Question
QUESTION: 38 year old male, I've been dealing with lower back and hip pain for years.  The hip pain seems to come on after stress from activity.  Hip pain will last about 5 days when it get's really bad and limits mobility.  Days 2-4 are the worst and effects sleeping as the pain is constantly there.  Range of motion is decreased and I can only lift my knee 50% of the way to my chest.

My radiology report says - "mild narrowing of posterior aspect of the intervertebral disk space at L5-S1. No evidence of spondylolysis....minimal retrolisthesis of L5 on S1 with slight decreased height of posterior aspect."  

Hip- "minimal narrowing of the superior coxofemoral joint space. A subchrondral cyst also noted in the lateral margin of acetabulum. These findings are in keeping with early degenerative change."  

Ultra sound on hip came back normal with "no significant joint enfusion. Anterior recess within normal limits."


Can you break this down for me and is it correct to define this as osteoarthritis?

ANSWER: Hi Brad,

Sorry to hear about your situation.

I do not see anything other than mild degenerative changes from the reports. Nothing to account for the loss of function and pain. While it is correct to say there is osteoarthritis, it does not seem to be an accelerated process. It is most likely, normal for your age and I would agree with "early degenerative changes", meaning nothing significant enough to account for your pain and loss of function.

So, without any other results from testing, I am going to assume the findings are not directly related to your pain and dysfunction. Therefore, I would consider another condition that would correspond to you complaints. A Psoas Syndrome. The syndrome features problems of the iliopsoas muscles which attach from the hip to deep in the lower back. It is characterized by both hip and back pain as well as dysfunction of the hip. Tears in this muscle can form scar tissue which does not heal properly causing decreased strength and pain from adhesions, which can attach to nerves and can become a chronic pain issue.

It is possible to determine if this is the case. If you can have somebody help. Lay on your back with your legs straight. Lift the good leg straight up about half way and let the foot angle toe out and have the leg angle straight but half way to the outside. So, on your back, straight legs, lift the good hip leg up about 45 degrees, toe out about 45 degrees and the leg apart, outward at about 45 degrees. Have someone press straight down towards the floor, not real hard, on your leg while you resist the pressure. Now do the same thing on the opposite side - bad leg. If there is a problem, you will notice a big difference in the strength of the muscle on the bad side. It may reproduce the pain you are having and you may not even need downward pressure to feel this.

If there is a problem noted while doing this, you will need to have it treated. Exercise will not help, neither will typical treatments. What you will need is a technique called Active Release, to remove the ill formed scar tissue, realign it with the muscle fibers and release any adhesions. This is done manually - no radiographs, needles, medications or surgery. It is not pleasant, but it is what it requires. If done right, you will notice a difference after just one treatment, which takes about 5 minutes. I would suggest finding a Certified Active Release Practitioner in your area. He or she can test the muscle for you and treat it if there is a problem. They are usually either a certified chiropractor or a physical therapist.

I had this problem some years ago and was so impressed with the results, I studied with the developer and used it in my own practice for many years with very good results. So, this is what I would want to rule out, prior to further testing or treatments. If it proves not to be the problem, there would be other avenues you and your doctor could peruse like injections, however, I would rule out a psoas problem at this point.

I hope this is the case and you can get well soon.

Kind Regards,

Dr. Steve



---------- FOLLOW-UP ----------

QUESTION: Thank you Dr. Steve,

The assessing physician did preform a test as you described and the pain increased when the leg was pushed outward to the left and inward to the right but did not seem to be effected by downward pressure.  Not sure if this helps?

I was given a conservative treatment option of hyaluronic acid, glucosamine, vitamin D and physio.  Also, an aggressive treatment option of HGH and Testosterone injections.  I'm not comfortable with the possible associated side effects of the latter option.   

Is there any other tests that should be preformed or is it just a case now of managing the pain and seeing what happens if Psoas Syndrome is ruled out?

Cheers,
Brad

Answer
Hi Brad,

Sometimes this type of testing is done to stress the hip joint itself and not specifically for the iliopsoas muscles, so I'm not sure it can be ruled out at this point. It seems like the treatment is focused on the joint itself. If there has been no significant improvement, and 50% on raising the knee does not seem significant, unless it was only 25% previous. If you feel an iliopsoas problem has been ruled out and your blood work results normal, other than perhaps hormonal levels, it is difficult to determine what tests should be done; maybe a bone scan or a contrast enhanced MRI, perhaps Gadolinium. If it is a problem with the joint, perhaps corticosteroid injection might help. I don't blame you regarding side effects from hormones, however, if you are not seeing any results, perhaps it would be worth a try. But, I would still be interested in the results from a certified ART practitioner to rule out musculotendinous involvement. There are other muscles that can be involved like the iliacus and adductors.

Regards,

Dr. Steve