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chronic adductor pain
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chronic adductor pain - April 4, 2008 10:34:40 PM
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rwillcott
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From: Canada
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I have a 45 year old female patient with a 14 year history of left adductor pain. She reports no mechanism of injury. Over the past 7 years she has had an increase in leg pain with prolonged standing and walking. She is a very discouraged person and does not seem optimistic about any recovery. She has seen everyone under the sun with no improvements. Her treatment has consisted of orthotics, massage, exercises, pelvic mobs, and on and on. She has also had every special test one can think of. She has even tried botox injections with no effect.
The lumbar spine is clear
Slump reproduces medial thigh pain
Reflexes WNL
Knee is clear
Pes Cavus
There is ++tenderness on palpation of the left mid adductors
Passive abduction is full and pain free
Resisted adduction is WNL
Passive hip flexion is 100 degrees and reproduces medial thigh pain
Flexion/Adduction quadrant of the left hip reproduces medial thigh pain
Thomas test revealed a tight left rec fem and ITB
Weak left hip extensors and abductors
I can't really think of a firm diagnosis. I have her perfroming exercises to improve left hip stability as well as stretching the tight structures.
She can be hard to deal with due to a negative attitude. She is one of those people that gives the impression that she wouldn't want anyone to help her despite her efforts to seek out many opinions.
I know that seems odd but that's the impression she gives me. I feel that there are clearly some psychosocial aspects to this case. Central sensitization seems likely as well.
I would like to know what everyone thinks of this patient. I'm curious what people think may be the cause of the hypersensitive adductors as well.
Rob
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RE: chronic adductor pain - April 5, 2008 7:30:03 AM
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PTupdate.com
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Sounds to me like a hip problem......100 deg flexion in a 45 year old is not very good. Plus, the fact that you can move the hip and reproduce the pain targets that joint all the more.
The palpation to the adductors is a very common finding...I just had a 44 year old family friend with fairly severe hip OA yesterday, and she was quite tender to upper adductors and quad. I am not sure if this is just a referred site that becomes tender.....much like the levator in so many neck problems. Or, if changes in muscular strategies due to the hip pathology over uses or over irritates those muscle groups. It could also be a neurogenic inflammation, as chemical irritants from joint inflammation have been found to leak out of joints and irritate surrounding tissues and nerves...especially in the lumbar facets.
Go thru the hip more, and see how the rotations are, what happens in FABER position, and what happens with combo movement of IR/add/flexion. Perform the FAI tests and get back up radiographs to help decide if dealing with bone or labral involvement.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: chronic adductor pain - April 5, 2008 11:43:14 AM
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cclem2000
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Could very well be a hip problem, but how did you clear the lumbar spine?
(+) slump (reproduction of symptoms) may lead me back to L-spine
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RE: chronic adductor pain - April 5, 2008 12:03:12 PM
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PTupdate.com
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cclem2000....slump stresses sciatic distribution, and odds are slim that it will hit the portions of L4 that may be in that area. Otherwise, sensory distribution comes off higher up the lumbar spine. Slumping done right, however, does flex the hip far past 100 deg, which probably is why they felt the pain during the test. Could easily verify via supine SLR with dorsiflexion and cervical/thoracic flexion, keeping hip below that pain threshold.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: chronic adductor pain - April 5, 2008 12:33:21 PM
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rwillcott
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Thanks for the help. I performed AROM of the lumbar spine plus repeated movements. Also, SLR was negative and all PA's of the lumbar spine were WNL.
I figured the hip was involved but found her symptoms a bit peculiar. Usually I find patients with the hip involved report radiating pain along the anterior hip and groin. Her's is a 2-3 inch section of the mid adductors.
I will perform a more thorough eval of the hip next session. I think I'll focus on the hip and continue with the exercise program I have begun.
I'll keep you udpated.
Thanks everyone,
Rob
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RE: chronic adductor pain - April 5, 2008 12:50:44 PM
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Kaden
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Rob,
Any diagnostics on the hip now or ever in her past with these complaints. Seems weird for a 45 year old to have this long of a history of hip pain. Could there be a congenital component of some sort?
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RE: chronic adductor pain - April 5, 2008 1:00:50 PM
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kamryn
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in case the 2nd link does not work
J Orthop Sports Phys Ther. 2006 Aug;36(8):588-99.
