Joined: May 2, 2004
My colleague has a patient with unusual symptoms and I'm trying to offer some assistance. Her pt is a 48 y/o female, athletic build, and no history of trauma that can be linked to her symptoms. Symptoms have been present since June 2007 and she relates the onset to an immediate feeling of LE weakness and "giving way" that subsided after a couple of days and the pain has persisted. She describes her symptoms as being located in the medial and sometimes lateral thigh and are only present when she attempts to sit with her legs crossed. Symptoms are described as tightness and pain in the medial thigh that will switch to the lateral thigh with 90 degree hip flexion combined with ER in supine. Hip external rotation with hip at 90 degrees is limited by approximately 30 degrees with a firm endfeel. All LE movements in standing are pain free and WFL. It's only when her hip is flexed to 90 degrees that she has pain with hip ER, abduction, or end range adduction. If I move her hip to 90 degrees and IR the pain disappears. If I move into end range ER the pain moves from the medial thigh to her lateral thigh. Overpressure through the LE with her hip at 90 creates hip pain. Scour test produces pain. MRI's are mostly negative but the orthopod says he noticed a "bone bruise" along the posterior aspect of her femoral head. According to the pt, her MRI had an area of "white" in the region suspected to be bruised. Cancer and fx were apparently not suspected. SIJ belt makes no difference in her pain or ROM. No LBP, LE numbness, or obvious dermatomal weakness. If you buy into leg length difference as an indicator of innominant rotation, she has a 1cm increase contralateral LL in supine and 1cm decrease contralateral LL in long leg sitting. I attempted muscle energy to address a possible anterior innominant rotation contralaterally and a similar technique on the ipsilateral side for posterior innominant rotation. Neither technique resulted in any change of symptoms. The only intervention that has been somewhat helpful is intermittent manual hip distraction to the symptomatic LE (in supine with knee extended and hip in slight flexion and abduction) that results in an immediate increase in available pain free hip adduction when the hip is at 90 degrees. I firmly believe that this patient is legit and no signs of inconsistency or symptoms magnification are apparent.
Has anyone come across anything like this? Please help.
< Message edited by MickeyPT -- January 19, 2008 6:46:44 PM >
Joined: October 9, 2001
From: Pittsburgh, PA USA
Interesting that you posted this, as I just abstracted an article on femoral acetabular impingement. While this case sounds like impingment, but perhaps of a different etiology, you may need to listen to what the MD is indicating. If an MRI was done, and the diagnosis "bone bruise" was given, something was seen on that scan to justify that diagnosis.
Certainly, all the positions and tests you performed could cause pain if that area is compressed, or impinged. I had hoped that by the end of this weekend, I'd have a few pics posted of the special tests for the impingement that can be done.
If my patient, I'd put her on a cane, limit the amount of WB she does, and to avoid provative positions and maneuvers. The article noted that PT tends to irritate these patients and should not be performed, and this may be a good case as to why......trying to do too much, or digging deep and performing some techniques that may not be warranted based on the presentation.
John M. Duffy, PT Board Certified Orthopaedic Clinical Specialist www.PTupdate.com
Joined: August 29, 2007
The concern for me is that external rotation is the provacative position. The osseus impingements with labral issues (cam) most often are in int rotation. The femoral head posteriorly would be expected to be most deeply seated in the acetabulum in external rotation. Was the possibility that the bruise actually was early OCD considered?
Joined: May 2, 2004
I've treated this patient one time since taking over her treatment last week. To my knowledge the Dr. hasn't suspected the possibility of early OCD. The MRI was performed approximately 6 weeks (3 1/2 months since injury) so it's fairly recent. I'm just confused why a "bruise" would last this long. During her last treatment session I performed some additional testing. With her knee bent to 90, I can adduct her LE approximately 20 degrees until she experiences pain. If I distract her hip and perform the same motion she can tolerate approximately 40 degrees before the onset of pain. I've altered her POC and d/c'd all closed chain LE activities. I've instead opted for open chain exercises on the pulley's, some combined with hip distraction for decompression. I've only seen her for one session but she reported significant relief in symptoms. I'm curious to see if her symptoms will return by the next time she arrives to therapy. I've never come across a situation like this so I appreciate the feedback. I'll keep you posted.