SpineUniverse Case Study Library

Lumbar Spine’s Role in Chronic Hip Pain Case

When evaluating a patient with hip pain, do not overlook the lumbar spine. In this case, the patient had no low back pain, but the spine was the trigger of pain and symptoms.

History

This 53-year-old female presented with gradual onset of left hip pain over 3 months accompanied by numbness and tingling sensations down her left leg toward the ankle causing medial shin numbness. She reported no history of trauma and denied prior hip or low back pain.

Symptoms

  • Pain is constant and reported as 4-5/10 (10 being worst pain)
  • No low back pain
  • Left hip pain radiates down into her left lateral and anterior leg toward the anterior knee
  • Numbness in left medial shin
  • Pain deep in left psoas muscle area

Symptoms worsened by:

  • Walking > 10 min.
  • Standing > 10 min.
  • Lifting > 7-10 lbs.
  • Twisting movements (eg, rolling in bed)
  • Lumbar extension
  • Walking up/down hills

Symptoms improved by:

  • Active Release Technique
  • Rest
  • Stopping activities

Pain Disability Questionnaire (PDQ) Score: 59% (lower is better)

Examination

The patient is 5’7” and weighs 160 pounds. Normal blood pressure and heart rate.

  • Normal hip and lumbar range of motion
  • Pain with eccentric hip flexor contraction when bringing the left leg downward to neutral from a flexed position while supine
  • Strength: Normal 5/5
  • Reflexes: Hypo patellar and Achilles (left) 1/4

Pain triggers (postures/loads/movements):

  • Heel drop test: Positive with neck flexion/extension = nerve irritation
  • Supine lying test: Reduced pain with lumbar neutral spine
  • Extension test: Positive with extension and extension and right rotation
  • Wall plank test: Positive with extension and flexion
  • Standing spine load test:  Positive with loading

Pre-Treatment Imaging

The patient’s hip x-ray and MRI studies are unremarkable for hip pathology. L5-S1 are visualized; the radiologist noted degenerative disc disease (50% loss of disc height).

sagittal MRI lumbar spine, L5-S1 disc degenerationFigure 1. Sagittal MRI demonstrates disc changes at L4-L5 and L5-S1, suggestive of disc degeneration.

enlarged view of L4-L5 and L5-S1 Figure 2. Enlarged lateral view of L4-L5 and L5-S1.

Activity and Prior Treatment

The patient reports hip pain and symptoms prevents her from exercising. Her previous exercise routine included yoga 2x/week, cycling 3x/week and volleyball.

Active Release Technique in the patient’s left hip and psoas muscle provided some relief.

Author’s Comment
Although the patient has been symptomatic for the past 3 months, I believe her exercise routines and activities of daily living have gradually contributed to degeneration of her lumbar spine.

Diagnosis

Chronic unstable L4-L5 and L5-S1 discs with moderate L5-S1 disc degeneration; left radicular symptoms associated with the L4 and L5 nerve roots with secondary hip symptoms (ICD-10: M51.36, M54.16).


Treatment

The patient is flexion, extension and compression intolerant. These types of movements may compromise healing of her disc damage. Therefore, movements that involve lumbar flexion or extension (yoga, cycling, volleyball) should be avoided.

  • Graston Technique and Active Release Technique to muscles of the low back and hip without engaging in flexion or extension
  • Mild chiropractic adjustments to the thoracic spine only
  • No lumbar spine adjustments
  • Lumbar spine nerve “flossing” to reduce the radicular pain to be added
  • No low back, psoas or hamstring stretches at this time, as these stretches will aggravate her symptoms, especially her radiating pain

Treatment frequency: 2x/week x 6 visits and re-evaluate.

In office and at home pain-free floor exercises that are spine-sparing and build core stability without spinal flexion/extension. She was instructed to keep active outside any painful range when possible, and to keep her spine in a neural position.

Outcome

Twenty-one days after the patient’s first visit, she presented for her sixth treatment and reexamination. She has closely complied with all aspects of the recommended treatment.

The patient reported a 90% improvement in pain and symptoms.

  • Pain is 0/10 from 4-5/10
  • Radicular symptoms into the left lower extremity have resolved
  • Activities of daily living are not limited, except rolling in bed causes some pain
  • She has not returned to yoga, SoulCycle (ie, spinning) or volleyball at this time

Pain triggers (postures/loads/movements)

  • Heel Drop Test: Resolved
  • Prone Lying Test: Resolved
  • Standing Extension Test: Much improved; pain is 1/10 with extension
  • Wall Plank Test: Resolved
  • Standing Spine Load Test: Much improved; pain is 1/10 with compressive loading

PDQ Score: 47% (pre-treatment: 59%)

Treatment Discharge
The patient was instructed to maintain a neutral spine when possible to help minimize lumbar extension and flexion. She can begin to gradually incorporate athletic activities into her activities of daily living (eg, yoga, cycling, volleyball).

Outcome at 6 Months

She continues to do well after discharge and reported, “Back is doing great. Back at yoga."

 

Peer Case Discussion

The author has obtained an excellent clinical outcome in an interesting, and somewhat unusual, case history. The presenting history of gradual hip pain without trauma, as well as numbness and tingling down the leg, leads to a differential diagnosis between hip and low back pathology.

The symptomatology further confounds the problem of diagnosis as there is no low back pain, and the patient reports radicular symptoms emanating from the hip area, as well as deep hip flexor pain. The author states that the Active Release Technique (ART) to the left hip and psoas provided some relief to the symptoms further clouding the issue. I find a lack of clarity in the pain triggers listed, and would have liked a more conventional list of hip vs. low back vs. sacral orthopedic tests, (ie, Trendelenberg, Thomas, Yeoman, FABER Patrick, Kemps), to help us understand the clinical rational better. The imaging was the linchpin of the diagnosis with no hip pathology revealed, and significant degenerative changes noted at L4-L5 and L5-S1.

