No Body Chart No Problem??

[David Brown]

I recently encountered a hip and low back patient that gave me pause and tested my differential diagnosis ability. The patient failed to fill out a body chart or fill in what kind of pain she was experiencing and where. She was also late to the appointment so I didn’t have time to give her back the paperwork to properly fill out. I decided to go into the eval blind and hope I could quickly make a hypothesis list early on in the subjective exam. The patient was a poor historian and had a difficult time describing when the pain began, why it began, and what types of activities aggravated her symptoms. She began to experience the pain in her left anterior and posterior hip following an ankle injury in which she had to wear a boot for 12 weeks, although she could not remember which ankle it was. I began to think that there was SI joint involvement, IT band irritation, and or hypertonicity of the glutes causing an excessive pulling on the distal attachments on the GT and potentially aggravating the bursa. Because the patient had a hard time explaining the nature and the 24 hour cycle of her pain in terms of irritability and severity, I ended up asking many, specific questions that the patient could not answer sufficiently. Although she wasn’t getting angry or frustrated, she was becoming exasperated because she could not provide a lot of the information pertaining to her condition. My mentor was present during the exam and I began to feel nervous because I was having immense difficulty understanding what was the main driver in the scenario. The patient’s left hip pain would worsen anteriorly with prolonged sitting, and in this position she also experienced low back pain on the same side as her hip that would occur following the onset of the hip pain. She would experience left lateral hip pain and the same anterior hip pain with running and bike riding and she would experience posterior hip pain with squatting during her home exercise routine.
I stepped out of the subjective exam, conversed with my mentor, and realized that I was having a difficult time hypothesizing what was going on as there seemed to be several different sources of pain facilitators at play here. After trying to develop a sense of direction as to where to take my exam, I went back in and tried to rule in the possibility of IT band syndrome and the source of the posterior gluteal pain, rule out SI involvement and low back contributions all the while neglecting the anterior hip pain initially. The patient during the functional exam was unable to perform a squat past 50% excursion and demonstrated a compensatory weight shift to the right lower extremity. My mentor and I tried different ways to differentiate what was causing her to lack full excursion by holding her hands to make it easier from a strength perspective and propping her heels up to lessen the influence of potentially tight calves but nothing changed. The patient had full lumbar AROM with mild pain with rotation on her left side which further perplexed me in terms of finding the source of her posterior gluteal pain as she was only mildly tender to palpation in the gluteal region and it did not reproduce her exact symptoms. I made a mistake of not performing CPAs for pain provocation to see if there was a lumbar facet referral of any kind. Passive hip flexion in supine yielded significant limitations with a firm, muscular end feel. Bringing her hip into a flexion adduction quadrant reproduced her anterior hip symptoms and it was in this moment that I finally had the realization that there was a possibility of a FAI. I performed a Scour which was negative, and then a FABER and FADIR both of which were positive. I felt stupid for not thinking of this in the moment and even more stupid for neglecting to rule out the SI joint altogether. I was able to reproduce the lateral hip pain over the GT with palpation and Ober’s. After sitting the patient up I began to discuss my findings and found I had a hard time explaining the source of her posterior hip pain and ended up stating that it was predominantly because of the tightness of her glutes which in reflection, if involved, would be more of a contributor of her pain rather than a facilitator, and I should have better ruled out lumbar involvement before making this conclusion. I found my educational piece to be a bit muddy in terms of explaining the source of the lateral and anterior hip pain as my thinking and conclusions were a bit muddy. I felt bad because the patient wanted to understand why she could not run or bike without pain, two activities she so desperately wanted to engage in to help and I felt my reasoning of improving the mobility and strength of the glutes wasn’t sufficient just in itself. In reflection, I think I should have expanded my educational piece to explain that I think the main pain drivers were the greater trochanteric bursa causing the lateral hip pain, and soft tissues being rubbed against an overgrowth of the acetabulum, the femoral head, or a combination of the two causing the anterior hip pain. I would have continued by saying that strengthening and mobility exercises of the hip can improve the stability of the hip and reduce the pain she is experiencing in both of these areas. In the future if encounter a patient that has difficulty articulating their pain and the details surrounding it, I may need to step out of the room and take notes on what I think is truly going on and plan my objective exam to be far more thorough so I can address everything I need to address and leave nothing on the table.

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