This topic contains 6 replies, has 4 voices, and was last updated by 
Carl Nottoli, DC August 5, 2019 at 7:29 am.
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Scott Glidden
45 year old female
L Hip/lower back sx
“pain in the butt”
7/10 intensity at time of exam. 4/10 lowest, 10/10 worst
sitting aggravates it (worse when sitting on ground)
laying down makes it better.Strength/Sensory/Reflex: WNL
SLR:
Left 80 degrees, 5/10 L posterior hip pain
Right 80 degrees 6/10 lower back painno adhesion
SHF:
Left: 3F, 3/10 lower back pain
Right 4F, 3/10 lower back painModerate adhesion in ad mag (2) bilaterally, 1+ adhesion in L hip capsule, 1 adhesion in R hip capsule
QLF: 00222
No sx during assessment1 adhesion at L L5 multifidus
KHE:
12″/mild stretch bilaterallySLPF 50%, 6/10 lower back tension
Diagnosis: adhesion in hips, disc degeneration, bilateral FAI.
4th Treatment appointment: Minimal symptoms until she stretched and “threw out” her back. Both hips are at 3F with anterior and lateral hip sx.
QLF has no adhesion, but score has not changed.I told her that both significant dysfunction have led to her lumbar spine being recruited to carry a lot more load than its designed for and that her degenerated hips have led to a significant disc injury. Her time in my office has now ended and she needs a referral for imaging and an ortho consult.
My question is this: My thoughts are that she needs to get her hips fixed and then there will be much less load on her spine. What complicates my thoughts is that her disc symptoms are to the point now that it is clearly a pain generator and if it can be screwed up by stretching/yawning with her arms overhead it is something that should also be dealt with.
What should I refer her out for: her hips or her lumbar spine?
Carl Nottoli, DC
All signs seem to be pointing more toward the lower back problem. Can you send a screen shot of the pain diagram?
Adam Holen D.C.
First I would want an explanation for how her back is 60% with essentially no adhesion. My initial thought is OA preventing flexion. I’m assuming you’ve assessed joint capsules at every level? I would expect the capsules to have adhesion if it’s OA, but you may just be late to the party.
Chronicity?
Has she done any hip lifts/good mornings? Support/stability seems like an issue if she has no symptoms, but can throw her back outstretching.
I agree with Carl, you need to figure out what’s going on in the back first before you look at secondary factors (hips), but symptom quality and location will be helpful in this case.
Scott Glidden
Her paraspinals are very hypertonic L3-L5, which is why I believe her spine isn’t moving–and I can’t really get into her joint capsules due to that. The pain is most definitely coming from her back, but my thought is “this back problem is likely stemming from bilaterally poor functioning hips. The hips stop flexing early and forces the body to compensate with spine flexion.”
Her SHF is a HARD stop now, but can get more ROM when externally rotating the hips. + for impingement with internal rotation, so that is making me thing degeneration is playing a big role here.
This has been bothering her to some degree or another for 4 years, while only throwing out her back 2.5 years ago and a few weeks ago that prompted her to come in. She considers her “stretching” incident not to be a “thrown out her back” thing, so who is to say how often it has actually occurred. She works mostly as a nanny of small children, so there lots of picking squirmy little ones up. On top of this, 3 weeks prior to seeing me she started SHRED 415, which is a very high-load workout.
Attached is the picture provided by the patient of her pain distribution. She describes it as a “pain in the butt” that radiates from her back and “pulses” when its really bad (which she stated was a 10/10 when at its worst). Previous to her stretch thing she said the pain was down to a 3-4/10 after a few treatment sessions.
I prescribed hip lifts at her first tx appointment and she states that she does them everyday.
Carl Nottoli, DC
Making the assumption that her hip problem is causing her back problem isn’t helpful, and it may not be accurate.
Get images on her lower back to see the extent of degeneration. She isn’t done with your care yet. She needs load management to get the tissue and spine inflammation down. Only then can you fully assess the tissue with her terrible QLF. At that point, then you can make a full diagnosis and prognosis of her condition.
Punting her to an orthopedic will not be in her best interest as they won’t take the time to assess function, structure, and load.
Make sense?
Christopher Stepien
While getting spine inflammation down til you can treat the low back effectively with load management and strengthening, we could treat the hips to see if adhesion helps hip flexion while sitting, no?
Carl Nottoli, DC
For sure, Chris. The adhesion was listed as 2 in Add mag and 1 in post. hip capsule so it should clean up quickly.
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