Conservative Management of Lumbopelvic and Genital Pain in a Female Army Veteran: A Case Report

Original Article

Conservative Management of Lumbopelvic and Genital Pain in a Female Army Veteran: A Case Report

Zachary A. Cupler, DC, MS1

1Physical Medicine & Rehabilitative Services, VA Butler Healthcare

[email protected]

Published: June 2018

Journal of the Academy of Chiropractic Orthopedists

June 2018, Volume 15, Issue 2

This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: http://www.dcorthoacademy.com. © 2018 Cupler and the Academy of Chiropractic Orthopedists.

Abstract

Background

To describe the management of a female patient with lumbopelvic and genital pain who responded to conservative management after ruling out visceral causation.

Case Presentation

A 56-year-old female Army veteran presented with chronic lumbopelvic and genital pain. Her primary care physician ruled out pelvic visceral origin. The patient was diagnosed with an upper lumbar derangement.

Management and Outcome

A directional preference, as defined by Mechanical Diagnosis and Therapy, was identified on evaluation, which guided our home exercise prescription. The patient was treated with mechanical flexion-distraction spinal manipulation in our office. Outcome measures included the Oswestry Disability Index (22%) and numeric pain scale (7 out of 10). The patient was discharged from an active care plan symptom-free with improved Oswestry Disability Index (2%), and she exhibited confidence in home care to successfully manage potential future episodes.

Conclusions

A female patient with lumbopelvic and genital pain responded favorably to flexion-distraction spinal manipulation and home exercise. A follow-up phone call 3 months later found the patient experienced a single episode of axial lumbar spine pain. She reported she self-managed the reoccurrence to resolution with the use of her home exercise plan. A musculoskeletal origin for lumbopelvic and genital pain should be considered when visceral etiology has been ruled out.

Indexing terms

lumbopelvic pain, chiropractic, flexion-distraction spinal manipulation, directional preference, McKenzie, Veteran, derangement

Background

Groin and lumbopelvic pain experienced by females can be caused by pain-sensitive structures such as the pelvic viscera or lumbopelvic musculoskeletal tissues, though neuropathic and psychogenic origins of pelvic pain should also be considered. Excluding endometriosis, the most common causes of chronic pelvic pain include pelvic varices, post-operative adhesions, interstitial cystitis and irritable bowel syndrome.1 Chronic pelvic pain is a descriptor of symptoms rather than a diagnosis and often multiple factors are present. Gyang et al. reported 14-22% of pelvic pain has been correlated with musculoskeletal origin.2 Pregnancy-related lumbopelvic pain management is well reported in the manual therapy literature.3,4,5,6 There is, however, a paucity of literature describing the management of post-menopausal women with lumbopelvic and groin pain of musculoskeletal origin not associated with pelvic floor dysfunction.

After evaluation to rule out red flags and pelvic organ pathology, the musculoskeletal anatomy of the region should be evaluated. Multiple tissues have been found to refer to the lumbopelvic region when stimulated. Discogenic referral to the hip and groin is most commonly associated with L1/L2 or L2/L3 discs.7 Upper lumbar disc lesion symptoms are far less common as discography reproduced L1/L2 and L2/L3 pain in only 2 of 223 consecutive patients who presented to a tertiary care center.8 Radicular pain from L1 and L2 is expected to result in symptoms affecting the hip and/or groin, yet, surgical decompression of L3 or L4 has been found to alleviate groin pain as well.9 Sacroiliac joint pain referral does not typically radiate to the anterior thigh or groin.10 Femoroacetabular joint pain referral occurs in the buttock, groin and distal to the knee 71%, 55%, and 22%, respectively, but never refers to the lumbar spine.11 Travell and Simons described lower quadrant and groin pain due to myofascial trigger points of either the quadratus lumborum, pectineus or iliopsoas.12 Thoracolumbar (Maigne’s) syndrome is a pain pattern of the low back, pelvis, groin or upper thighs, and has been associated with zygapophyseal joints and the posterior rami of the involved segments.13.

Previous cases of lumbopelvic and groin pain have been described in the chiropractic literature, including management of pregnancy-related lumbopelvic pain,14,15,16 pubic symphysis diastasis,17 paraesthetica meralgia, 18,19 testicular pain, 20, 21 and femoroacetabular impingement 22. Additional cases of similar presentations have been reported by athletic trainiers23 and physical therapists.24

Recent conservative low back pain clinical recommendations have focused on patient subgroupings based on symptom presentation, cluster testing, observance of the centralization phenomena, motor impairment, and psychosocial co-morbidities.25,26 Centralization is observed in radiating spine pain that responds to repeated spine loading strategies, resulting in the distal symptoms moving more proximal or towards the midline. In contrast to centralization, peripheralization is the distal migration of symptoms.26 Improvement in an obstructed range of motion may be observed without centralization. The concept of centralization versus peripheralization can be utilized as a clinical guide for the patient, to monitor his or her own symptoms outside the clinic. Importantly, centralization has been identified as a clinically reliable tool.27 In the absence of observed centralization or peripheralization, a direction that improves the obstructed range of motion is identified as the directional preference.

