In my practice I regularly see patients who complain of back, hip and pelvic pain. So I was not surprised when a 54-year-old woman came to see me with pain and stiffness in her right hip and pelvic area.
The pain had come slowly with no trauma to the area. She said the pain made it difficult to sleep at night and worse in the morning, but with a little activity the pain would improve. She described the pain as a sharp sensation that was often even more tender.
Most of the times when people experience pain and discomfort in this region, it is due to a group of six muscles called external hip rotators that are located in the pelvis. Their main function is to open the hips or turn the leg to the side.
It is common for a patient’s external hip rotators to be very tight, which puts the leg in an uncomfortable position. The easiest way to test this is to look at your legs while lying on your back. When your toes are pointing towards the ceiling, your external hip rotators are working properly. If one or both feet are turned to one side, it is most likely due to tight external hip rotators.
This patient had the classic external rotation of the leg. When I put the leg in the correct position, she felt a lot of stretch in the outer hip rotators and an increase in pain in her leg. Pain that travels is called referred or referred pain. It’s a common symptom of tense external hip rotators because these muscles often press on the sciatic nerve in the pelvis, which moves along the back of the leg.
I did several other tests and eventually diagnosed her with trochanteric bursitis (swelling of small sacs around the hipbone), piriformis syndrome (pain and dysfunction of one of the external hip rotators), sciatica (pain along the sciatic nerve), and hip strain. I started treating the patient with a special form of myofascial release called the patch technique to loosen the external hip rotators and ultimately relieve the pressure they put on the sciatic nerve.
At the end of the first appointment, the patient said she had practically no pelvic pain. But there was one symptom that was still the same: the pain going down her leg. In some cases this is normal as it may take some time for the external hip rotators to loosen enough to stop putting pressure on the sciatic nerve.
After several visits with the patient, she no longer had pelvic pain, but leg pain persisted. This made me wonder if the pain was actually from the sciatic nerve or from somewhere else.
We ordered X-rays and MRIs to see what was going on with the bones and soft tissues in the back, hips, and pelvis. The MRIs confirmed the bursitis and tendonitis in the pelvic muscles.
What was surprising was that the MRI also showed that the patient had a narrowing of the spaces in the spine where the nerves that went into the leg were. With this new information, I was able to see that the hip muscles weren’t causing the pain as I thought before.
At our next appointment, I added physical therapy that involved the spine in hopes of reducing the narrowing or “pinching” that was affecting the spinal nerves. After five sessions focusing on the spine, the patient had practically no leg pain.
This case was a good reminder of the importance of looking beyond the location of pain in diagnosing and treating the body.
To make sure the patient could remain pain-free, I asked Brian Warenius, Clinical Director of Excel Physical Therapy at Blue Bell, for help. In non-traumatic injuries, most symptoms appear initially because the patient has developed a bad habit or some kind of weakness in the area. Until these problems are resolved, the patient will often experience temporary relief, but a flare-up will occur a few months later.
According to Warenius, there are two simple and safe exercises a patient can perform to strengthen and stabilize the back and hips.
There isn’t much movement in this first exercise. Lie on your stomach with an exercise ball and your arms on top of the ball. Press your arms against the ball while activating your core muscles without moving your back. Hold for 2 to 3 seconds and then release. Repeat 10 times.
In the second exercise, start by lying on your side with your lower leg slightly bent so that you feel stable. Raise your top leg towards the ceiling and hold it for a second. Repeat this 10 times, and then do the other leg. If the exercise is too easy, try adding a resistance band above your knees.
As always, if you have any questions, contact your doctor.
Marc Legere is a chiropractor who specializes in myofascial release in Blue Bell. He can be reached at [email protected]