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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 history5
PMHx: G2P2, mild intermittent asthma

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

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

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?

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

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

Muscle Energy Technique

  • Greenman, English 3rd ed.,p368
anterior innominate
Muscle Energy Anterior Innominate
  • Greenman, English 3rd ed.,p388
internally rotated lower extremity
Combined Treatment-Muscle energy and direct myofascial releaseInternally 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

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

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
  • 1 Iliacus
  • Primal Pictures, Complete Human Anatomy, 2004
anterior pelvic tender points
Anterior Pelvic tender points
  • DiGiovanna, 3rd edition, p. 332
treatment illiacus tender point
Counterstrain

Hold for 90 seconds or until a release is palpated

Treatment:Illiacus Tender point
  • DiGiovanna, 3rd edition, p. 332
fascial connections
Pelvis and AbdomenFascial Connections

Netter, 2nd edition, p.234

myofascial treatment of pelvis
Direct Treatment

Hold tissues at fascial barrier

and wait for release

Myofascial Treatment of Pelvis

FOM, 2nd edition, p. 946

myofascial treatment of pelvis26
Direct treatment

Rotate innominate into the barrier and

wait until a release is palpated

Myofascial Treatment of Pelvis
inguinal ligament release
Ligamentous articular release

Contact inguinal ligament with hypothenar eminence

Maintain superior, medial, and posterior pressure

Wait for a release

Inguinal Ligament Release

Speece, 2001, p79

references
Brooks, 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
references29
Netter, 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