can be fairly easily sorted" may have
been overly optimistic but agree with djb in that somebody who really knows
there stuff should look in detail at the structure of the hip (CT etc).
Unless you can really clear the joint component I think to subject him to more physio or a period of rest as TJCSmith seems to advocating when he has already
had 2 years of problems is perhaps not in is his best interests, especially
for a sportsman.

Title:	hip pain
Added by:	chapman
Posted:	09 December 2008 19:16

a really interesting thread with plenty of good ideas. tim powell and myself speak a lot on this complex topic.
definately a case by case basis with, perhaps, challenging clinical reasoning for recommendation to surgery.
one can quote plenty of successful outcomes. however, unfortunately, my recent experience has been less than favourable. on my suggestion a patient sought further advice for a relatively low grade impingement (albeit one that limited his preferred career pathway) that proceeded to surgery. following an unsuccessful outcome, including that from revision surgery, he is worse off than initial presentation.
the moral here, i think, is that such intervention may well be far from straight forward. they say you can't win them all, but.........................
mike
ps another case of mine, from a few years back, failed to respond to all physiotherapeutic interventions quoted thus far. he went away, engrossed himself in other activities for a year or so and re-emerged asymptomatic............hmmmmm

Title:	Hip Pain
Added by:	Femke
Posted:	09 December 2008 19:35

Have you considered large inguinal hernia? Gillmoor's Groin??
Ask radiologist to check his MRI for this, or refer him for US scan...
I agree with process of elimination, and can't harm to get a second orthopaedic opinion either...
Muscle Imbalances will be present now 2 years into injury... Can never tell if that was cause of 'original' injury...
Where was original pain, what aggr this at time...has this changed since 2 years?
Any tenderness over Symphysis Pubis?
Let us know how you get on!

Title:	Hip pain?
Added by:	MelanieSweetland
Posted:	10 December 2008 08:49

There have been a couple of suggestions regarding the SI joint. I have found a lot of sportsmen and women suffer with a malalignment of the SI joint which gives pain into the groin which to the patient feels like the hip joint. Flexion at the hip and knee with adduction can relieve this problem, it will also stretch all the muscles around the area.

Title:	Hip impingement
Added by:	timpowell
Posted:	10 December 2008 11:47

I think what this thread has shown is that there is alot that cause potential pain in the hip in and groin. The general consensus in Australia where groin is the number one cause of injury in the AFL is that hernias/gilmore's groin/inguinal wall disruption does not exist. Below are a couple of references from Dr Geoff Verrall, who presented at this year's ACPSM conference, who is an AFL team Dr and has done a sizeable amount of research into this condtion.

Geoffrey M. Verrall, Lachlan Henry, Nicola L. Fazzalari, John P. Slavotinek, and Roger D. Oakeshott
Bone Biopsy of the Parasymphyseal Pubic Bone Region in Athletes With Chronic Groin Injury Demonstrates New Woven Bone Formation Consistent With a Diagnosis of Pubic Bone Stress Injury
Am. J. Sports Med., first published on Oct 20, 2008

Geoffrey M. Verrall, John P. Slavotinek, Gerald T. Fon, and Peter G. Barnes
Outcome of Conservative Management of Athletic Chronic Groin Injury Diagnosed as Pubic Bone Stress Injury
Am. J. Sports Med., Mar 2007; 35: 467 - 474.

Essential conservative rehab does seem beneficial provided the right diagnosis is obtained.

I am currently involved in a research project with Mark Norton and his SpR looking at outcomes of hip debridement surgery in military patients that we hope will be published in the JBJS. The hip impingement surgical community is divided as to whether to do open or arthroscopic surgery - each has plus points and down points but generally less numbers will be able to have arthroscopic due to accessing lesion arthroscopically,

What I would comment on is that anyone who thinks labral tears/hip impingement can be 'easily sorted out' is kidding themselves. I have rehabbed several people after this operation and been in theatre for several ops. It is technically difficult surgery for the surgeon and painful for the patient and as Mike Chapman has eluded to - it does have failures.

