Pelvic Pain. Developed for OUCOM CORE by: Anna Wright, D.O. Edited by: Katrina Rakowsky D.O., Imber Coppinger, D.O. and the CORE Osteopathic Principles and Practices Committee. 31 yr old female presents for continued RLQ/inguinal pain
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Developed for OUCOM CORE
by: Anna Wright, D.O.
Edited by: Katrina Rakowsky D.O., Imber Coppinger, D.O.
CORE Osteopathic Principles and Practices Committee
Began after right inguinal herniorrhaphy with a difficult, unusually painful recovery
Now continuing after 6 months S/P surgery
Worse with stress or activity
Describes pain as “Deep ache” 3/10 on pain scale. “Pins and needle” sensation superficially.
Better after yoga but becomes worse 30 minutes laterCC: RLQ pain
No changes in menstruation, pain not associated with menses.
Negative trauma history
Otherwise no complaintsPatient History
PSHx: R inguinal herniorrhaphy, tonsillectomy
Meds: multivitamin, Albuterol inhaler PRN,
SocHx: Married, 2 year old son. Denies tobacco, etoh, or drug use.
FamHx: Non-contributory.Patient History
Lungs: CTAB habits.
Heart: RRR without murmur
Abd: obese, soft, BS+, nontender, no masses noted,
Neuro:CN II-XII intact, DTR 2/4, no sensory or motor lossPhysical Exam
R anteriorly rotated innominate habits.
Restriction of pelvic diaphragm
R lower extremity is internally rotated
Anterior MF restriction over R inguinal ligamentOsteopathic Findings
2. Are there any tests you would like to order?What do you think?
CBC/ BMP tested and normal.
Urine pregnancy test negativeTest Results
Usually due to nerve entrapment with scar tissue or mesh placement
Ilioinguinal and genitofemoral nerves are the most common nerves injured due to their location in the inguinal canal.Herniorrhaphy
Upper medial thigh (ilioinguinal extends inferior to genitofemoral distribution)
Base of penis and scrotum in men
Labia majora and mons pubis in women
Originates at L1-L2Ilioinguinaland Genitofemoral nervedistributions
Balance fascia to normalize tension on nerves
Improve lymphatic flowGoals of Treatment
Muscle Energy Technique
Muscle Energy motionAnterior Innominate
Kimberly, 2000, p267-269
Maintain capsular tension while release
externally rotating hip
Use muscle energy to internally
Kimberly, 2000, p267-269Capsular Tension
Maintain capsular tension
while leg is being fully extended
Gentle pressure will indicate whether there is increased tension or congestion in the hemi-diaphragm.
Spasm of pelvic diaphragm may influence sacral or pelvic function.Pelvic Diaphragm
Moore, Clinically Oriented Anatomy, 4th Edition, 1999, p.400
Speece, 1st edition, p71-73
Treat with direct myofascial treatment, resisting respiratory motion.
The thoracic diaphragm can be monitored for synchrony of motion between the two – pelvic & thoracic diaphragmsTreatment
Counterstrain respiratory motion.
Hold for 90 seconds or until a release is palpatedTreatment:Illiacus Tender point
Pelvis and Abdomen respiratory motion.Fascial Connections
Netter, 2nd edition, p.234
Direct Treatment respiratory motion.
Hold tissues at fascial barrier
and wait for releaseMyofascial Treatment of Pelvis
FOM, 2nd edition, p. 946
Direct treatment respiratory motion.
Rotate innominate into the barrier and
wait until a release is palpatedMyofascial Treatment of Pelvis
Ligamentous articular release respiratory motion.
Contact inguinal ligament with hypothenar eminence
Maintain superior, medial, and posterior pressure
Wait for a releaseInguinal Ligament Release
Speece, 2001, p79
Brooks, respiratory motion.Abdominal Wall and Groin Hernias, Uptodate.com. 2005
Greenman, Principles of Manual Medicine, 3rd ed. Lippincott. 2003. pp 338-388
Kimberly, Kimberly Manual, Walsworth, 2000, pp267-269
Moore, Clinically Oriented Anatomy, 4th ed. Williams and Wilkins. 1999. p 400References
Netter, respiratory motion.Atlas of Human Anatomy, 2nd ed. Novartis.1997. p 234
Speece, Ligamentous Articular Strain, Eastland. 2001. pp 71-73, 79
Ward, Foundations of Osteopathic Medicine, Lippincott. 2003. p 946-947References