by zac mackenzie
This week I commenced treatment with a patient who was suffering from some pain in the buttock and hip region that had been bugging her for the last couple of months. The patient, let’s call her Sam, told me that the pain came on gradually without any obvious or specific cause... Unfortunately, however, it had grown in intensity over the past couple of weeks so she thought she better get it checked out. Sam also commented on her history of episodic lower back pain that tends to recur every 4-5 months before resolving on its own.
Due to the area of the pain and low back pain history I was suspicious that her gluteal pain may actually be a lower back problem in disguise! The buttock region is a very common site of referred pain from the lumbar spine, so it was important to include an assessment of her lower back in my examination. However, during assessment of the lower back there seemed to be no real issues other than some general tightness and low back movement didn’t seem to initiate any glute pain. When examining the hip I was able to elicit some pain during movements that stretch the glute tendons as well as when asking them to contract. I could also produce pain during palpation of the glute tendons. During strength testing I also found that her right glute seemed to test significantly weaker than the left.
These findings might indicate that she was experiencing symptoms related to a localised irritation in and around her gluteal (hip) tendons. If we were to do an ultrasound of the hip, we might see some signs of tendinopathy in the tendons, and perhaps a degree of bursitis near the greater trochanter. Unfortunately, once this area of the body gets sore and sensitive, it can be easily exacerbated and perpetuated by every day activities that compress and further irritate the tendons.
During treatment, we carried out some relieving massage and mobilisation interventions to the lumbar spine and hip, and we talked about some ways she could modify some of her every day activities so as to minimise the degree to which she compresses and irritates her tendons. The modifications we spoke about included avoiding leaning on that hip when standing, sitting cross legged, and lying on the effected side in bed.
We also looked to find an appropriate exercise to begin improving the “health” of her hip tendons with some targeted strengthening exercises. We spoke about the need to get the intensity of the exercise load just right… not so much that we further irritate things, but enough to drive a positive response. And we discussed how it is perfectly fine to adjust the intensity of exercise to suit fluctuations in her symptoms from day to day. I outlined that rehab will generally involve progression of glute and lower limb strengthening exercises as well as improving low back mobility.
Next week we will discuss how she went with the activity modifications as well as try to progress her strength exercise. I’m really looking forward to seeing how she progresses.
This week I had a follow up with my gluteal (hip) irritation patient. She said she felt like there was improvement in pain. Only feeling the pain on a few occasions and when she felt it, it wasn’t as intense. She did say that she had been having an increase in headaches and neck tightness over the last two days however. These symptoms seemed to come and go every few months for her as well.
I assessed her neck and identified a restricted joint in the upper neck which seemed to bring on some head symptoms. We call these types of headaches cervicogenic headaches, where the origin of the head symptoms are secondary to an issue occurring in the neck. I treated that segment which seemed to be relieving as well as gave her some upper back and neck mobility exercises for her to continue at home.
We went over the behaviour modifications that we went through in the initial session as well as progressed her strength exercise. She also advised me that she would be leaving the country in the next few weeks so our plan over the next session will be to reassess her neck and headaches as well as outline a rehab plan so she can continue her rehab when she leaves
During this third and final session, we outlined how the next couple months would look in terms of rehab for her hip and reassessed her headache symptoms.
Sam advised me that her headaches had been improved this week with only minor headaches occurring in the morning. In response to this we reviewed the exercises she had already been doing and added some progressions that she could begin when the existing ones became too comfortable.
We set out a rehab plan which showed progression of exercises looking at the next two months. I emphasized the importance of seeing the rehab program through to completion and advised her that it would be of benefit to seek out a physiotherapist to help guide her through the end stages of rehab and any obstacles that she might encounter along the way.
It was a pleasure to treat this patient and hopefully she can continue her rehab overseas and completely resolve her hip issue.