As I have already mentioned in a previous post this guy needs to get a diagnosis. I am not sure where you are DMW but Mark Norton takes out of area referrals or get him into a good sports physician to help you - he has struggled on for 2 years now don't waste time with some of our professions more tenuous Rx without a diagnosis either by exclusion or second opinion.

feel free to contact me should you wish: CULDROSE-PHYSIO@mod.uk
Tim

Title:	Hip pain
Added by:	TJCSmith
Posted:	13 December 2008 11:54

Thank you Tim Powell for the interesting references. As for my own comment on December 7 all I wanted to know was 'had there been a sufficient period of appropriate rest from aggravating factors following the injury and had the management over the past two years been appropriate'. I was not advocating further rest or physio if these issues had been addressed in the past. Clearly a diagnosis that the whole medical team agree on is needed to guide further management. With such a difficult injury all areas of clinical reasoning must be considered and this includes previous management.

Title:	Hip Pain
Added by:	asharp
Posted:	07 January 2009 10:43

Really difficult to treat. Suggest referral to specialist groin , hip specialist such as Ernest Schilders Professor Leeds / Bradford. e.schilders@btopenworld.com who specialises in sports related hip injury.
RX - symphysis pubis dysfunction. ME techniques I have found useful sometimes.Good luck

Groin pain

noreply@blogspirit.com (PhysioCharlie) — Mon, 12 Jan 2009 15:08:56 +0100

Geoffrey M. Verrall, Lachlan Henry, Nicola L. Fazzalari, John P. Slavotinek, and Roger D. Oakeshott
Bone Biopsy of the Parasymphyseal Pubic Bone Region in Athletes With Chronic Groin Injury Demonstrates New Woven Bone Formation Consistent With a Diagnosis of Pubic Bone Stress Injury
Am. J. Sports Med., first published on Oct 20, 2008 http://ajs.sagepub.com/cgi/content/full/36/12/2425

Geoffrey M. Verrall, John P. Slavotinek, Gerald T. Fon, and Peter G. Barnes
Outcome of Conservative Management of Athletic Chronic Groin Injury Diagnosed as Pubic Bone Stress Injury
Am. J. Sports Med., Mar 2007; 35: 467 - 474. http://ajs.sagepub.com/cgi/content/full/35/3/467

Hamstrings rehab

noreply@blogspirit.com (PhysioCharlie) — Tue, 21 Oct 2008 17:00:00 +0200

http://www.sportex.net/newsite/common/mainframe.asp?txtOrigin=%2Fnewsite%2Fcommon%2Fhome%2Easp%3F

http://www.sportex.net

Conditioning the hamstrings: training considerations for performance and injury prevention
by Dr Duncan N. French, Published in sportEX dynamics, Issue: 15, Pages: 18-22

"The hamstrings themselves are most active during the late swing phase, through early to mid-stance phase of the running gait cycle. They act to decelerate the forward momentum of the leg and reverse the swing action via active hip extension. During the late swing phase, the bicep femoris experiences a great degree of mechanical stretch, thereby becoming susceptible to specific injuries related to the lengthening of the musculotendon unit. In listening to athletes who have experienced hamstring strains many report that their injury occurred as a result of acting to decelerate their body or working their limbs through an exaggerated range of motion as they emphasised their stride length during a sprinting action. The majority of hamstring strains occur during the eccentric actions of the blocking and plant phases of running gait, with most occurring during the plant phase as muscles move into a lengthened position whilst also experiencing high tensile loads. Training of the hamstrings to manage these forces should therefore be a critical part of any athletes preparatory activities".

References

1. Santana JC. Hamstrings of Steel: Preventing the Pull, Part I - Isolated Versus Integrated Function. Strength and Conditioning Journal 2000; 22(6):35 - 36

2. Brandon R and Cleather D. Training the hamstrings for high speed running ? Part II. Professional Strength and Conditioning 2007;7

3. Lieber RL. Skeletal muscle structure, function, and plasticity. Lippincott, Williams and Wilkins 2002. ISBN 0781730619