Links
Clinical outcomes following manual physical therapy and exercise for hip osteoarthritis: A case series.
MacDonald CW, Whitman JM, Cleland JA, Smith M, Hoeksma HL.Centennial Physical Therapy, Colorado Sport and Spine Centers, 5731 Silverstone Terrace #120, Colorado Springs, CO 80919, USA. physiocam@adelphia.net
STUDY DESIGN: Case series describing the outcomes of individual patients with hip osteoarthritis treated with manual physical therapy and exercise. CASE DESCRIPTION: Seven patients referred to physical therapy with hip osteoarthritis and/or hip pain were included in this case series. All patients were treated with manual physical therapy followed by exercises to maximize strength and range of motion. Six of 7 patients completed a Harris Hip Score at initial examination and discharge from physical therapy, and 1 patient completed a Global Rating of Change Scale at discharge. OUTCOMES: Three males and 4 females with a median age of 62 years (range, 52-80 years) and median duration of symptoms of 9 months (range, 2-60 months) participated in this case series. The median number of physical therapy sessions attended was 5 (range, 4-12). The median increase in total passive range of motion of the hip was 82 degrees (range, 70 degrees-86 degrees). The median improvement on the Harris Hip Score was 25 points (range, 15-38 points). The single patient who completed the Global Rating of Change Scale at discharge reported being "a great deal better." Numeric pain rating scores decreased by a mean of 5 points (range, 2-7 points) on 0-to-10-point scale. DISCUSSION: All patients exhibited reductions in pain and increases in passive range of motion, as well as a clinically meaningful improvement in function. Although we can not infer a cause and effect relationship from a case series, the outcomes with these patients are similar to others reported in the literature that have demonstrated superior clinical outcomes associated with manual physical therapy and exercise for hip osteoarthritis compared to exercise alone.
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RE: chronic adductor pain - April 5, 2008 1:46:51 PM
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proud
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This women sounds like she has psycho-social issues. Persistent pain is a weird and wackey thing and often sends patho-anatomically driven PT's and other specialists around the bend.
Rwillcott suspects something is "odd" with this ladies reaction. That says alot.
Have you scored the BECK?
Often, patients with psycho-social issues really need that under control. Something PT's can do very little for besides re-assuring that nothing is sinsiter, get the person moving in a graduated exercise program. The studies above are spot on...but does this lady have OA?
This person has had "every special test under the sun". So to think there is some unfound block within the hip is a little optomistic.
These patients are not great for business if you do things right. This lady is looking for a magician to finally cure her problem. It will likely not happen. But somewhere, somehow....someone is going to have to give her the straight facts( nothing mechanically wrong....anxiety and depression and attitude are the main enemies etc etc).
She'll hate it...hate you and tell all her friends about how much of a bad PT you must be...resulting in bad publicity for your business. Sounds great doesn't it?
But you'll have been right and likley given her the one real tool to work with to finally move on....
Fire away....
edit: Given the wide variablity in what consitutes "physiotherapy" and the often wackey evaluation that ensues( see "trigger points" below)....I think there is nothing wrong with really searching all the possible patho-anatomical explainations. Who knows what sort of "PT" this lady has had in the past.
A good PT though should be able to sort out that possibility within 2-3 sessions. If nothing stands out....see my above...
< Message edited by proud -- April 5, 2008 2:26:07 PM >
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RE: chronic adductor pain - April 5, 2008 1:47:43 PM
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kjjones1212
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It may seem a little simple minded but have you palpated the adductors for spasms or "trigger points". A lot of times the hip adductors act as hip flexors/extensors when the iliopsoas or other hip flexors are weak. Since this is not its main job it gets "pissed" =pain. I would palpate the entire muscle feeling for hypertonic/tender areas and then do a 90 seconds ischemic muscle release to area then retest hip flexion to see if improved in range,strength or pain. Then once muscle is spasm free start re -training and then find out why original hip flexors are not performing. hip joint issues, low back, etc.
just a thought
KJ
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RE: chronic adductor pain - April 5, 2008 6:55:56 PM
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rwillcott
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From: Canada
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proud,
I agree with everything you've said. That's exactly what's crossed my mind. Yesterday I asked her about all the tests that she had done. Once she finished explaining to me how all these different professionals could not find anything I reinforced that this was a good sign that nothing was 'ripped, torn or broken'. I then explained the very basics of chronic pain and the importance of an exercise program. She became very defensive at this point.
