Two months ago this patient slipped whilst at work on a plastic bag. He landed on his left side and twisted his hip at the same time. This was very painful and a lot of bruising came out over the next few days. He could not put any weight on the leg, so he went to have an X-ray at A&E. They reported no fracture around the hip or pelvis. But he did sustain some rib fractures. This patient had some physiotherapy at the local hospital, but this was just some exercises and he received no hands on treatment. His symptoms did not seem to be improving and he still needed to take a high levels of pain killers. He does think his walking has improved, but he can’t walk for longer than 5 minutes before the pain in the front of the hip worsens. Movements of the hip are painful and restricted, particularly out to the side which the patient needs to do to continue his dance training.
Daily pattern – his symptoms seem worse first thing in the morning and at the end of the day.
Social History – his hobby is dancing, Jazz, Tap and Ballet and he is currently a student.
Medication – strong painkillers and anti-inflammatories
On examination he presented with generally good posture and muscle tone. He had no pain at rest. No bruising or swelling noted.
Active hip flexion (knee to chest) and abduction (leg out to side) were restricted to half range due to pain over the anterior and lateral hip. His walking was relatively normal with no limp.
On palpation he was very sore over the psoas tendon (hip flexor tendon) and TFL/Gluteal muscles. Active straight leg raise was painful and difficult to lift off the floor. The psoas, TFL and gluteus muscles were weak on strength testing. There was also lots of muscular shortening around the hip.
No neural symptoms noted, full nerve mobility not tested due to restricted range of movement.
The hip joint did not appear restricted; however this was difficult to test due to pain.
My clinical diagnosis was of trauma/twisting type strain to the anterior and lateral hip structures, particularly the psoas and TFL muscles. This can take up to three months to recover from with the correct treatment from the outset.
I discussed the presentation with the patient to ensure he had a good understanding of the problem and the likely outcome of treatment which he had not had from his previous treatment. I treated the injured tendons with soft tissue mobilisation, stretching, a graduated strengthening programme and light cardio-vascular exercise. His rehabilitation programme concentrated on achieving full active movement first and we then progressed to strengthening once this was achieved.
I also advised this patient to break from his work station regularly and take lots of short walks during the day within pain limits.
He was seen eight times over three months and he regained full range of movement and near full muscular strength. His muscles returned to a normal length around the hip and he was able to walk pain free for 2-3 miles. He had returned to light dancing practice and has a clear plan to progress to full fitness over the next few months. He was no longer taking pain killers and felt he “had his life back” following his physiotherapy. The patient wished he had attended sooner rather than waiting two months to see a specialist.
It is important to get an early diagnosis with injuries as they can become chronic and almost “out of control”, when really if you do the right things early on, healing is much more efficient and the pain much less! Some injuries can take up to a year to fully recover from in terms of muscular strength and healing.