4. Gambetta V and Benton D. A systematic approach to hamstring prevention and rehabilitation. www.gambetta.com/resources

5. Boyle M. Functional Training for Sports. Human Kinetics 2003. ISBN 073604681X.

Interventions for Hip OA

noreply@blogspirit.com (PhysioCharlie) — Mon, 08 Sep 2008 15:45:52 +0200

http://www.ptjournal.org/cgi/reprint/ptj.20070042v1

Effectiveness of Nonpharmacological and Nonsurgical Interventions for Hip Osteoarthritis: An Umbrella Review of High-Quality Systematic Reviews, (2007) Moe et al, Volume 87 Number 12 Physical Therapy

An increasing number of systematic reviews are available regarding nonpharmacological and nonsurgical interventions for hip osteoarthritis (OA). The objectives of this article are to identify high-quality systematic reviews on the effect of nonpharmacological and nonsurgical interventions for hip OA and to summarize available high-quality evidence for these treatment approaches.

The authors identified and screened 204 reviews. Two independent reviewers using a previously pilot-tested quality assessment form assessed the full text of 58 reviews. Six reviews were of sufficient high quality and could be included for further analyses. There was moderate-quality evidence that acupuncture and diacerein have no effect on pain and function. There was low-quality evidence that strengthening exercises and avocado/ soybean unsaponifiables reduce pain and that diacerein decreases radiographic OA progression. There was insufficient high-quality evidence regarding nonpharmacological and nonsurgical interventions for hip OA, and further primary studies and reviews are needed.

Hip Ax and differential diagnosis

noreply@blogspirit.com (PhysioCharlie) — Tue, 01 Jul 2008 10:46:49 +0200

I presented a IST on 26/06/07 on Hip Ax:

Hip Ax IST

Adapted from a presentation by Claire Small, physios in sport

Hip and Groin Pain - A Dilemma

Lack of specific clinical tests, Co-existence of multiple pathologies, Pain is not a good localiser of pathology

Groin Pain - ?Causes

Hip joint pathology

Adductor pathology

Inguinal pathology

Pubic pathology

Psoas pathology

Referred pain – M/S or Visceral

Stress or OP fracture, pelvis, femur

Dislocation/ subluxation/ dysplasia

Hernia; inguinal/femoral

Nerve entrapment

Tumour, infection, muscle calcification

Osteonecrosis, inflamed lymph nodes

Ankylosing Spondylitis, Lupus

Lateral Buttock Area - ?Causes

Trochanteric bursitis

Tendonitis of abductors/ external rotators

Apophysitis of greater trochanter

Referral from Lx

Thrombosis of gluteal arteries

Pubic Area - ?Causes

Sprain of pubic symphysis

Ostetis pubis

Abdominal muscle strain

Bladder infection

Gilmores groin

Anterior & Lateral Thigh

Strain of quadriceps

Meralgia paresthetica

Entrapment of femoral nerve

Medial Thigh

Strain of adductor muscles

Entrapment of obturator nerve

Referred pain from hip or knee

Buttock pain - Causes

Piriformis syndrome

Lx radicular/ referred

Gluteal/ Hams strain

Ischial burstis

Superior, inferior gluteal nerve palsy

Differential Diagnosis

Referral from:

Lx, knee, SI jt

Visceral – intra-abdominal; urologic, gynecologic, GI

Critical diagnoses:

Osteonecrosis, septic arthritis, acute fractures and avulsion fracture, malignant tumours, femoroacetabular impingement – MRI, X-ray

Strain, tendinitis, tendonosis:

Partial or complete avulsion; Adductor longus, rectus femoris, hamstrings, Iliopsoas. – MRI, X-ray

Femoroacetabular impingement

Cam - jamming of an abnormal femoral head with increasing radius into the acetabulum

Pincer - linear contact between the acetabular rim and the femoral head-neck junction

Labral Tears

Most common cause for mechanical hip symptoms – 20% of athletes with groin pain

Location; ant, post, superior

Etiology; Degenerative, dysplasic, traumatic, idiopathic

Hx; clicking, catching, locking

Differential Diagnosis

Developmental Dysplasia (DDH)

Slipped Capital Femoral Epiphysis (SCFE)

Differential Diagnosis

Vascular

Avascular necrosis

Infarction and muscular necrosis

Lumbopelvic Function (Claire Small)

