Guest guest Posted February 18, 2004 Report Share Posted February 18, 2004 Grant, From many similar past patients (many rugby players) I have found L4 nerve root to be the culprit. Slump test would be negative. Try pressing on the facet joint at L3/4 of the involved side to see if there is tenderness. If so manipulation is the key. I always go to the spine first with any extremity complaint as long as there are no glaringly obvious positive tests of joint dysfunction. Manipulate first and see what is left peripherally and then treat that. Eg., I just had a physio/marathoner in with c/o inner thigh/groin pain which was not a muscular strain - L3 nerve root was the cause and manipulation markedly reduce the symptoms immediately. Hope this helps. Dr J , MSc, DC Whangarei Chiropractic Centre 20 Kensington Avenue (64-9)-437-7345 Whangarei NEW ZEALAND " Nothing is forever except for Heaven & hell - CHOOSE CAREFULLY " (unknown) Pain in Hip > I have a young male athlete, aged 17. He is an avid rugby player who cannot run at the moment. Rugby season starts in about 4 weeks. Below is his history and as many symptoms as I could get that might help with a diagnosis. > > In early September 2003 he had a menisectomy on his left knee. 3 months later (December) he noticed a " shooting " pain in his right gluteal muscles. Since he had spent the previous night on an uncomfortable bed he assumed that the pain would go away. It did not. > > At first he saw a doctor who suggested that it would disappear after a week. After seeing a physio some weeks later he started training with me. The physio said that his TFL was too tight and need stretching. This was incorporated into his training. It seemed to disappear after a week. Unfortunately it has returned. > > Below is a list of all/any information I could get from the patient: > > 1) Gluteal stretching seems to relieve the pain temporally. > 2) The pain is described as a " shooting, pinching " pain. (Neural?) > 3) The pressure/release of pressure during jogging and running exacerbates the pain. He is uncertain at what stage of jogging there is pain (ie foot strike, toe off etc) but knows that it " oscillates " between pain and no pain. > 4) Squats (sumo, front nor back), deadlifts and lunges do not seem to aggravate any symptoms. > 5) During everyday activities the pain is always there, although he can forget about it if performing another task. He cannot forget about it during any running activities. > 6) Lying in a supine position, hips and knees flexed at 90 deg, I can reproduce the pain moving his hip between internal/external rotation. The pain is only felt during the movement, and not when held at the point of pain. The point of pain is somewhere around neutral. > 7) Negative slump test > 8) Pain on the ipsilateral single legged hyper-extension test in his low back. > > If you require any more information, please let me know. > > > Regards, > > Grant > Strength and Rehabilitation Consultant > B.Sc. (Hons) Ex. Sci. > M.A.A.E.S.S., M.A.S.C.A. > > PHYSIOKINETICS > Gold Coast, Australia > (+61) 409 625 263 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 19, 2004 Report Share Posted February 19, 2004 Out of all of the information you presented here the only thing that sticks out to me is in your very first statement... " I have a young male athlete, age 17. " I feel that more information is necessary just from this statement alone due to the fact that there are no established expectations from him nor established goals for further sport participation. Does he want to be pain free forever? Does he want to be pain free while playing sport? Does he plan to commit to whatever program he is given to rectify this problem? Does he realize (at a tender age of 17) that rugby is a very competitive sport and if he continues to participate he may never truly be pain free?! It sounds to me that he is still quite capable of participating in several acitivities without pain. My suggestion is to stick with those acitivities because that could just be the exact rehab (for lack of a better word) or unload he needs to come back to whatever sport he plans to play. That is the reality of it. We, as professionals, can only create the environment for our clients (I don't see patients) to peform in and whether it be in strength, speed, flexiblity, etc., it is through pain we learn much more about ourselves. We learn our limitations, our expectations, and our ability to overcome them regardless of how painfull they might be!! J Sanidad Redwood City, CA \Grant wrote: I have a young male athlete, aged 17. He is an avid rugby player who cannot run at the moment. Rugby season starts in about 4 weeks. Below is his history and as many symptoms as I could get that might help with a diagnosis. In early September 2003 he had a menisectomy on his left knee. 3 months later (December) he noticed a “shooting” pain in his right gluteal muscles. Since he had spent the previous night on an uncomfortable bed he assumed that the pain would go away. It did not. At first he saw a doctor who suggested that it would disappear after a week. After seeing a physio some weeks later he started training with me. The physio said that his TFL was too tight and need stretching. This was incorporated into his training. It seemed to disappear after a week. Unfortunately it has returned. Below is a list of all/any information I could get from the patient: 1) Gluteal stretching seems to relieve the pain temporally. 