The purpose of this case is to describe the management of lumbopelvic and groin pain that responded to mechanical flexion-distraction manipulation and home exercises. There is a paucity of literature with regards to the conservative management of lumbopelvic and groin pain in women who are not pregnant.

Case Presentation:

A 56 year-old postmenopausal, female Army veteran was referred by her primary care physician (PCP) to a chiropractic office at a Veterans Affairs Medical Center for intermittent low back and pelvic pain in an L1-L2 dermatomal distribution. Her symptoms developed 6 months earlier without trauma or reported illness and symptoms. Lumbar spine pain radiated to the groin, genitals as well as anterior and medial upper thighs 3-to-4 times per week and could last the remainder of the day. She noted her symptoms were typically associated with bending and lifting at work. Thigh, groin and vaginal pain only occurred concurrently with back pain. A revised Oswestry Disability Index (rODI) was performed during her initial evaluation and her score was 11 out of 50 (22%), while her initial Numeric Pain Rating was 7 out of 10. Dyspareunia was present since the onset of her symptoms, though she did not experience hematuria or dysuria and was not concerned about the possibility of a sexually transmitted disease.

A review of systems revealed hypolipoproteinemia, fibrocystic disease of the breast, gastroesophageal reflux disorder, and osteopenia. She was twice gravida and had healthy deliveries on both occasions. The patient reported having a levonorgestrel-releasing intrauterine device from age 45 and to age 56, and she had not had a menstrual cycle for at least 10 years due to menopause. She did not report constitutional symptoms. Her medication was limited to naproxen taken as needed since the onset of her symptoms. She also reported being a 42 pack-year smoker. Her home workout routine included sit-ups and non-specific leg exercises that did not produce lumbopelvic or genital pain.

Prior to presentation to our clinic, her PCP performed an internal pelvic exam, which was unremarkable. The PCP ordered additional testing; a lumbar MRI revealed mild multilevel degenerative changes and a syrinx at the thoracolumbar junction (figure 1), while a pelvic ultrasound visualized a normal sized, mildly heterogonous uterus without evidence of fibroid. There were no abnormalities identified with the transvaginal ultrasound.

Figure 1: Lumbar MRI Mid-sagittal T2 weighted.

Hyper-intense signal within the cord demonstrates an upper lumbar syrinx (blue arrow) of idiopathic origin.

On presentation to the chiropractic clinic, the patient’s vital signs were all within normal limits. Kemp’s test, nerve tension testing, and sacroiliac provocation maneuvers did not produce symptoms. Supine knee-to-chest was pain-free with full hip flexion. FABER and FADIR tests were unobstructed and pain-free. Palpation was negative for tenderness and myofascial hypertonicity throughout the lumbar paraspinals, iliopsoas insertions, and genitofemoral nerves. Segmental motion palpation was unrestricted and did not produce concordant symptoms. Repeated end range loading in prone was restricted in extension and pain-free. No identifiable centralization or peripheralization was identified. Lumbar active range of motion (AROM) revealed focal pain-free moderate restriction of movement into extension at the thoracolumbar spine while flexion was pain-free and unrestricted.

In the absence of hip, sacroiliac, or neural tension findings, and focal obstruction to thoracolumbar extension without centralization or peripheralization of symptoms, a working diagnosis of L1/L2 lumbar derangement, as defined by McKenzie, was made with extension identified as the directional preference.28 Following a detailed discussion related to our findings, the patient agreed to a course of rehabilitative exercise and mechanical flexion-distraction manipulation26,29 at a frequency of 1 time per week for 3 weeks. Goals included a reduction of intermittent lumbopelvic and genital pain by at least 50% in 4 weeks, improvement in rODI by 10 points, and increased functional independence.

The patient was prescribed prone press-ups to be performed at home and work 10 times, 4-5 times per day or when she appreciated onset of symptoms. She was taught to understand the centralization and peripheralization phenomena, thus allowing her to monitor her symptom response to exercise.27 Flexion-distraction manipulation was performed in a neutral plane at each follow-up visit.

The patient did not experience peripheralization of symptoms with her home exercise throughout the course of care. She reported compliance with the home exercise and was able to demonstrate the exercise in office. A modified exercise while standing was provided so that she could induce extension into her thoracolumbar spine when she was at work.