I will take a closer look at the hip next session. I will emphasize the importance of the exercise program. If no improvement I will again reinforce my opinion and exercise program. I know that she won't be happy however, I would like to think that her family doctor and others will appreciate that I did he right thing.
Thanks,
Rob
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RE: chronic adductor pain - April 5, 2008 11:39:22 PM
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Kaden
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So I can't read. Apparently the "every test under the sun" line did not register. So strike the diagnostics question. I do agree with the psychosocial...but always a touchy subject.
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RE: chronic adductor pain - April 6, 2008 12:20:41 PM
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proud
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quote:
I know that she won't be happy however, I would like to think that her family doctor and others will appreciate that I did he right thing.
Thanks,
Rob
You know, it's sad but in actual fact...the family doctor just wants this person far far away in all likelihood. Whether she is getting a rub down at the local masseur, getting her spine adjusted, feet rubbed, cranial sutures "therapied" or whatever....they just don't want to see this person again.
So...in the end, you create more work for the physician by trying to engage them in the factual information. The physician will likley also hate you.
It's sad but true. Physicians are busy enough with patients they can help to truly care about these persistent pain types. It's a rare bird if the physician does actually care.
It's a real pickle for the PT that understands things and the associated business difficulties really will not change until the day that the only provider that ANY NMSK patient can see is a PT. Nothing else is funded by insurance. That way, mis-information and wackey techniques can be minimized and physicians will have no real choice but to work almost for the PT. What the PT says is acted upon and implemented becuase the expert in conservative NMSK has advised.
Of course, we as a profession have a long long way to go before we achieve that. Far too many PT's doing cranio-sacral therapy, MFR, trying to find "trigger points" etc etc.
They just don't get it. They have failed the one thing they have going for them supposedly....a university degree with all the tools to think critically. The information is out there to guide them appropriatly if they invest the time.
There is a dichotomy within those PT's. One group just does it because it's bringing them short term financial success. The second group is just plain naive. Both are unacceptable and the result should be a revoked license to practice...if we were regulating our profession correctly.
Hey, if you are naive enough to believe in CST...go to it. Just don't bill it under PT. Have your license revoked and hang a shingle that says "Craniosacral person inside".
< Message edited by proud -- April 6, 2008 12:57:43 PM >
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RE: chronic adductor pain - April 7, 2008 9:26:52 AM
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Shill
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One of my favorite questions in a situation like this is, "How consistent have you been making changes suggested by those you have seen for addressing this thigh pain?" If the answer is "not very", then there may still be some potential for improvement. I then ask, "How is this lack of change working for you, is the problem improving?" (in similar words, not necessarily exact). Patient says "not well". Could we then agree that you will need to make a change to potentially change this problem? If they say yes, they are willing to learn, willing to try to improve, and therefore they can be seen. If not, they are truly not a willing participant in the rehabilitation process, and should not be seen.
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RE: chronic adductor pain - April 8, 2008 9:33:46 PM
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rwillcott
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Saw this lady again today for follow-up. Last session I talked to her about chronic pain and the importance of continuing with a walking prgram and exercise despite discomfort. I sent her home with some glut med/max exercises. Much to my suprise she reported a reduction in pain. She has been perfroming her exercises and she did a good job demonstrating them in the clinic. I'd like to think that with some more education to reinforce the importance of the exercises she'll continue on this track.
I noticed today she wanted me to explain again why she had been having the pain. I spent more time explaining the hip and the importance of some of the muscles around it. She seemed to understand my explanation.
I tried to reflect on what I did with this patient to help her. My impression is that the education was more important than the actual exercises.
Rob
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RE: chronic adductor pain - April 8, 2008 10:21:09 PM
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proud
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quote:
ORIGINAL: rwillcott
Saw this lady again today for follow-up. Last session I talked to her about chronic pain and the importance of continuing with a walking prgram and exercise despite discomfort. I sent her home with some glut med/max exercises. Much to my suprise she reported a reduction in pain. She has been perfroming her exercises and she did a good job demonstrating them in the clinic. I'd like to think that with some more education to reinforce the importance of the exercises she'll continue on this track.
