The Hip Replacement Helped, but...

[Jason Silvernail]

Hi.
I've got a man in his early 40s with long term Right hip pain in the groin. He had a THR about 2-3 years ago (!) which has relieved about 75% of his pain, but continues to have occasional sharp anterior hip pain, very localized, with certain movements.

He reported some success when a former chiro of his "stretched his iliopsoas" for "psoas tendonitis" but that only gave him temporary relief. He has all the usual indications by history that he has mechanical pain.

The hip ROM is very good considering the THR, some increase in anterior pain with flexion and flex/IR combination, and a little weak in hip flexion. I treated him with simple contact, hip mobilization, with sidelying neurodynamics a la Shacklock and with iliopsoas and hip retraining a la Sahrmann. No dice.

I've done about 3 sessions of DNM with him, the first time my positioning was not that good, so I think two good sessions. I used Diane's treatment manual and am trying the femoral techniques because that's the only real place he's symptomatic or tender. He ends up feeling sore and warm after the treatment, but not much improvement so far. Also, this is "exhausting" for my forearm muscles! :D

I'm monitoring the tender point with one hand, providing the skin stretch distally with the other, and holding for 3-5 minutes each time in slightly different directions from the painful area. I'm not getting any softening that I can feel and he certainly doesn't appear to be improving. He's pretty dejected over all about the lack of improvement, but generally positive that he improved so much from the hip replacement and has been very good on home compliance (especially his hip position that Barrett talks about).

Ideas?

[bernard]

How is his lumbar area?

[nari]

He is very young for a THR! Was the reason trauma, Perthe's...?

I'm thinking there may be a reason for ongoing pain other than a cranky CNS. As Bernard suggested, what is his lumbar spine doing, especially at the TLJ??

Nari

[Barrett Dorko]

Jason,

I presume you've worked with him in standing where he can change in unique ways and that he is pursuing ideomotion regularly on his own. I also wonder what his response to anti-inflammatory medication has been.

After five or six visits (total) with no further progress I would guess you've done what you can.

[Diane]

Yup. I would move on. I'd check the L spine too, but higher on my list would be the knee. Specifically, check the infrapatellar branch of the saphenous nerve. It may be entrapped painlessly but tenderly. If it's scrunched up at the knee, the entire nerve up into the groin can be mechanically deformed, with pain felt in the groin. So you might be on the right nerve but at the wrong "end".

[Erica]

I would also check lumbar spine (TL Jxn). What movements aggravate the sx's? Could be a pull from somewhere higher up. Any trauma? falls? Erica

[BB]

Hi Jason,

Initially my forearms got quite tired as well with DNM. Pay attention to how evenly you distribute the contact through your hands and that you are distributing the force through the whole body, not just pushing with your hands. This helped me a whole bunch as did practice.

Also helpful was to allow myself to move ideomotorically during the treatment so that it does not become a 5 minute isometric but instead is continuous motion. As their nervous system is testing yours it becomes imperative that you are comfortable, otherwise they will know, even if non-consciously which will affect the perception of the amount of threat you bring to the table.

I would also be interested in what you'd find in the posterior hip. Envision Sahrmann's anterior glide of femoral head MIS and check the areas that would be involved there. Often times when I encounter someone who is obviously in mechanical pain but lacks tenderness, and who I want to decrease the sensitized tissue before using SC, I'll let there movement tendencies guide where I treat. In the above example, if they have findings consistent with the anterior glide MIS, I'll treat the areas consistent with it. Usually works for me. Sounds as though this person may fit into a Hip IR/ADD and ant. glide MIS.

[christophb]

What Cory said...

re: the forearm soreness, same thing happened initially with me, and on days when I tend to be impatient and want to do stuff, I tend to be more sore. The most success I have with DNM usually never relates to a reduction in tenderness but a palpable softening in the area being treated... I'm still hit or miss being patient enough to let this happen consistently. I would hit up post hip and do SC in standing (perhaps even starting with the head in sitting and progress to standing if you haven't tired it).