Over the course of 4 visits, she experienced a single episode of axial low back pain that resolved with home exercise. On the fourth visit, re-assessment of rODI demonstrated a 91% lumbar, pelvic or genital pain since the last visit. She had performed all work duties without limitation. (Table 1)

Table 1: Key characteristics of office visits. Associated clinical findings, outcome measures, treatment and home exercise for visits 1 through 5.

Visit

1

2

3

4

5

Painful Episodes

3-4 per week

Zero episodes in last week; no peripheralization of symptoms

1 episode

axial back pain; resolved with home exercise; no peripheralization of symptoms

Zero episodes in last week; performed heavy lifting at work with no pain; no peripheralization of symptoms

Zero episodes in 1 month; performed heavy lifting at work with no pain; no peripheralization of symptoms

Active Lumbar ROM

Flexion: full, pain-free

Extension: moderate limitation, non-painful

Flexion: full, pain-free

Extension: mild limitation, non-painful

Flexion: full, pain-free

Extension: mild to no limitation, non-painful

Flexion: full, pain-free

Extension: mild limitation, non-painful

Flexion: full, pain-free

Extension: full, pain-free

Segmental Restriction

None

Thoracolumbar junction

Thoracolumbar junction

Thoracolumbar junction

None

Office

Treatment

Mechanical flexion-distraction

Mechanical flexion-distraction

Mechanical flexion-distraction

Re-assessment only

Active Home Care

Prone press-up

4-5x/day; or when symptoms develop

Continue Prone press-up 4-5x/day

Modified standing press-up for work provided

Continue Prone press-up 4-5x/day

Modified standing press-up for work provided

Continue Prone press-up 4-5x/day

Modified standing press-up for work provided

Continue Prone press-up 1-2x/day;

Educated

rODI

11/50, 22%

1/50; 2%

10, 91% improvement

Numeric Pain Rating scale

7/10

0/10

0/10

0/10

7, 100% improvement

At visit 5, 8 weeks following initial evaluation and 4 weeks since the prior visit, the patient was discharged from care as she was symptom-free for greater than 1 month and performing all tasks at work and home. She was advised to follow-up with her neurologist’s imaging recommendations to adequately assess the visualized thoracolumbar syrinx.

A follow-up phone call at 3 months found the patient to be symptom-free. She reported a single episode of back pain without groin or thigh pain that she managed through prescribed home exercise and generalized stretching. Follow-up thoracic and cervical MRI evaluations with contrast did not appreciate any extension of the syrinx from the thoracolumbar junction and she was provided a diagnosis of idiopathic syrinx.

Discussion

The working diagnosis of an L1-L2 lumbar derangement was confirmed based on the patient’s response to care. The centralization phenomenon is well documented as a prognostic factor and patient education tool in the literature.27, 28 The use of centralization concept aided the patient in self-management by guiding her through hurt versus harm conceptualization, thus minimizing reliance on passive care, and gained the confidence to self-manage a reoccurrence to resolution.

The differential diagnosis for this case includes gynecologic, genitourinary conditions and musculoskeletal conditions, including but not limited to upper lumbar derangement, upper lumbar radiculitis due to herniation, sacroiliac joint dysfunction, trigger points of the quadratus lumborum, meralgia paresthetica, femoroacetabular impingement, and genitofemoral nerve entrapment. Thoracolumbar (Maigne’s) Syndrome has a similar presentation to an upper lumbar derangement, and it cannot be necessarily excluded from the diagnosis in this specific case as Maigne and McKenzie might be describing the same functional lesion. Work-up of the lumbar syrinx was necessary to rule out additional etiology.

Conclusions

There are few reported cases of conservatively managed lumbopelvic pain and radiating genital pain in women of non-child bearing age. This case report demonstrates management and resolution of intermittent lumbopelvic pain with associated bilateral genital pain with patient-generated end-range loading exercises and mechanical flexion-distraction spinal manipulation. Integrated medical and chiropractic care led to a resolution of the patient’s symptoms.

Limitations

While interesting, this case report is limited in its scope and cannot be utilized as a generalization for patient care.

Consent:

Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-In-Chief of this journal.

List of Abbreviations:
FABER: flexion abduction external rotation
FADIR: flexion adduction internal rotation
MRI: magnetic resonance imaging
PCP: Primary care physician
rODI: revised Oswestry Disability Index
ROM: range of motion

Competing Interests:

No funding sources or conflicts of interest were reported for this report.

Acknowledgments:

This work was conducted at and supported by VA Butler Healthcare. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, Department of Veterans Affairs, or the United States Government. The author would also like to thank Dr. James Demetrious for his editorial support.

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