Loss of effective load transfer across the pelvis

Overstrain and breakdown of tissues within the region

Mechanical overload of pelvic region

Pain, Inflammation, Degeneration

Assessment

Age; SCFE 10-20 yrs,

Hx; Mechanism of injury

SQ’s; urogenital problems, pelvic, abdo or back surgery, pregnant, SA, B+B

Invests; missed trauma, bld tests

DH; st’s, alcohol

SH; female triad

Area of pain – body chart

Assessment

Obs;

Alignment Lx, hip, pelvis, LLD

ASIS = pubic symphysis

Pelvic tilt; ant, post, lateral, rot

Glutei – well rounded, equal in size

Posture, gait – antalgic, trendelenburg

Lumbar spine

Active range of motion

- quality - muscle control

- range - muscle length

- neural mobility & Tests

Manual segmental examination

Thoracolumbar fascia

Quadratus lumborum

Core stability

Sacroilliac joint

Pelvis

Rotation?

Upslip?

3 x positive kinetic tests

Anterior and posterior gapping

Long situp – LLD?

ASLR (Mens et al 2002)

Assess response to various types of compression

Stabilising mechanisms

Motor control patterns

Delayed TrA activation, (Cowen et al 2004)

Loss of pelvic control, (Mens et al 2006)

Neuropathodynamics

Sciatic nerve

Femoral nerve

Obturator nerve

Hip joint

Trendelenburg, LLD

Hip AROM, PROM

Resisted, muscle tests; Glutes, adductors

Hip quadrant, FABER, sit up - illiopsoas

Labrum, Impingement tests, piriformis

Thomas test, Accessory; lat dist

Pulses

Palpation, Lx, PSIS, ishial tuberosities, illiac crests, piriformis, psoas

Pubis

Pubic overstrain

Pubic tenderness

Positive “Squeeze” test

- Adductor weakness

- Pain provocation

Adductor guarding

Hip pain in Athletes

noreply@blogspirit.com (PhysioCharlie) — Wed, 11 Jun 2008 11:59:41 +0200

I found this on hip examination and differential diagnosis:

http://www.aafp.org/afp/20000401/2109.html

Piriformis

noreply@blogspirit.com (PhysioCharlie) — Tue, 27 Mar 2007 13:12:44 +0200

I had a patient see me recently with what appeared to be piriformis syndrome. I wondered what else to recommend other than stretches and trigger point rx.

I went on the CSP website and found this:

Over Active Piriformis?

Added by: stalkedtoast
Posted: 08 March 2007 09:55

I have been treating a 25 year old active female for an over active piriformis, on assessment Lx was clear as was SI joint. Piriformis test was positive, and on palpation there were trigger points in piriformis, Gluteus medius and ½ way down ITB. She complains of buttock pain when walking, sitting for ½ hour and up/down stairs. She is a runner and this also aggravates it, however non impact work such as the cross trainer and cycling relieve the pain just for it to come back ½ hour later. I have given her stretches for piriformis and glutes as well as trigger point acupuncture and trigger point work at home which has relieved it temporarily. Piriformis test is now negative with the only trigger point is in ITB – ITB test is negative. I have asked her to increase her stretches and trigger point work to see if this helps.

Other than that does anyone have any other ideas, I have read Amanda Cottles question which helped to clear SI joint.

Thanks

Replies:

Title:	More questions
Added by:	sambowden
Posted:	09 March 2007 19:03

What is the ITB test? Do you mean Obers (modified or not)?

What is the piriformis test? Do you mean stretching it?

How did you clear the Lx - does this include neurodynamic testing?]

thanks

Sam

Title:	overactive piriformis?
Added by:	stalkedtoast
Posted:	13 March 2007 16:22

Obers test both mod and non mod = negative

Piriformis stretch test

Lx Ax includes neurodynamic testing - unable to reproduce symptoms from examinationa nd testing of Lx

Title:	SIJ force closure?
Added by:	Christopher Davenport
Posted:	14 March 2007 21:28

Have you checked force closure at the SIJ? A good test to do is the active straight leg raise. With the patient supine ask her to lift one leg a couple of inches off the plinth. Check whether her pelvis tilts laterally as she lifts, indicates poor force closure if pelvis tilts. Do this separately on both legs to compare. Then apply compression through the ASIS on both sides (at the the same time) The patient should find it easier to lift her leg. If positive lumbo-pelvic stability work might be helpful.

