Case study

Subjective examination
Sttbject 17-year~old maJe student
Playing in high-level senjor soccer team
with training three times a week in
adctition to a n1atch on the weekend

Plays as midfielder
Right foot dominant
H PC About 4/ 12 ago noticed slight stiffness in groin
the morrung after a strenuous match . Insidious
onset
Gradually got worse until about 2/ 12 ago could
not train or play without right-sided groin pain..
Performance was also waning with a loss of
power and acceleration
On advice of team trainer rested fron1 all training
and playing for 6/ 52, but on reswnption of
tra injng 2/52 ago groin pain returned
immediately. Seen by GP who ordered X-rays and
a bone scan, and referred hin1 to physiotherapy
PMH We.II-controlled asthma. Uses one puff of a
preventer daily (Flixitide). Rarely needs to use
reliever (Ventolin)
Episode of Osgood- Schlatters syndrmne when
14 years old after joining soccer developn1ent
squad. Resolved after 1 year through
modification of activity
Otherwise well and not seeing the doctor for any
olhe.r condition

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Aggravating fac1ors Running, especi ally when sprinting and when
cutting (changing direction)
Kicl<lng, especially when taking a comer
No pain o n sneezing o r coughing
Easin g facto rs Avoidance of aggravating activities
Nigh t Sleep unaffected
Daily pau ern Sytnpton1s are dependent on activity. Now
affecti ng whenever tries to run or kick a ball
Notices in m orn ing, t;ikes 10 to 15 minutes
to ease
Altitude/ Concerned that the problem appears to be
expectations getting worse. Had thought it would just go
away
Receives payment for playing in soccer team
which he had planned to continue to help
support his studies at university

Pain a nd VAS current pain at rest = 0

dysfu n ctio n sco res VAS worst level of pain in the last week = 9
(kicking across from a corner)
VAS worst level of pain in the last week =
8 (when attempting to sprint)

Physical examination
Observatio n In standing, no obvious wasting or pelvic
asymmetry
With walking, observed excessive-pelvic tilting
(obJ iquity) in the frontal plane
Palpation Tender to palpation at tendon attaching to
right medial inferior pubic ramus
Trigger point tenden1ess to muscle belly distal
to medial inferior pubic ramus
Tender at right side of pubic symphysis
Movement Right hip flex.ion = 130°, no pain = left
Right hip extensfon = 25°, no pain = left
Right hip abduction = 45", pain (VAS = 3),
left = 55°
Right hip interna.lf eicternal rotation = left
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Functio nal tes Ling ■ Squeeze test (patient supine with hip
Oe.xed 45°, examiner places fist between
patient knees, and asks patient to
bilaterally adductJ repro duced right groin
pain (VAS = 4)
■ Resisted sLraight-leg right hip adduction
reproduced right groin pain (VAS = 4)
■ Right hip quadrant (passive hip flex.io n,
adduction and intern al ro talio n) o nly
very slight pain, similar to discomfort
when tested on the left side
• 111om as test (slight restriction o n right
compared to left with only slight
repro duction of pain (V.-'\S = 0.5) when
hip tle,.:ion r esisted)
■ Abdomma.l muscle tesling:
1. global muscles, only slight pain (VAS
= 1) o n resisted abd ominal tlexio n
2. stabilising muscles, assessed jo supine
with a pressure cuff bio feedback unit
placed in the small of the back. He
could increase the pressure in the cuff

from 40 to 43 mmHg for 3 seconds 4

ti1nes before unwanted activity from
global n1usdes was obse1ved
■ Stanclli1g on one leg (Trendelenburg test),
only slight drop of pelvis obseJVed,
within normal limits ( < 10°)
1nvestigatio ns X-ray: no abnormaUty detected
(completed 1/52 ago) Bone scan: indicated some increased uptake
in the right inferior pubic region

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Questions
1. Whal is your provisional diagnosis?
2. What are me key findi ngs from your examinaiion that led to your
provisional diagnosis?
3. What other co nunon causes of groin pain did you consider in
making your diagnosis?
,t. Whal are son1e less co mmon causes of groin pain thal you need 10
consider when examining this patient? Briefly explain why these a re
considered unlikely at this stage.
5. Whal is Osgood - SchJatter's disease and what is its relevance to the
current condition?
6. What are the significance of the bone scan findin gs and the
assessment of the abdominal stabilising musdes, and do these
findings tie in with 1.he other assessment findings?
7. Which of the symptoms and signs will you place on your priority
list?
8. How will you address these in your physiotherapy treatment plan?