2) The pain is described as a “shooting, pinching” pain. (Neural?) 3) The pressure/release of pressure during jogging and running exacerbates the pain. He is uncertain at what stage of jogging there is pain (ie foot strike, toe off etc) but knows that it “oscillates” between pain and no pain. 4) Squats (sumo, front nor back), deadlifts and lunges do not seem to aggravate any symptoms. 5) During everyday activities the pain is always there, although he can forget about it if performing another task. He cannot forget about it during any running activities. 6) Lying in a supine position, hips and knees flexed at 90 deg, I can reproduce the pain moving his hip between internal/external rotation. The pain is only felt during the movement, and not when held at the point of pain. The point of pain is somewhere around neutral. 7) Negative slump test 8) Pain on the ipsilateral single legged hyper-extension test in his low back. If you require any more information, please let me know. Regards, Grant Strength and Rehabilitation Consultant B.Sc. (Hons) Ex. Sci. M.A.A.E.S.S., M.A.S.C.A. PHYSIOKINETICS Gold Coast, Australia (+61) 409 625 263 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2004 Report Share Posted February 20, 2004 Hello Grant, There are a couple of things about this young man that strike me as problematic. The fact that he has pain in a limited arc which you state can be brought on by rotating the hip in supine is of concern. Also is the report of almost constant daily pain, worsened with running. The fact that he can squat & deadlift would seem to negate a gluteal strain or muscular tear to the gluteus complex. Also, the negative slump test together with the aforementioned comments makes me doubt a lumbar intervertebral disc lesion. A few possibilities come to mind; I have seen athletes who sustained small tears to the labrum of the hip present in a similar manner. The pain is felt when the head of the femur rolls over the injured labral tissue, hence the on-off pain reports. This can be confirmed only upon MRI. Treatment may include excision of the damaged labral tissue, though it is not always necessary. A nother possibility could be piriformis syndrome. The pain may be felt in an area that a layperson could describe as " in the glutes " . Is there a restriction in motion of hip rotation in either direction? You also did not mention any elements of hip strength in isolated tests. This may be telling. From this distance, one can only speculate at possible pathology and without benefit of directly interviewing the patient. Hope this helps. Good luck Ernie Roy PT, CSCS Northfield, NH, USA > I have a young male athlete, aged 17. He is an avid rugby player who cannot run at the moment. Rugby season starts in about 4 weeks. Below is his history and as many symptoms as I could get that might help with a diagnosis. > > In early September 2003 he had a menisectomy on his left knee. 3 months later (December) he noticed a " shooting " pain in his right gluteal muscles. Since he had spent the previous night on an uncomfortable bed he assumed that the pain would go away. It did not. > > At first he saw a doctor who suggested that it would disappear after a week. After seeing a physio some weeks later he started training with me. The physio said that his TFL was too tight and need stretching. This was incorporated into his training. It seemed to disappear after a week. Unfortunately it has returned. > > Below is a list of all/any information I could get from the patient: > > 1) Gluteal stretching seems to relieve the pain temporally. > 2) The pain is described as a " shooting, pinching " pain. (Neural?) > 3) The pressure/release of pressure during jogging and running exacerbates the pain. He is uncertain at what stage of jogging there is pain (ie foot strike, toe off etc) but knows that it " oscillates " between pain and no pain. > 4) Squats (sumo, front nor back), deadlifts and lunges do not seem to aggravate any symptoms. > 5) During everyday activities the pain is always there, although he can forget about it if performing another task. He cannot forget about it during any running activities. > 6) Lying in a supine position, hips and knees flexed at 90 deg, I can reproduce the pain moving his hip between internal/external rotation. The pain is only felt during the movement, and not when held at the point of pain. The point of pain is somewhere around neutral. > 7) Negative slump test > 8) Pain on the ipsilateral single legged hyper-extension test in his low back. > > If you require any more information, please let me know. > > > Regards, > > Grant > Strength and Rehabilitation Consultant > B.Sc. (Hons) Ex. Sci. > M.A.A.E.S.S., M.A.S.C.A. > > PHYSIOKINETICS > Gold Coast, Australia > (+61) 409 625 263 > > -- > ___________________________________________________________ > Sign-up for Ads Free at Mail.com > http://promo.mail.com/adsfreejump.htm Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 28, 2004 Report Share Posted February 28, 2004 Greetings Norma, Interesting there is any question regarding groin injury from Corey who has pain with squats and with standing and stretching which nearly brings him to the ground. That sounds like L3 nerve root. My rule is always go