The author’s observations that elicited the pain; yoga, cycling, volleyball was astute and his conclusion that her exercise routine and activities of daily living (ADLs) have led to a gradual degenerative process in the lumbar spine was insightful and pointed to a spot-on diagnosis.

The conclusion that the patient was intolerant of certain movements, and these should be avoided during treatment was keen. Utilization of Graston and ART on the low back and hip was also a fine idea, as rehabilitation and restoration of the musculature is key to long-term pain relief without relapse.

I did find it surprising that the author did not adjust the lumbar spine. There are several non-force and non-rotary techniques (ie, Sacro-Occipital Technique, Activator) that I feel might have been successfully utilized to manipulate the affected spinal segments and facilitate removal of the pressure on the intervertebral nerve roots at L4 and L5.

The outcome reported is a superior one. Pain scale and PDQ score dropped significantly, ADLs were restored, radicular and hip pain was resolved, and pain triggers virtually disappeared. The patient remains pain free at six months’ post discharge. One could not ask for a better result. Outstanding.

Peer Case Discussion

“Gradual onset of left hip pain” does not identify the location of pain. Individuals with reported hip pain could be groin pain, lateral trochanteric pain, lower buttocks' pain and thigh pain (anterior, lateral or even posterior). Identification of the specific location is important to help with the differential diagnosis. This is why a pain diagram filled out by the patient is so important to allow visual description.

Some of the descriptors help to specify the potential pathology. “Pain deep in the psoas muscle” points to groin pain, not an uncommon presentation of hip disorders as well as femoral radiculopathy. Left hip pain radiating down the anterior and lateral thigh can originate as hip pathology but upper lumbar radiculopathy can also cover that pattern. “Numbness and tingling sensations” are not hip-related symptoms but are radiculopathic in nature.

Questions have to be asked that relate to hip aggravating factors such as leg cross-overs, getting in and out of a car, stair climbing/descending and getting on/off a bike. Hip patients might need a cane while those with radiculopathy generally don’t need walking aids. Foraminal and lateral recess stenosis patients have leg pain with standing/walking that disappears with sitting or squatting. A famous question is the “shopping cart sign." Do the patients look forward to pushing a shopping cart at the grocery store as this position allows flexion and therefore, relief of the buttocks and leg pain due to stenosis?

To the examination. There is pain inhibition testing the psoas muscle. "Pain with eccentric hip flexor contraction when bringing the left leg downward to neutral from a flexed position while supine” could be hip or femoral radiculopathy. Reflexes do not fit well with a radiculopathy (diminished patellar and Achilles left reflexes reflecting L3-4 and S1 roots). Normally with a radiculopathy, only one root (reflex) should be affected. I’m unclear what the “extension test” indicates. Is this pain with held extension of the spine? What does positive mean? Is there local back pain, reproduction of groin pain or radiating pain down the leg? A report of the symptom location would be helpful.

The diagnosis of “unstable discs at L4-5 and L5-S1” does not fit with the traditional definition of instability (3mm or more of motion with flexion/extension X-rays). There is no discussion of foraminal stenosis, which is potentially the diagnosis here. However, the most likely level of foraminal stenosis is L5-S1, which is the level of the most severe degenerative disc disease height loss. This would affect the L5 root, which does not fit with reflex deficit (noted above) or with groin pain as the L5 root typically refers to the buttocks and down the leg to the medial side of the foot.

Treatment was very effective. The patient recovered from her radiculopathy and is doing well.

Author's Response to Dr. Corenman's Commentary

Thank you for your comments and insights.

Before the patient came to my office, she was evaluated by an orthopaedic physician whose specialty is shoulder, knee and hip treatment/surgery. After his examination, he ordered a pelvic x-ray and pelvic MRI. He did not consider the lumbar spine at all since the patient did not report low back pain. After reviewing his findings and the imaging (did he fail to see the collapsed disc?), he referred the patient for hip treatment with a physical therapist. I am not sure if the physical therapist performed an assessment to determine the cause of the patient’s pain, or if therapy was performed based on symptom location. The physical therapy treatment was unsuccessful.

It would appear neither the orthopaedist nor physical therapist considered or solicited the postures, movements or loads that caused or relieved the patient’s pain. The patient was seeking pain relief and frankly, expected both practitioners to determine the cause and formulate a treatment plan to alleviate her symptoms.

I determined the movement mechanisms that aggravated her symptoms and provided exercises and movements to prevent exacerbating her symptoms. For example, the patient was lumbar extension intolerant, meaning lumbar extension increased her leg pain. (Let’s put aside, for a moment, the potential reason for her pain, facet imbrication, arthritic facet joints, disc instability, anterior longitudinal ligament stretch, etc.) There are many yoga movements that require lumbar extension. If I had not instructed her to stop yoga and movements that aggravated her symptoms, my treatment would have been less effective or not effective at all. The orthopaedic physician and physical therapist did not solicit her extension intolerance and did not recommend stopping those movements, including yoga practice twice a week. Neither provider solicited her flexion and compression intolerances either.

In the end, tissues become damaged from mechanical loads, and it must be the physician’s responsibility to determine the postures, movements and loads that flare and relieve symptoms and then coach the patient to stay within their tolerances.

On a separate note, the patient received both an x-ray and MRI but reported no trauma. With my method of evaluation, I would not have referred her for imaging. Rather, I would have waited to see her response to treatment first. There were no red flags in her history. Had treatment not been effective, then imaging could have been ordered. In this patient’s case, she could have saved herself x-ray exposure and the cost of the MRI, as imaging was clearly not required.

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