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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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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


Cc rlq pain

31 yr old female presents for continued RLQ/inguinal pain

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 later

CC: RLQ pain



Patient history

No bowel or bladder changes, pain not associated with bowel habits.

No changes in menstruation, pain not associated with menses.

No fevers/chills

Negative trauma history

Otherwise no complaints

Patient History


Patient history1

PMHx: G2P2, mild intermittent asthma habits.

PSHx: R inguinal herniorrhaphy, tonsillectomy

Allergies: NKDA

Meds: multivitamin, Albuterol inhaler PRN,

SocHx: Married, 2 year old son. Denies tobacco, etoh, or drug use.

FamHx: Non-contributory.

Patient History


Physical exam

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 loss

Physical Exam


Osteopathic findings

R anteriorly rotated innominate habits.

Pubic compression

Restriction of pelvic diaphragm

R lower extremity is internally rotated

Iliopsoas tenderpoint

Anterior MF restriction over R inguinal ligament

Osteopathic Findings


What do you think

What is your differential diagnosis? habits.

2. Are there any tests you would like to order?

What do you think?


Test results

1. Pelvic US with attention Right inguinal area was negative.

CBC/ BMP tested and normal.

Urine pregnancy test negative

Test Results


Herniorrhaphy

Up to 30% of pts report neuralgia after surgery negative.

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


Ilioinguinal and genitofemoral nerve distributions

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-L2

Ilioinguinaland Genitofemoral nervedistributions


Goals of treatment

Realign bony structures to improve osseous and muscular motion

Balance fascia to normalize tension on nerves

Improve lymphatic flow

Goals of Treatment


Pubic compression
Pubic compression motion

Muscle Energy Technique

  • Greenman, English 3rd ed.,p368


Anterior innominate

Muscle Energy motion

Anterior Innominate

  • Greenman, English 3rd ed.,p388


Internally rotated lower extremity

Combined Treatment-Muscle energy and direct myofascial release

Internally rotated lower extremity

  • Place femur into internal rotation

  • use muscle energy to externally

  • Rotate femur

  • Repeat

  • Maintain capsular tension while

  • moving hip into full flexion

  • Use muscle energy to extend at the hip

  • Repeat

Kimberly, 2000, p267-269


Capsular tension

Maintain capsular tension while release

externally rotating hip

Use muscle energy to internally

Rotate femur

Repeat

Kimberly, 2000, p267-269

Capsular Tension

Maintain capsular tension

while leg is being fully extended


Pelvic diaphragm

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


Pelvic diaphragm technique
Pelvic Diaphragm Technique tension or congestion in the hemi-diaphragm.

Speece, 1st edition, p71-73


Treatment

Treat with direct myofascial treatment, resisting respiratory motion.

The thoracic diaphragm can be monitored for synchrony of motion between the two – pelvic & thoracic diaphragms

Treatment


Iliacus tenderpoint
Iliacus Tenderpoint respiratory motion.

  • 1 Iliacus

  • Primal Pictures, Complete Human Anatomy, 2004


Illiopsoas
Illiopsoas respiratory motion.


Anterior pelvic tender points
Anterior Pelvic tender points respiratory motion.

  • DiGiovanna, 3rd edition, p. 332


Treatment illiacus tender point

Counterstrain respiratory motion.

Hold for 90 seconds or until a release is palpated

Treatment:Illiacus Tender point

  • DiGiovanna, 3rd edition, p. 332


Fascial connections

Pelvis and Abdomen respiratory motion.

Fascial Connections

Netter, 2nd edition, p.234


Myofascial treatment of pelvis

Direct Treatment respiratory motion.

Hold tissues at fascial barrier

and wait for release

Myofascial Treatment of Pelvis

FOM, 2nd edition, p. 946


Myofascial treatment of pelvis1

Direct treatment respiratory motion.

Rotate innominate into the barrier and

wait until a release is palpated

Myofascial Treatment of Pelvis


Inguinal ligament release

Ligamentous articular release respiratory motion.

Contact inguinal ligament with hypothenar eminence

Maintain superior, medial, and posterior pressure

Wait for a release

Inguinal Ligament Release

Speece, 2001, p79


References

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 400

References


References1

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 946-947

References


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