to the spine FIRST unless it is very clear it is muscular/ligamentous. For lower extremity the breakdown is as follows L3 - groin - testicular pain L4 - anterior thigh and/or knee pain L5 - posterior/lateral glut pain with radiation into the lateral aspect of the thigh S1 - pain in the posterior thigh in to the calf and/or heel, e.g.., pain like an Achilles tendonitis or heel pain like a plantar fascitis. I had a case several years ago where a lady (non-athlete) had been diagnosed with heel spurs as seen on x-rays. She had had all kinds of physio and was about to go for a surgical consult. It took 6-7 treatments to resolve with the 1st treatment producing 50%+ reduction in pain. I was even surprised as I felt the symptoms were from the heel spurs but she also had marked tenderness with pressure on L5 and signs of S1 nerve root involvement (e.g.., mildly positive Slump test). Always go to the spine first.... As far as spinal manipulation therapy (SMT) goes chiropractors are probably the most trained. However I have met and been treated by physios who have trained in SMT and are good. In regards to the possibility of disc involvement anyone qualified in SMT should be able to figure that out and treat accordingly. The best way of treating a disc related problem is by combining manipulation and mobilisation with flexion-distraction therapy (FDT). This is usually a chiro-thing. The best way to find out who to go to is asked around, particularly in gyms. And do ask the chiro - if that is the choice - if he or she uses FDT. Hope the above helps. Dr J , MSc, DC Whangarei Chiropractic Centre 20 Kensington Avenue (64-9)-437-7345 Whangarei NEW ZEALAND " Nothing is forever except for Heaven & hell - CHOOSE CAREFULLY " (unknown) ----- Original Message ----- Norma Ivie wrote: > Hi Dr. , > > You say manipulation of L3 or L4 helps to relieve the pain in Lower > extremities. Would you recommend maipulation if the client had slightly > herniated disc at L3- L4 L4-L5 & bulging disc at S1? The client can still > function no heavy load bearing on the cervica as in squats, client continues > to run 3-4 miles several times a week & continues to train with weights. > > Do you think Chiropractic & massage therapy to be useful in this > situation? > By the way, the client is also a firefighter & after wearing the airpack > in a structure fire or training exercise's complains of more pain. > Any advice or information would be greatly helpful. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 28, 2004 Report Share Posted March 28, 2004 Grant, Could you update us as to the progress of this case? I have been diagnosed with piriformis syndrome, and have all of the symptoms noted above apart from (3), and I don't know what (8) involves exactly. If anyone else has guidelines for recovering from this please let me know, or references to journal articles. I have been advised just to stretch gluteals (non-painful stretches) and strengthen hip, along with superficial heating methods. How long should I persist with this before asking for a referral to a surgeon? Register, Guildford, Surrey, UK > I have a young male athlete, aged 17. He is an avid rugby player who cannot run at the moment. Rugby season starts in about 4 weeks. Below is his history and as many symptoms as I could get that might help with a diagnosis. > > In early September 2003 he had a menisectomy on his left knee. 3 months later (December) he noticed a " shooting " pain in his right gluteal muscles. Since he had spent the previous night on an uncomfortable bed he assumed that the pain would go away. It did not. > > At first he saw a doctor who suggested that it would disappear after a week. After seeing a physio some weeks later he started training with me. The physio said that his TFL was too tight and need stretching. This was incorporated into his training. It seemed to disappear after a week. Unfortunately it has returned. > > Below is a list of all/any information I could get from the patient: > > 1) Gluteal stretching seems to relieve the pain temporally. > 2) The pain is described as a " shooting, pinching " pain. (Neural?) > 3) The pressure/release of pressure during jogging and running exacerbates the pain. He is uncertain at what stage of jogging there is pain (ie foot strike, toe off etc) but knows that it " oscillates " between pain and no pain. > 4) Squats (sumo, front nor back), deadlifts and lunges do not seem to aggravate any symptoms. > 5) During everyday activities the pain is always there, although he can forget about it if performing another task. He cannot forget about it during any running activities. > 6) Lying in a supine position, hips and knees flexed at 90 deg, I can reproduce the pain moving his hip between internal/external rotation. The pain is only felt during the movement, and not when held at the point of pain. The point of pain is somewhere around neutral. > 7) Negative slump test > 8) Pain on the ipsilateral single legged hyper-extension test in his low back. > > If you require any more information, please let me know. > > > Regards, > > Grant > Strength and Rehabilitation Consultant > B.Sc. (Hons) Ex. Sci. > M.A.A.E.S.S., M.A.S.C.A. > > PHYSIOKINETICS > Gold Coast, Australia > (+61) 409 625 263 Quote Link to comment Share on other sites More sharing options...
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