It's also worth checking whether her running shoes are suitable for her foot type as lateral rotators may be over loaded trying to decelerate pronation if not controlled.

Title:	ckc is functional for runners
Added by:	duncanjak
Posted:	22 March 2007 07:10

Hi
look at trigger point may be TFL
start activating glut med bent knee turn out
work on core and hip stability closed kinetic chain
start bridging, four point knealing and progress
also work on stability on one leg
agree with SIJ comments

Title:	Piriformis overactivity
Added by:	Rachel Harris
Posted:	22 March 2007 08:44

Releasing these structures off is necessary but will only have short term benefits, if you do not strengthen up her gluts (med and max) and core stability. You will need sure she can not only activate them in crook lying/prone etc.. but also when running, otherwise she will resort to her piriformis becoming overactive again and trigger points coming back. She has to stop running until she can activate gluts and tranversus. You my have to start with real basics like staic gluts and progress on slowly. Then start doing hill walking on treadmill then progress to running for very short times, she should not induce pain. Its takes time but you have to re-educate the normal firing pattern of the muscles. Try and make her aware of clenching gluts when walking/standing etc.. so as functional as possible.

Title:	thank you
Added by:	stalkedtoast
Posted:	22 March 2007 13:36

Thanks everyone for their ideas and thoughts, I’ll certainly try out your recommendations.

Title:	pilates for glut / ham timing
Added by:	gillianbrown
Posted:	25 March 2007 12:29

I would assess her in prone with some hip extension pilates work eg swimming level 1 or one leg kick level 2, to see when her gluts kick in (or not, as the case may be). it abnormalities apparent then grade her exrcise accordingly depending what she can control

Piriformis

noreply@blogspirit.com (PhysioCharlie) — Tue, 27 Mar 2007 13:11:20 +0200

I had a patient see me recently with what appeared to be piriformis syndrome. I wondered what else to recommend other than stretches and trigger point rx.

I went on the CSP website and found this:

Over Active Piriformis?

Replies:

Title:	More questions
Added by:	sambowden
Posted:	09 March 2007 19:03

What is the ITB test? Do you mean Obers (modified or not)?

What is the piriformis test? Do you mean stretching it?

How did you clear the Lx - does this include neurodynamic testing?]

thanks

Sam

Title:	overactive piriformis?
Added by:	stalkedtoast
Posted:	13 March 2007 16:22

Obers test both mod and non mod = negative

Piriformis stretch test

Lx Ax includes neurodynamic testing - unable to reproduce symptoms from examinationa nd testing of Lx

Title:	SIJ force closure?
Added by:	Christopher Davenport
Posted:	14 March 2007 21:28

Title:	ckc is functional for runners
Added by:	duncanjak
Posted:	22 March 2007 07:10

Title:	Piriformis overactivity
Added by:	Rachel Harris
Posted:	22 March 2007 08:44

Title:	thank you
Added by:	stalkedtoast
Posted:	22 March 2007 13:36

Thanks everyone for their ideas and thoughts, I’ll certainly try out your recommendations.

Title:	pilates for glut / ham timing
Added by:	gillianbrown
Posted:	25 March 2007 12:29

Osteitis Pubis

noreply@blogspirit.com (PhysioCharlie) — Wed, 16 Aug 2006 13:25:00 +0200

I had a young footballer that has been puzzling me for a few weeks now. He came in with left groin pain after playing a very tough game of football. He had tried rest from football for 2 months but to no avail. Palpation of the ant pubic rami was painful and the left adductors were painful and weak to resistance. The pubic symphysis joint was aligned but the right SI jt was a little stiff on Peidallau's test, stork test was negative. He had a previous stomach muscle injury but no evidence of any hernia.

The footballer thought he had gilmores groin but after a bit of research I am more convinced he has Osteitis Pubis. See research attached:

OSEITIS_PUBIS.doc

Ostetis_pubis_in_footballers.pdf

I have given him hip strengthening and core stability exercises, told him to rest from football for at least 3 months and started him on a cycling programme. I am using low pulsed ultrasound on the ant pubic rami.