Medical mystery: What was causing woman’s chronic hip pain?

In my practice, I regularly see patients complaining 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 around her right hip and pelvis.

The pain had come on slowly, without any trauma to the area. She said the pain made sleeping at night difficult and was worse in the morning but, with a little activity, the pain level would improve. She described the pain as a sharp sensation that was often even more tender to the touch.

In most cases in which people have pain and discomfort in this region, it is because of a group of six muscles called the external hip rotators, located in the pelvis. Their primary function is to open up your hip or rotate your leg out to the side.

It is common that a patient’s external hip rotators are very tight, which puts the leg in an awkward position. The easiest way to test this is to look at your legs when you are lying on your back. If your toes face toward the ceiling, your external hip rotators are functioning properly. If one or both of your feet are rotated out to the side, it is most likely due to tight external hip rotators.

This patient had the classic external rotation of the leg. When I placed the leg in its proper position, she felt a strong stretch in the external hip rotators and an increase in pain going into her leg. Pain that travels is called referred or radiating pain. It is a common symptom of tight external hip rotators because these muscles often press down onto the sciatic nerve in the pelvis, which travels down the back of the leg.

I performed several other tests and ultimately diagnosed her with trochanteric bursitis (swelling of small sacs around the hip bone), piriformis syndrome (pain and dysfunction of one of the external hip rotators), sciatica (pain along the sciatic nerve), and a hip strain. I began treating the patient with a specific form of myofascial release called Patch Technique to loosen up the external hip rotators and ultimately lessen the pressure they put onto the sciatic nerve.

At the end of the first appointment, the patient said she had virtually no pain in her pelvic area. But there was one symptom that was still the same: the pain going down her leg. In some cases that’s normal, as it can take time to loosen up the external hip rotators enough to stop putting pressure on the sciatic nerve.

After working with the patient for a few visits, she no longer had any pain in the pelvic area, but the leg pain continued. This had me wondering whether the pain was in fact coming 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 tissue in the back, hip and pelvis. The MRIs confirmed the bursitis and tendinitis in the pelvic muscles.

What was a surprise was that the MRI also showed that the patient had a narrowing of the spaces in the spine where the nerves that travel into the leg were located. With this new information, I was able to see that it wasn’t the hip muscles that were causing the pain, as I previously thought.

In our next appointment, I added physical therapy that included the spine with the hopes of reducing the amount of narrowing or “pinching” that was affecting the spinal nerves. After five sessions focusing on the spine, the patient had virtually no leg pain.

This case was a good reminder that it’s important to look beyond the site of pain when diagnosing and treating the body.

To ensure that the patient would be able to remain pain free, I reached out to Brian Warenius, clinic director of Excel Physical Therapy in Blue Bell, for help. In non-traumatic injuries, most symptoms initially come on because the patient had developed a bad habit, or some type of weakness in the area. Until these issues are addressed, the patient will often get temporary relief but have a flare-up a few months later.

Warenius said there are two simple and safe exercises that a patient can perform to strengthen and stabilize the back and hip.

In this first exercise, there isn’t much movement. Lie down with an exercise ball on your stomach and arms on the 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 toward the ceiling and hold for one second. Repeat 10 times, then perform on the other leg. If the exercise is too easy, try adding a resistance band above your knees.

As always, consult your physician with any questions.

Marc Legere is a chiropractor specializing in myofascial release in Blue Bell. He can be reached at mlegere@patchtechnique.com.