Ask a PT

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Posted - 01/23/2007 :  16:10:32  Show Profile  Reply with Quote
Our user asked: "I am a PT who has been treating a pt for several weeks now. Her mechanism of injury was slipping and falling onto L side(glut and shoulder)on 10/06. She has pain only with sitting longer than 30 minutes and describes it as burning in L gluteal. Trunk AROM WNL without pain, repeated movements were painfree.Minimal to no restrictions at L lumbar region mm. MRI NEGATIVE-unremarkable. SI jt negative with provacative tests. PA pressure at lumbar spine WNL. L HS with slight limitation compared to right. Also has mild limitations with hip IR and presents with tissue restriction L hip ER. Ive tried mechanical traction with minimal benefit. Leg pull helps while doing it with minimal carryover.Lumbar stab act have been performed for last 5 weeks now. I was convinced it was coming from LB but all tests do not reproduce symptoms. I thought maybe fascial restriction at L gluteal ? Any advice or suggestions would be helpful. Thanks"

Ask a PT Response: "Thanks for sharing your case and allowing me to help you brainstorm. It sounds like you have done a good job trying to rule out the etiology of pain. Since you have cleared the back with the various special tests and with the MRI, I would assume her symptoms are not coming from there. You describe her symptomology as a burning pain in the L gluteal region with onset only after sitting for a prolonged period (> 30 min). This would lead me to take a closer look at both the hip and SI joints and see if there is a mechanical or postural dysfunction in this area as a result of a fall onto the L buttock. How is the palpation of the Hip & SI areas? How is the flexibility and strength of the muscles which attach to these areas? Are anatomical landmarks congruent and line up? Is there marked tenderness in these regions? Is there a leg lenth discrepancy? You mentioned there is slight L hamstring limitation vs the R hamstring and that there are limitations with L hip IR and ER compared to the right. This could be secondary to the fall as the SI joint is not designed for much motion and any alteration can disrupt the length tension relationship to the muscles that attach in this region. You mentioned that L LE distraction helps decrease the sx but there is no carryover. From this info we might be able to assume that symptoms are caused from a load on the SI joint, in this case sitting. Have any sitting SI tests been performed and if so are they positive? Is there a difference for your patient with sitting on a softer surface vs harder surface? If you are answering yes to some of these questions than you may want to consider mechanical dysfunction of the SI resulting in impingement of the ligaments surrounding the SI joint or possible compression of a nerve or artery in the region as well. Other items to consider are a SI sprain, or damage to the articular cartilage lining the SI joint which is irritated when a load is applied. Since you have already been working on her back and core, I would look at other alternatives. I would focus on your problem list which you mentioned- improving hamstring and hip IR/ER ROM/flexibility and any other items that may be problematic at the SI or hip region. Treatment could also include joint mobs and muscle energy techniques. Perhaps participation in an aquatic therapy program may be beneficial as well, as this will take some load of the joints and allow the patient to recover faster. Just some thoughts which I hope will help. Keep me updated on how things go."