Case of the Week 1-21-13: Adductor Strain?
I saw a new eval last week for right knee pain and groin pain. Like many of the cases I post, things were not as they seem.
The patient is a male in his late 60s, retired, but very active. He is able to play basketball, golf, and tennis. His primary complaints are intermittent right medial knee pain and intermittent left groin pain, felt at the proximal adductors.
The eval was as follows:
Subjective: Pt reports having R ankle fused 7-8 years ago and is pain free for the most part in that area. He has THA on L hip 5-6 years ago. Currently c/o R medial knee pain in the last two months, intermittent rated 4/10. Also notes intermittent L proximal adductor pain rated 6/10. Sx worse with L hip abduction open chain, L hip adductor closed chain (dragging foot on the ground). He is able to golf, play tennis, but is not able to walk the dog without pain in his right knee.
Objective: fair sitting posture
key: F = functional (WNL), D = dysfunctional, N = non-painful, P = painful, PDM = pain during movement, ERP = end range pain, LRF = lat rotation and flexion, MRE = med rotation and extension
Flexion Left FN Right DP
Extension Left 5 Right 0/hard
Int Rot Left FN Right DN, mod
Ext Rot Left FN Right FN
Dorsiflexion Left FN Right DN, (fused)
Plantarflexion Left FN Right DN (fused)
Tibial IR Left DN Right DN, B sev
Hip abd Left 5/5 Right 4/5
Hip ext Left 5/5 Right 4/5
More would have normally been tested, but he was the case I spoke about on last Fridays post and spend about 15 minutes discussing trying out mirror box therapy for his unilateral essential tremor.
During the movement testing, I could not reproduce his left groin pain with passive abduction, ER of the left hip, or resisted adduction. Passive SLR of the right side reproduced left groin pain, as did resisted right hip extension (4/5 compared to left side which was 5/5).
Since he had history of right talocrural fusion 7-8 years ago, I explained that helping his right hip gain mobility and strength would most likely help his intermittent knee pain. Also, since his left groin complaints could only be reproduced with right hip passive SLR and resisted extension, I also stated I would not treat his left hip if after treatment, the re-testing showed change in his left hip.
Treatment: IASTM to the right QL, upper and lower lateral LE patterns (ITB and lateral tibia contours). tibial IR MWM. and hip MWM to improve IR with a belt.
After this treatment, SLR was re-tested along with resisted hip extension on the right. The patient was pleasantly surprised to feel complete relief of his left groin pain. He was shown self repeated hip IR, tibial IR for HEP along with bridges with TA activation.
Prior to ther ex, he also tried his dynamic golf warmups, which consisted of SLS and rapidly swinging his hips across his body in the frontal plane. This was normally painful for the last few months and now was pain free. His right knee was also now pain free in walking.
I have not seen him yet for follow up, but I think we're off to a good start. I already know what else I'm going to assess on the second visit. What would you look at based on the given information?