I noticed today she wanted me to explain again why she had been having the pain. I spent more time explaining the hip and the importance of some of the muscles around it. She seemed to understand my explanation.
I tried to reflect on what I did with this patient to help her. My impression is that the education was more important than the actual exercises.
Rob
Or the attention. Often people in persistent pain love any attention. They are clever. If they tell you they are feeling "better"...they know they'll likley get more of your attention.
Question and one you may likley never know: Does this woman have adequate social support? Good friends? A happy marriage? etc?
Cynical I know...but persistent pain and deep psyhco-social issues are often related( The group over at Somasimple would disagree but....it is what it is).
In any case, if you can parlay the trust she seems to have in you into a change in her exercise patterns and the way she thinks about pain....perhaps you can help her.
I just think you may find yourself frustrated in the end with this woman.
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RE: chronic adductor pain - April 8, 2008 10:55:10 PM
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rwillcott
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From: Canada
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There are definetly some of these issues present that you just mentioned. So say she comes back with an increase in pain for no reason. Obviously I can't say with 100% certainty that it's caused by these psychsocial issues. But lets say it is. Why do these people develop muscuoloskeletal pain? Why don't they end up with bad dreams and go see a psychiatrist? I had once read in a Back Letter that chronic LBP in people with underlying pyschosocial issues is considered 'surrogate' pain. Meaning everything else in my life is not good right now and to add this pain is too much. Therefore, my pain is too much for me to handle therefore I must seek help.
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RE: chronic adductor pain - April 9, 2008 12:54:27 AM
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steve
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The incidence of chronic pain for people with personality and anxiety disorders is much greater than the general population. The anxiety disorder patient makes perfect sense - they become fearful and hypervigilant about their symptoms and in one study I read the incidence of chronic pain for this population was 40%. With respect to the personality disorder patient (This would be the manipulative patient you mention, Proud) my personal theory is they aernt developed enough as an individual to cope with pain - ie Most of us have significant social roles and relationships and when we are injured dont fall below the level of "Coping" where as the personality disorder patient has multiple areas in life that are below average - relationships, employment etc. and when they are injured they cant get to a level where they can cope. Of course I'm no psychologist.....
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RE: chronic adductor pain - April 9, 2008 7:38:54 PM
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proud
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What an outstanding thread this has become.
Actually, I recently took a course regarding "pain science" by Debbie Patterson. It is truly amazing what happens physiologically in persistent pain patients. I sat there during the first 4 hours of the 2 day course mesmerized by the level of knowledge this lady had.
If anyone in Canada ever gets a chance to take the course...just for that 4 hours it's worth it. You could likely find the next course on this site: http://www.aptei.com/:
Mind you the rest of the course was slightly "fluffy" in my opinion and I think reached a bit in terms of how best to treat it( bizzare relaxation CD's, panic pages for patients, I mean....really getting patients to become even MORE pain focused in my opinion). I disagreed with most of the recomendations with the exception of the pain science educational component.
Anyway, the impression I got from the course was that persistent pain should be treated as if it's not the patients fault. Afterall, the CNS just has "taken over"...
Alright, I'll buy that....but I'm willing to hedge a bet that no matter how softly you try to treat persistent pain.....it persists. No matter how you try to link the most recent knowledge of pain physiology with specific treatment....the more spinning the patient does.
These patients simply need to develop coping skills( as Steve hinted). Unfortunately, the ability to develop this is likely long past it's best before date as we are dealing with an adult population.
Truly, I think the best approach would be some couselling, CBT, coping strategies and having EVER NMSK provider from the PT to the Physician delivering the same message: That there is nothing patho-anatomically wrong with them. Nothing is ripped, torn or broken or in danger of doing so. They absolutely need to exercise, eat right, and stop clinician searching. They can chose to let the pain beat them...or they can beat the pain. Their choice....not ours.
Somehow this has to be done without increasing the anxiety level of an already hypervigilent person. It's tough....but I think the right thing to do.
< Message edited by proud -- April 9, 2008 8:02:25 PM >
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RE: adductor sprain - April 17, 2008 1:03:45 AM
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sunshine20
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on the note of the adductors...wanted to know possible exercises and treatments of a groin strain.
patient is into competitive sports and has already started bike riding and wants to begin hiking. patient has had a strains on the same side 2 years ago.
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