CASE STUDY .
Subjective examination
Subject 38-year-old female
Right leg donunant
HPC Right lateral hip and thigh pain that can
radiate to knee
Started approxilnately 1/ 12 ago
Woke up with pain after a long shopping day
PMH Overweight (BMJ > 27)
Neck pain and headaches
AggravatiJ1g factors Walking
Sleeping on right side
Sleeping on a hard mattress

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Easing facto rs Rest and ke
Nigbt Wakes up frequently, particularly when
lying on Tight side, or on left side with
right hip in add uction and knee resting
on the mattress
Da ily paltcm Pain during and after prolonged
standing and walking
General h ea lth Overweight. No other problems
reported . Not using any medication
A:nitude/ ls not sure whetl1er treatment will
expectatio ns provide i1nmediate relief, but hopes that
at least sbe will be able to sleep better.
Between pain experienced at n ight and
her youngest child waking up a ad
demanding attention she does not get
m ud1 sleep and feels fatigued

·r ai'n a nd VAS current pain at rest before activity = 2

dysfu nctio n sea res VAS usu al level of pain when waki ng up
at njght = 8
VAS us ual level of pajn during and after
activity in tl1e last week = 7
VAS worst level of pam in the last week = 9
Lower Extremity Fw,ctional Scale 48/80
(Binkley et al 1999 )

Objective examination
Sta nd ing Visibly overweight
Wide hips, but knees are touching each
other
Valgu s position of knees and ankles
Pronated feet with reasonable
longitudinal arches
Palpation Although skin temperature (Tsk) arow1d
hjp and along the thigh appeared normal,
that of the posterior aspect of the
trocbant er may have been a little elevated
Tenderness of tile iliotibial tract and th.e
bony posterior aspect of the greater
trochanter1 with a boggy feeling aroW1d
the location of the bursa

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Musdtc le11g1.h Tensor fasdae latae - tight
Gluteus rnedius - Light.
Gluteus rnin irnus - Light
Fw1tt:ional 1.e sting, Wa lking wilh a positlve Trendelenburg
including ROM ru1d and with pronated feet
suength Difficulty lifl.ing opposi te hip in stand.ing
and when walking (VAS rises 10 4)
Flexing and ,1dduc1.ing the hip during the
swinging p h<ISe of the right leg when
walking slowly ls associated with an
audible and palpable dick on the lat.era!
side of the hip, whereas the standing
p hase of the right leg is associa ted with
pa in and dlfficu lty holding the pe lvis
horiltontal
Resisling abdua: ion in supine showed
reduced strength o n dght side
Joint. lllobllity appeared normal,
although combined hip fle.':ion,
adduclion and internal ro ta tion o f the
hip ( in supine) [el I Light and wa~
associa ted with la teral hip pain and pain
aJong th e lateral side of the thigh
True leg length discrepancy (Hoppenfie ld
1986). Left leg almost 3 cm sh oner Lhan
right leg

Questions
l. Based on the informa tion presented, what. is your provisio nal
ctiagnosis?
2, What sign s and symptollls lead you 10 I.bis dlagnosis, and wha t Is I.he
likely mechan ism th at con i.ribu tes 10 1.he problem?
3. How wil l you address these in your ueaunen( p lan?
•l . What kind o f common and less common problems need to be
e.xduded?
5. What are I.h e b io1necbanical factois I.ha t could conuibu te to I.he
current comp la int?
6. How will I.be expectalions oft.he pa lie nt in lJ uence your 1.reaunent?
7, Is the patien t likely 10 benefit from referral 10 other beall.b
professionals?