Weekend 5 Case Presentation

[Katie Long]

Hey all, please see the attached document for next weekend.

1. Given this information, what is your primary hypothesis? What differential diagnoses do you have?
2. Is there a potential psychosocial factor involved in the fact that he has a family history or testicular CA despite the fact that his testing is negative?
3. What (if any) referrals would you consider for this patient? Are there any factors that you find concerning? Is this patient appropriate for OP ortho PT care?
4. I have never seen a patient presenting like this as a new therapist. I often have trouble having confidence in myself and exuding confidence to my patients when I am unfamiliar with a patient’s presentation. How do you approach patient education, prognosis and patient buy-in with a patient when their case is unfamiliar to you?
5. What HEP would you send this patient home with on day 1?

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[Tyler France]

Hey Katie,

Definitely an interesting case. Have other medical providers ruled out a hernia as a cause of his symptoms? Considering many of his aggs include increased intra-abdominal pressure, that would be my first thought. If that has been ruled out and we are looking at a strictly MSK cause of the pain, I would have to lean towards SIJ dysfunction due to the 4 positive findings from the test cluster, though it seems curious with no mechanism. Did this pain begin insidiously or was there a mechanism to it? Have you asked him if he is worried that his pain may be coming from cancer? I would say that his answer to that question could determine whether that may be a factor in his treatment. Has he seen a urologist? I would be most concerned about the testicular pain when emptying a full bladder in the morning.

[Justin Pretlow]

Hi Katie,

1. Nature of Sx seems consistent with athletic pubalgia(despite not being a high level athlete, or was he?). Diff Dx: Si joint dysfunction, pudendal nerve entrapment, pubic symphysis dysfunction, FAI, iliopsoas tendinopathy.
2. I think the family history of CA and chronic nature of symptoms could contribute to hyper awareness concerning his pain.
3. Aggravation of symptoms with emptying a full bladder is concerning. I assume he’s seen a urologist? Is he being followed by other Dr.’s besides his primary care? He sounds appropriate for PT but I would want to make sure he has been completely worked up by his referring physician. Any imaging?
4. If I’m unfamiliar with a patient’s presentation, I try to make sure I explain well what I think is going on and make sure the patient understands the plan and what the next step will be if that plan does not work.
5. This one’s hard to answer. I would probably address a movement pattern that he has to do for work (eg squatting) and try out a couple of exercises that may improve that movement pattern or decrease symptoms with that movement pattern.

[Katie Long]

Hi guys, thanks for the discussion! He has had a CT scan and been seen by a urologist and has had GI/GU/Hernia and CA all ruled out in addition to the mentioned sonogram. He said his family history of CA caused him to seek care in the first place, but he stated that he felt better knowing that it was ruled out. There was no mechanism and he is/was not an athlete of any kind.

[Jennifer Boyle]

Hey Katie! Thanks for your case for this weekend. It is definitely a presentation I have not seen either. Did you use any special questions to further r/o the other more serious things other than cancer? I think that his family history can have an impact in his psychosocial presentation but this is a great place for you to step in and show him how mechanical some of his symptoms are presenting. Hopefully showing him that movements can provoke his pains can help put his mind at ease and at the same time help use pt education to build his confidence in you to treat him. Its great that he is feeling better knowing that CA has been ruled out and will also help with pt buy-in. You mentioned him seeing a urologist, has this presented with any new findings that may help understand why he is having pain emptying his bladder?

[Michael McMurray]

Please think neural entrapment in the region.
Various nerves – illioinginual, obturator, femoral, pudendal, genitofemoral.

How would you asses these specific nerves?
Would you refer, and to who?

[Sarah Bosserman]

Hi Katie! interesting case. Pudendal or obturator nerves came to mind with pain patterns and symptoms (pudendal worsens with sitting and obturator with hip abduction and extension). Thinking about differentials of SIJ, FAI, iliopsoas/adductor tendinopathy. Did you find any significant muscle weakness? 2 years is a long time, has the pain been intermittent with more recent exacerbation or consistent and did the groin or LBP come first (or at the same time)? Was just curious about the quality of his motion if he has had pain for that long, seems like he has some significant hypomobility in lumbar spine and hip and how they may affect how he bends and lifts.

[Michael McMurray]

Should be on your differential.

Good recent review here.

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[Katie Long]

Yes, I definitely should have had peripheral nerve entrapment on my differential list. Unfortunately, Eric posted this article on our discussion board two days after I evaluated him! I had not really even considered some of those peripheral nerve entrapments until that article, but need to be better about including them on my differential list.

[Katie Long]

Hey all, here are those articles I used! Hope they help!

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[Scott Resetar]

Hi everyone,
I showed this thread to our Women’s Health Specialist, and here was her reply.

“It does seem like maybe some of his (+) findings for LBP and SIJ may be secondary, compensatory patterns for PFMD. Neuralgia is certainly a good thought, except nerve pain tends to not ease quickly. Sounds to me like classic male pelvic floor muscle dysfunction likely picking up a little pudendal nerve either at levator ani or obturator internus. I’d be curious to know about hamstring tension, SLR findings and fascial restrictions. Pudendal neuralgia is often provoked with hip flexion past 90 with or without ER. I wonder if he gets any rectal pain or ever feels fullness like he is sitting on a ball. Fasical assessment? Hyper- or hypomobility testing throughout? Again, many findings to me scream PFM overactivity, I’d refer this guy to a pelvic floor PT for further assessment and consider co-treating! ”

Hope that helps!

[Katie Long]

Hi Scott, these are all some good points, however he ended up only coming in for a couple of sessions before he hurt his shoulder and decided to seek care from an orthopedic surgeon for that and put this on hold. I contacted two pelvic floor PTs and they gave me some tips while I was seeing him so I had some help from them too! Thanks for the input!

[Katie Long]

Hi Everyone,

I don’t know if there is anyone still emotionally invested in this case or not, but I wanted to post an update. I have now successfully treated this gentleman for his shoulder pain and today was his first session back for his groin/pelvic floor pain. He continues to have (+) Adductor squeeze test for reproduction of his groin, testicular and adductor pain. He also continues to have sx provocation with L spine ROM testing, although considerably better. He no longer has groin pain provoked with CPA spinal accessory motion testing. He no longer has sx provocation into his testicles or groin with palpation to his adductors, although continues to demonstrate significant tone upon palpation. His hip flexors and TA are very hypertonic and produce his anterior groin pain with palpation. We needled his right adductor magnus and provided some STM to his left and with re-assessment of his adductor squeeze, he denied ANY testicular pain!! The rest of the session was focused on flexibility (butterfly, happy baby, quad stretching) and he reported reduction of his sx from a 10/10 to a 4/10 following the session!

Katie

[Justin Pretlow]

Hi Katie,
How did you make the decision to dry needle his adductors? I don’t know much about appropriate needling scenarios.

[Katie Long]

Hey Justin,

So I decided to needle his adductors because at his initial visit, palpation to the adductors reproduced his groin and testicular pain. The adductors can also refer into the groin. I was also hoping to utilize the needling to reduce tone of the adductors and therefore reduce tension/pull on the inguinal canal and pubic symphysis. It has been a very successful intervention for him so far.

We have moved on to addressing his rectus abdominus (which also refers to his testicles with palpation) and his obliques with STM (in addition to his adductors and lumbar spine impairments). He has been able to perform functional activities such as back squatting, bench pressing, hip thrusters and cable workouts in the gym following manual tx with no reproduction of his sx!!

[Justin Pretlow]

Thanks for the clarification – that makes sense.
Glad to hear he’s responding so well.

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