This is a case presentation that I knew I had to share with my readers as i’m sure you will be as shocked with the ‘results’ as I was.
A 23 year old girl presents to me with an acute onset of left groin/hip pain after sitting down in a car 3 days prior. She came to me after getting a massage from an RMT at my clinic and was in even worse pain. She reported that after the pain started she went to the ER where the attending physician diagnosed it as a hip flexor strain/spasm. There was no imaging done.
Her complaint was that of an anterior/medial groin pain that was worse with hip flexion but was in little to no pain at rest. Her flexion/adduction/internal rotation test was positive for re-producing her complaint. She also mentioned that she has a history of hip discomfort from time to time while skiing and biking. My mind immediately went into differential diagnosis mode…could it be femoroacetabular impingement, labral tear, hip flexor strain, ingunial nerve irritation, pelvic alignment issue…the list goes on.
I continued to assess her using palpation, movemnet screens and length tension tests for the adductors, hip flexors, glutes, and quads. I also noted a mild anterior innominate on that side (yes, I know the studies proving we can’t really tell blah blah blah). After reviewing in my head her MOI and her complaint of pain with hip flexion and how a massage made no changes in her pain, I gave her a preliminary diagnosis of FAI. I treated her with gentle mobilizations of the posterior hip capsule, thomas test hip flexor stretching and soft tissue work to the adductors. She reported “feeling better” after the initial session. Fast forward two weeks later…
She comes back to me two weeks later stating that she felt amazing for one week after my treatment, which obviously made me happy. BUT she had xrays in her hand that she wanted to show me. She went on to tell me that while at the gym doing squats one week later the same pain returned but even worse then before. She stated that she could barley move her leg without pain. She went back to the ER and this time they decided to do xrays….and you won’t believe what they found:
Sewing needle in her leg!!
Do you see the red circle? Well, that is a sewing needle that got logged into her adductor muscles right behind her pubic bone on the left side….SERIOUSLY?!?!
She told me that when she sat down in that car (when the pain first started) she felt an immediate bout of pain but had no idea why. She was moving apartments and apparently a needle was sticking up from the car seat and BAM…right in the leg. How there was no blood or sign of the needle for almost 3 weeks (from time of injury to time of xray) is astounding to me. I also have no idea how my treatment abolished her pain for almost a full week…yes, she literally resumed her life pain free until squatting at the gym made her sore again.
Anatomically, let’s think of how lucky she was…aside from all the muscles she must had hit with that needle, she also has one more major anatomical structure she avoided…can you guess what it is?
The needle could have easily hit her femoral artery causing a whole host of other issues! Yikes!
Femoral artery anyone?
Although this is a freakish case, it does make me think about something quite important. My mind was all about biomechanics, and finding the route cause of her pain and not simply treating her symptoms. This can possibly get us in trouble at times because if we are so caught up at finding what we believe is the “cause” of the problem, we might actually miss the real cause, which might be staring right in front of us. Now, I admit that I am VERY lucky my treatment didn’t make anything worse, but there was no way that from her history I would think she was impaled by a metal object! This case made me realize that anything can walk into our doors as physiotherapists and we have a duty to our patient to make sure their pain is actually within our scope of practice to treat instead of assuming it’s due to faulty movement patterns, motor controls issues or any other catch phrase term that is popular now.
Hope you found this as interesting as I did!
Oh yeah, the doctors took out the needle using local anesthetic and she was pain free 2 hours after the surgery…go figure!
jessephysio 
Cool case Jesse! You won’t come across this ever again! I think you did the right thing and was able to find a mechical reason to her complaints. You gave a clinical diagnosis and treated appropriately. Just like you said, who knows how she was good for a week…but you made just millimeter changes inner body that did it.
I would have done same thing. If you did niot get a response, you would have referred on. Much more finial reasoning here thn in most PT offices, especially massage offices too.
Interesting case. I think this really highlights the fact that we can easily be fooled by patient response. It is very easy to assume that if a patient has a positive response to our treatment we have found the “true cause” of the pain. Pain is such a complex experience that it becomes near impossible to determine why a patient’s pain changes. Maybe it was expectation, placebo etc..
Thanks for sharing.