hip pain/locking with intercourse

[indytravl]

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anyone have any thoughts about the following case?

37y female with improvement in back & hip complaints after therapy. Now her "only complaint" is that the left hip gets difficult (?locks) for her to extend out during intercourse. Says husband has to help her straighten it out because of pain. Has som sij tenderness on palpation, no popping/ snapping/clunking of the hip on ranging, not really having pain with IR/ER/faber during exam, no tenderenss over greater trochanter.

appreciate helpful advice...

 

[PMR 4 MSK]

anyone have any thoughts about the following case?

37y female with improvement in back & hip complaints after therapy. Now her "only complaint" is that the left hip gets difficult (?locks) for her to extend out during intercourse. Says husband has to help her straighten it out because of pain. Has som sij tenderness on palpation, no popping/ snapping/clunking of the hip on ranging, not really having pain with IR/ER/faber during exam, no tenderenss over greater trochanter.

appreciate helpful advice...

What do the xray and MRI of the hip show?

 

[SSdoc33]

sounds like SIJ dysfunction

 

[Finally M3]

Get an MRI of the hip, maybe an injury to the glenoid labrum.

 

[Ludicolo]

Why are we jumping to an MRI of the hip?

Question if this is true mechanical locking. If it is then yes, think things like labral tear, snapping hip syndrome due to subluxing ITB or rectus femoris tendon. Your exam says otherwise though. Could be SIJ (does the SIJ "lock"?), or may be piriformis/gluteal muscle pain/cramp/spasm secondary to (ahem) overuse. Or perhaps involvement of one of the other hip external rotators. Next time you examine her, try out some SIJ or piriformis provocation maneuvers. Does she have symptoms any times other than intercourse?

The patient may benefit from education in (ahem again) “activity modification”.

 

[lobelsteve]

Doggie style, problem solved.

But I say that for most low back, hip problems.

FAIS. Femoral acetabular impingement syndrome. Xray?

 

[Finally M3]

Doggie style, problem solved.

But I say that for most low back, hip problems.

FAIS. Femoral acetabular impingement syndrome. Xray?

Interesting abdominal/paraspinal home program you are recommending.

For ludiculo, this portion of the H&P, "Says husband has to help her straighten it out because of pain", makes me think it's a true mechanical problem. Of course you don't need to jump to MRI...

I also like Steve's suggestion of FAIS...but would this lock?

 

[PMR 4 MSK]

Why are we jumping to an MRI of the hip?

Because no one ever got sued for ordering too many MRI's. 😉

 

[rehab_sports_dr]

I think many of the previous suggestions are excellent, particularly consideration of femoro-acetabular labral pathology

One additional consideration that is worth considering is pelvic floor dysfunction, and obturator internus spasticity in particular. With the group of pelvic floor therapists I work with, we find anecdotally that the subset of patients that are referred by msk specialists (as opposed to referred because urinary incontinence) have a very high incidence of obturator internus spasticity

This makes sense anatomically, since the fascial sheath of the obturator internus, the arcus tendineous, serves as the anchor for the other pelvic floor musculature

To assess, certain things on history can cue you off (multiple pain generators about the pelvic girdle, urge incontinence, difficulty holding in flatus, pain with intercourse), and exam (positive posterior pelvic pain provocation test, pain with active straight leg raise that is relieved with pelvic compression). If you have a suspicion, I'd suggest considering use of a PT with specialization with pelvic floor therapy

 

[DOctorJay]

dynamic imaging with Ultrasound

 

[Ludicolo]

dynamic imaging with Ultrasound

During intercourse!?! 😱

 

[nleeds24]

One additional consideration that is worth considering is pelvic floor dysfunction, and obturator internus spasticity in particular. This makes sense anatomically, since the fascial sheath of the obturator internus, the arcus tendineous, serves as the anchor for the other pelvic floor musculature

To assess, certain things on history can cue you off (multiple pain generators about the pelvic girdle, urge incontinence, difficulty holding in flatus, pain with intercourse), and exam (positive posterior pelvic pain provocation test, pain with active straight leg raise that is relieved with pelvic compression). If you have a suspicion, I'd suggest considering use of a PT with specialization with pelvic floor therapy[/QUOTE]

Interesting idea. My Physical exam texts don't go into detail regarding pelvic floor dysfunction and examination techniques. What would you recommend as a good source to read textbook wise? Hopefully one with plenty of illustrations.

