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Pelvic Pain

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

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  1. 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

  2. 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

  3. What other information would you like to know about the patient?

  4. 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

  5. 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

  6. 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

  7. 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

  8. What is your differential diagnosis? 2. Are there any tests you would like to order? What do you think?

  9. 1. Pelvic US with attention Right inguinal area was negative. CBC/ BMP tested and normal. Urine pregnancy test negative Test Results

  10. 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

  11. 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

  12. Realign bony structures to improve osseous and muscular motion Balance fascia to normalize tension on nerves Improve lymphatic flow Goals of Treatment

  13. Pubic compression Muscle Energy Technique • Greenman, English 3rd ed.,p368

  14. Muscle Energy Anterior Innominate • Greenman, English 3rd ed.,p388

  15. 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

  16. 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

  17. 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

  18. Pelvic Diaphragm Technique Speece, 1st edition, p71-73

  19. 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

  20. Iliacus Tenderpoint • 1 Iliacus • Primal Pictures, Complete Human Anatomy, 2004

  21. Illiopsoas

  22. Anterior Pelvic tender points • DiGiovanna, 3rd edition, p. 332

  23. Counterstrain Hold for 90 seconds or until a release is palpated Treatment:Illiacus Tender point • DiGiovanna, 3rd edition, p. 332

  24. Pelvis and Abdomen Fascial Connections Netter, 2nd edition, p.234

  25. Direct Treatment Hold tissues at fascial barrier and wait for release Myofascial Treatment of Pelvis FOM, 2nd edition, p. 946

  26. Direct treatment Rotate innominate into the barrier and wait until a release is palpated Myofascial Treatment of Pelvis

  27. 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

  28. 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

  29. 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

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