A triathlete with right hip pain improved her condition with chiropractic spinal manipulation, heat, and stretching

A 38-year-old avid triathlete and mother of three presented to my office with a chief complaint of right hip pain of approximately 11¼2 months’ duration. She explained that the symptoms began as a mild tightness several months prior while training for a spring triathlon. Training included running, swimming, and biking several times per week. Although the tightness was persistent, it was mild and did not limit her ability to train.

Russel V. Antico, DC, CCSP, CSCS, works through a lumbar stabilization routine with the patient.

In mid May 2005, she competed in and finished the triathlon, but later that same day the tightness she had been experiencing in her right hip turned to pain. After taking a few days off, applying ice to her hip and trying to stretch the area, the pain subsided and she began training again. This time, her sights were on a fall marathon. She felt right hip pain and tightness once again, but symptoms were mild and did not interfere with her training. Two days prior to presenting to my office, she had done a 15-mile run. She reported that during the run, pain remained mild, but upon finishing, the pain became sharp and quite severe. She attempted to swim the following day and found that it was not painful and actually provided some temporary relief from her symptoms.

Patient History and Examination
Upon presenting to my office, the patient was experiencing a sharp pain in her right hip that was said to come and go. Pain was said to be increased with standing from a seated position, as well as after most forms of exercise, with swimming being the exception. Episodes of right low-back pain were reported, as well as periodic pain in the right groin area. Prior episodes of low-back or hip pain were denied. Symptoms were rated a 6 out of 10 on a Visual Analog Scale.

An examination of her right hip and low back revealed gross ranges of motion to be essentially normal. Palpation of the right lumbar para-spinal musculature, piriformis, gluteus medius, and gluteus maximus revealed moderate hypertonicity and tenderness. Hypertonicity was also pronounced at the right hip flexor group and tensor fascia lata (TFL). Ober’s and Yeoman’s (an ortho test for sacroiliac [SI] dysfunction) tests were positive on the right. Muscle-strength testing of the lower extremities was 5/5 throughout with pain being reported by the patient upon testing the right, one joint hip flexor. X-rays were not indicated at that time.

Diagnosis and Treatment
The patient was diagnosed with right SI joint dysfunction and associated muscular hypertonicity/inflammation. My thought was that there must have been a slight overtraining scenario that resulted in hypomobility of the right SI joint. With her intense training schedule continuing, the muscles surrounding the right hip were forced into a compensatory role, and over the next several months became quite tight and inflamed (especially the hip flexors). Finally, the intensity and duration of the actual triathlon resulted in the acute pain not previously experienced. The nonweight-bearing nature of swimming allowed the patient to “mobilize” the region without the pounding and stress associated with running and biking, and did not cause the symptoms felt with the other activities.

The patient returned for a report of findings a few days later, and after having a detailed discussion with her regarding her diagnosis and the possible cause, treatment was initiated. Treatment included chiropractic spinal manipulation to the lumbo-sacral region as well as joint mobilization to the right hip. Heat was applied to the right hip flexor and TFL with proprioceptive neuromuscular facilitation (PNF) stretching and myofascial release technique being performed as indicated. Thomas’ stretch was used on the hip flexors. Trigger-point therapy was performed on the right gluteus medius. Prior to leaving the office, the patient was shown a flexibility routine focused on the lower back and hip. Special attention was given to a stretch for the right iliotibial band. She was instructed to perform these stretches two to three times per day, especially after her training. She was also dispensed an anti-inflammatory supplement containing bromelain. Home icing instructions were reviewed. I use heat in the office for a short duration (10 minutes) to help loosen up the area for more effective stretching and mobilization. If inflammation is severe, ice is applied after treatment. Home ice and anti-inflammatory supplements are prescribed to address the inflammation. Although I did not have her discontinue training, she was advised to keep it at a low intensity for the next 2–4 weeks.

For the next 4 weeks, the patient was treated three times per week. Like most athletes I treat, she followed my treatment recommendations precisely and although she was eager to train at a higher intensity, she limited her runs, swims, and bike rides to shorter, slower-paced sessions.

Response to Care
After approximately three to five treatments, the patient reported that all low-back pain had essentially resolved and she denied any additional episodes of groin pain. Standing from a seated position no longer caused pain, and she was completing her training sessions pain free. Just as several months prior, the only remaining symptom was the tightness in her right hip. Like before, intensity was mild.

At that point the patient was advised to slowly increase her training intensity—a longer run here, a faster pace there. Special attention was paid to ensure adherence to flexibility, icing, and proper rest. Over the next 2 weeks, she continued to increase her distance and pace. She reported episodes of mild pain in her right low back, but they were infrequent and short-lived. Overall, she was experiencing a decrease in all symptoms, including the tightness.

As a result of her favorable response to care, the patient’s treatment frequency was reduced to one to two treatments per week for 3 weeks. A lumbar spine facilitation and stabilization routine was prescribed, and the patient returned to regular training.

As fall approached and the marathon neared, the patient progressed through her training, completing an 18-mile run and a 21-mile run. She reported that overall she felt great but was still experiencing periodic mild tightness in the right hip, primarily with her longer runs and her speed workouts.

On October 15, the patient finished a half marathon. I was working the postrace chiropractic tent and saw her immediately following the race. She reported having a great run with minimal tightness. On October 30, she completed her marathon and did great. Her hip did not bother her during the race.

The patient is currently being seen periodically for maintenance care. She continues to perform the prescribed flexibility and stability routine and feels that it has really made a difference. She continues to complain of periodic, mild tightness in the right hip. She was placed on glucosamine sulfate/chondroitin sulfate (1500 mg per day for 8–10 weeks and 500 mg from then on). On her last visit, she was referred for right hip x-rays to rule out osteoarthritis. Results are pending. CP

Russel V. Antico, CCSP, CSCS, is founder and clinical director of Howard County Chiropractic Spine & Sports Rehabilitation, LLC in Columbia, Md. Contact him at chiro.spinesport@verizon.net.