Case study: Hip and Lower back pain (LBP)
Presentation: Female 32 years of age presented with acute onset R hip pain and chronic but now acute LBP
History: intermittent runner since the age of 18 with episodes of LBP and not bad but some ongoing R hip pain. The patient is now 4 months into training for a half marathon in 3 months. No history of trauma. No history of leg pain.
Patient now feels pain in the back is aggravated with running and sitting. The hip is aggravated with walking, running and climbing stairs. Pain also laying on her right side and even a little on her left. Both the hip pain and low back pain feel stiff first in the morning and can feel better with a little movement. The same presentation occurs with sitting for a period of greater than 1 hour
Examination:
- Standing: tilt and rotation of the pelvis; external rotation of the L hip, pain aggravated with single leg stand R and patient forward bending
- Slump test is positive for LBP, not hip pain. Deep tendon reflexes (DTR) are normal
- Laying: L leg short, R hip range of movement (ROM) restricted with restricted length R hamstring, flexion of R hip and post compression increases pain in the hip.
- Palpation: R intrinsic hip muscles are tender to touch as is the insertion of the hamstring tendon. Tender and short adductors on the R side
Diagnostic comments:
This was a classic presentation of leg length inequality driving an irritation in the hip musculature and also aggravating the low back pain. The hip pain was an injury to the dynamic stabilising muscles of the hip, notably the gluteus med and the posterior capsule and trochanteric bursa. The low back pain is an aggravated disc from previous strain and the hip dysfunction was loading the lumbar disc and causing irritation and hence low back pain.
Both of these injuries were aggravated by running but not caused by it. The prevention would have been to have had a physical and functional screen assessment prior to running in order to screen for any bio mechanical compromise and potential injury triggers.
Treatment:
The treatment focused initially on reducing the inflammation around the hip (acupuncture, NSAID’s, ICE, rest). Then we corrected the leg length difference via a combination of stretching, soft tissue massage and orthotics. Finally we performed a functional assessment which helped us to isolate areas of movement weakness and then initiated a program of strengthening and stretching. This included core challenging exercises to assist with both the low back pain and hip dysfunction. Breathing activation was also engaged to support this process.
The response was good and the patient began a slow process of core strengthening (6-8wks), gluteal strengthening and lower limb stretching (6-8wks). She then initiated running with a change of technique (such as breathing and foot landing), duration and frequency.
Initially she was unable to make the starting line for her first half marathon but has since successfully completed 2.