 

[lobelsteve]

Pelvic floor dysfunction is some MN specific pathology that exists only in the minds of Rochester myofascists. It certainly will not cause hip girdle locking requiring assistance to return to normal position.

One additional consideration that is worth considering is pelvic floor dysfunction, and obturator internus spasticity in particular. This makes sense anatomically, since the fascial sheath of the obturator internus, the arcus tendineous, serves as the anchor for the other pelvic floor musculature

To assess, certain things on history can cue you off (multiple pain generators about the pelvic girdle, urge incontinence, difficulty holding in flatus, pain with intercourse), and exam (positive posterior pelvic pain provocation test, pain with active straight leg raise that is relieved with pelvic compression). If you have a suspicion, I'd suggest considering use of a PT with specialization with pelvic floor therapy

Interesting idea. My Physical exam texts don't go into detail regarding pelvic floor dysfunction and examination techniques. What would you recommend as a good source to read textbook wise? Hopefully one with plenty of illustrations.[/QUOTE]

 

[elr1983]

Sorry if I misunderstood, but is the pain with extension in her SI joint, so more posterior? Or does she have pain elsewhere but is tender on her SI joint?

 

[Disciple]

To assess, certain things on history can cue you off (multiple pain generators about the pelvic girdle, urge incontinence, difficulty holding in flatus, pain with intercourse), and exam (positive posterior pelvic pain provocation test, pain with active straight leg raise that is relieved with pelvic compression). If you have a suspicion, I'd suggest considering use of a PT with specialization with pelvic floor therapy

How far do you take your physical examination in these cases?

I know some of the PM&R experts in this area do bimanual pelvic examinations.

At the risk of being less knowledgeable about musculoskeletal medicine, I have no desire to revisit this type or evaluation.

 

[axm397]

docs who specialize in pelvic pain perform internal examinations routinely. obviously, if it's outside your comfort zone and training, i would refer

 

[axm397]

anyone have any thoughts about the following case?

37y female with improvement in back & hip complaints after therapy. Now her "only complaint" is that the left hip gets difficult (?locks) for her to extend out during intercourse. Says husband has to help her straighten it out because of pain. Has som sij tenderness on palpation, no popping/ snapping/clunking of the hip on ranging, not really having pain with IR/ER/faber during exam, no tenderenss over greater trochanter.

appreciate helpful advice...

funny - just saw pt referred for hip/pubic area/buttock pain after intercourse - on exam had a very impressive pelvic shift and rotation - i got her pelvis halfway back into position and injected her SI ligament and got her into PT for correction of the pelvic obliquity and pelvic/lumbar stabilization.

did u examine for pelvic obliquity?

 

[rehab_sports_dr]

There are many things that you can look at without doing an internal evaluation

1. Active straight leg raise- have the patient actively flex their hip while supine with an extended knee and assess for instability and pain, and then repeat while manually stabilizing the pelvis. Improvement suggests pelvic instability

2. Posterior pelvic pain provocation test- patient supine, hip at 90, knee at 90, axially load through the femur. Posterior pelvic pain suggests pelvic floor dysfunction

3. Single leg squat

4. Single leg stand

5. Two legged squat, repeating with manual pelvic stabilization

How far do you take your physical examination in these cases?

I know some of the PM&R experts in this area do bimanual pelvic examinations.

At the risk of being less knowledgeable about musculoskeletal medicine, I have no desire to revisit this type or evaluation.

 

[drusso]

Pelvic floor dysfunction is some MN specific pathology that exists only in the minds of Rochester myofascists. It certainly will not cause hip girdle locking requiring assistance to return to normal position. [/COLOR]

Interesting idea. My Physical exam texts don't go into detail regarding pelvic floor dysfunction and examination techniques. What would you recommend as a good source to read textbook wise? Hopefully one with plenty of illustrations.

[/QUOTE]


Refer to DP in Reno, NV. He has a proven TX for these problems that never fails.

 

[lobelsteve]

Refer to DP in Reno, NV. He has a proven TX for these problems that never fails.[/QUOTE]

Now I know why you're moving there....

MSPVDCNA- MetroSexual Pelvic Floor Dysfunction Clinics of North America