[kongen]

Not to hijack the thread, but the osteopathic "listening test" is defined as "passive drawing of the hand to the fixation in the tissues", which they use a lot in the book I've been reading lately (manipulation of the peripheral nerves). Is it bogus? Any osteopaths care to comment? Just wondering how this fits in with moving ideomotorically while using DNM.. is it the same.. hmm

[Diane]

I'm not an osteopath but I'll throw in a comment anyway - it would be nice if the osetopathic description included some mention of the practitioner's own "brain", maybe those spatial map areas that the Blakeslees' discuss in their book, that incorporate "objects" that the hands touch into the "grid" of the actively mapping brain.

It would get the practitioner-mind off mesoderm, however more minutely. It would leave open more possibility for recognizing that "treatment process" consists of two nervous systems interacting, not just one doing something to someone else's "tissue".

[Jon Newman]

Hi Jason,

Out of curiosity which hip mobilizations did you perform?

[Jason Silvernail]

Thanks for all the suggestions, guys.
Lower back is fine - NL movement and movements don't aggravate the hip.

Diane, I'll check his knee.
Barrett-
he gets some good movement, but no characteristics of correction and no change in the hip post-movement.
Cory-
his exam mimics Sahrmann's anterior glide MSI, and my exercise prescription was targeted to that initially - gluteal activation and strengthening, iliopsoas eccentrics, etc. I tried that when the simple contact didn't get me anywhere. Could you be more specific about what you're advising?
Jon-
He was painful in full flexion and IR, so I used posterior glide mobs in flexion, inf glide mobs in flexion with a belt, and lateral glide mobs with belt. Like everyone else here, I'm not convinced I'm doing something "jointy" when I do those.

Thanks again for the feedback - keep it coming. I really think this guy has a local mechanical pain issue, and I really want to help him.

[Jon Newman]

What about long axis distraction with or without a thrust?

Shouldn't this guy be avoiding a full flexion/internal rotation position anyway? Maybe pain in that position is helpful?

[Diane]

Jason, if you're going to check his knee, check it prone too; make sure obturator nerve is nice and mobile above the knee, inner thigh. It plugs right into skin there, easy to get hold of and move.

Erica has a good suggestion, checking the mib back. Most of the cutaneous nerves feeding skin over the inguinal zone emerge from upper lumbars and swing round at various depths, surfacing right through the inguinal ligament. One of them certainly could be getting pulled on from above. Eg., the iliohypogastric nerve could be entrapped on the silent hip side, tilting the trunk slightly, setting up a roar in some other nerve on the affected hip side.

[BB]

I'd be curious if he is protective of obturator with consequent hamstring, adductor activity. Also, I'd be curious of the cluneals area involvement and if the Gluts and hip rotators have become protective.

I'd treat them as Diane describes treating the inner thigh, inguinal area, posterior hip, and outer hip.

I'd also check involvement down in the lower leg, does he walk with his hip in ER....is it involved with protective mechanisms in the lower leg.....has the lateral trunk become protective as well.

If he demonstrated progress with treatment of any of these areas, I'd likely keep treating along the path of those neural structures down to the feet. I'd look diagonally up the trunk toward the opposite shoulder and neck.

Often I've found if the area of one illiopsoas is protective and is being stubborn treating the other one takes care of it. They are, after all, separated by only a few degrees of branching from eachother.

[Jason Silvernail]

I'm all for checking - what am I checking for? How will I know if these areas require treatment? Firmness of tissue and/or tender points?

Jon- I did do the long axis distraction rather gently, and he and I both felt what was an uncomfortable joint distraction that didn't appear to change his hip pain, so we stopped.

[BB]

Responses consistent with the protective responses of an abnormal neurodynamic: They are the opposite of the characteristics of correction.

Local findings such as the tenderness, taught tissue

Less Local findings such as what would typically be considered a flexibility test, but may represent a protective mechanism limiting muscle length excursion.
So, if SLR or "hamstring length" testing were significant in your estimation, try to treat the posterior and inner thigh. If IR was limited/evoked protective resonses, treat the outer hip.

In absence of local findings, let their manner of moving be your guide.

[Diane]

What BB said. And tender spots are good to find as clues too. You don't have to dig in to find them, they are right at the skin surface.

[cathyph]

Hi, I know its a bit out of normal range for solutions here, but anytime I see anterior hip pain like this I look to the kidney, which, if not moving properly, will lock up the psoas and play out in the anterior hip region to the groin. very simple holding that connects diaphragm to pelvic floor may help mobilize. Instruction in self-management techniques for diaphragmatic breathing to the belly are very helpful. Also, PMHx of hernia repair, appendectomy or cholecystectomy may play out as residual dysfunction to the hip in this manner. The nervous system impulses from these (blocked) visceral points may very well play out in this manner. If the problem presents "outside the box" and isn't particularly responding so far, why not look a bit further abroad?

[Mabo]

I had a discussion with an orthopedic surgeon yesterday about THR. The tendency in the last few years is all about minimal invasive surgery. Therefore the incision will be made more posterior and the only muscle they detach is the m.piriformis. Could here be the problem ? It was not mentioned in the discussion so far.

[Luke Rickards]

Hi Jason,

I often get good results with sharp/pinching anterior hip pain agg. by flexion using a fairly strong capsular stretch into the capsular pattern (usually in combo with MET).

Patient supine. Stand on the R side of the table facing the patient with the patient's hip slightly flexed so that the heel can sit comfortably into your L lateral inguinal region just below the ASIS. Contact the knee with your L hand and guide the hip just up to the restrictive movement barrier for a caspular pattern- I find Int Rot first, then abd, then flexion best. Often the patient will describe stretch sensation in exactly the same region they are feeling the pain. From here go very slowly (because it can be a strong sensation, especially into flexion) into each vector using contract/ relax, ie "slowly push your foot into my leg" - then move a few mm into flexion, "slowly push the inside of your knee into my hand" - then move a few mm into abd. When they contract the sensation will increase so let them judge how hard to push by what they feel is within their comfort level. Obviously the same goes for how far you move the hip after it. Give the tissue a little break in neutral after a minute or so and then repeat a few times if necessary. I find this much more effective if the patient is abdominal breathing at the same time.

[ginger]

Jason , Active movements of the upper lumbar spine are very unlikely to either prove or disprove involvement of T12/L1/2 as a potential source of your patients "hip " pain. It will be necessary to mobilise these joints for sufficient time to release protective tone around them , to provide a clear indicator of involvement . Were you to do so , the results could be felt( in terms of reduced 'hip " pain ) in less than ten minutes of skillfull hands on effort. CM is the best way to do this, I recommend it to you.
The motto of never believing any one elses diagnosis is a good one to silently mutter as we put our hands to work, certainly this remains true , even in the face of incontrovertible evidence of hip pathology, where the usual picture of complete pain cessation post THR ,fails.
All the best with your patient.

[super ape]

has he been proven to NOT have a sports hernia/athletic pubalgia?
the torn fascia transversalis tends to not be found via diagnostic images and cannot be palpated aside from the posterior inguinal wall, by someone with much experience with this. take it from one who suffered (and still suffers) from the exact injury.
the injury can easily cause all kinds of compensatory patterns and compartment syndromes. psoas + gluteals + adductors + more.

[bernard]

Jason,
Try this: Patient is lying supine on the opposite side (Left side) of the problem. The left leg is flexed and comfortable.

Take the R one flexed and comfortable and extends the hip 10/12 times slowly with low amplitude with a little abduction.

If it works, the patient will tell you immediately when he will return supine.