Manual Therapy (1998) 3(3), 159-161 © 1998 Harcourt Brace & Co Ltd

Case study

Grave's, gravity and the groin: a case study

K. Sims

Department of Physiotherapy, University of Queensland, St Lucia, Queensland, Australia

PRESENTATION

A 36-year-old woman presented to physiotherapy with pain in the areas of both groins, and the inferomedial aspect of both knees (see Fig. 1). They had been present for 2 years but had worsened following a motor vehicle accident 1 month previously. The pains were intermittent and related to walking. Initially, they had been minor but had now become more noticeable and were present in the hips and knees through both stance and swing phase of gait. Pain was activity depen- dent and gradually increased in proportion to the amount of walking. The patient reported experiencing multiple bilateral ankle sprains over the years. She also reported feeling weak in her leg muscles, espe- cially when walking up stairs.

The patient was a university student and moderately active, but did not participate in any regular sporting activity. Her general health was good.

PHYSICAL EXAMINATION

The patient had bilateral genu valgum and both femurs were internally rotated. During gait she exhibited exces- sive and prolonged pronation, in addition to hyper- extending knees and internally rotating femurs during stance phase. She exhibited a positive Trendelenberg test bilaterally.

Hip range of motion was normal and pain free in flexion, abduction and adduction. Internal rotation in supine was 45 degrees bilaterally and reproduced her groin pain (right>left). External rotation in supine was 40 degrees and 20 degrees in prone. In prone, hip extension beyond neutral caused immediate anterior rotation of the innominate bone indicating a restriction to hip extension.

Kevin Sims, Dip Phty, M Phty St, Associate Lecturer, Department of Physiotherapy, University of Queensland, St Lucia 4072, Queensland, Australia.

Knees also had full pain free range of motion. There was, however, some pain during a squat. Patellae were both tender on the inferomedial borders and compres- sion of the patellofemoral joint was painful bilaterally. The medial glide of both patellae was restricted, espe- cially with the iliotibial band (ITB) on stretch. The pain in the squat could be diminished by the application of a medial glide to the patellae.

The patient exhibited poor activation of the gluteus maximus, medius and vasti of the knee in specific tests and in functional activities. The ITB exhibited decreased extensibility bilaterally in the Ober test.

CLINICAL INTERPRETATION

It was reasoned that the patients symptoms could be linked to her faulty biomechanics. The bilateral genu valgum could predispose her to excessive internal rota- tion of the femur. As internal rotation of the hip repro- duced the patients groin pain it was felt that the exces- sive internal rotation, which occurred during gait, was creating an area of localized stress in the hip joint. The poor gluteal activation prevented control of the internal rotation of the femur.

With regard to knee pain, it was reasoned that the excessive internal rotation, in conjunction with the tight lateral structures of the thigh, was creating a lateral tracking problem of her patellae. Her very poor vastus medialis obliquus (VMO) activation was compounding the problem.

The poor activation of the gluteals and VMO was noted and it was considered that this could also be related to the patients past history of recurrent ankle sprains. This type of injury has been shown to alter the behaviour of the proximal musculature (Bullock-Saxton 1994).

TREATMENT

The first priority was to improve the underlying biome- chanical faults.

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Fig. 1 Symptomatic areas in patient with hip and knee pain.

Treatment 1

A taping procedure was used to decrease the amount of mid-foot pronation. On reassessment this was found to have reduced the amount of internal rotation during walking although it did not alter the groin pain. In order to improve her gluteal muscle function the patient per- formed an isometric holding contraction with the hip positioned in inner range of hip extension. This was achieved by lying supine on a bed with the exercising leg resting on the floor to one side with the knee bent at 90 degrees.

Treatment 2

The patient reported that although the tape had sup- ported her feet better and her knee pain had improved, the groin pain had remained the same. A manual therapy technique (mobilization with movement of internal rotation of the hip with distraction applied by a seatbelt) was used to try to reduce the pain on internal rotation of the hip (Mulligan 1996). This did not alter the pain she had at end range internal rotation. Her gluteal exercises were progressed and VMO exercises added. A tempo- rary felt orthotic was used to control the excessive mid- foot pronation.

Subsequent treatments

Over the next 8 weeks the patient received 13 treatments. The treatment approach could be broadly divided into four categories: correction of dynamic alignment, man- ual therapy, muscle lengthening and facilitation.

Taping of the feet and the felt orthotic had reduced her knee pain and so a permanent orthotic was supplied. This controlled the excessive mid-foot pronation and reduced the amount of femoral internal rotation but con- tinued use did not relieve the hip pain to any perceptible amount.

Manual therapy techniques were used to reduce pain at the end of range of internal rotation and to improve gluteal activation by neurophysiological mechanisms. The previously used technique for internal rotation was re-tried but discarded after two further occasions as it failed to have an effect. A physiological grade III with compression in side lying was used but it too did not change the end range pain on internal rotation. Medial glides of the patella were performed with the ITB on stretch. This reduced the knee pain on squatting. To obtain longer term benefits the patellae were taped medially. The restriction of hip extension was treated using a postero-anterior glide combined with hip exten- sion. This appeared to slowly improve the extension movement.

Lengthening exercises were given to the ITB and to the tensor fasciae lata. The patient lengthened the ITB by modifying a stretch of the rectus femoris in standing by posterior pelvic tilting and then adducting the thigh.

Facilitation strategies were used to improve the per- formance of the VMO and the gluteii. All exercises began initially with emphasis on isolation of specific muscle activity. An EMG biofeedback unit proved a useful adjunct to achieve this. The exercises were quickly progressed into weight bearing positions where the emphasis was on improving endurance. Facilitatory taping was used to the buttock to encourage activation of the gluteals during gait (McConnell 1995). This pro- cedure reduced the amount of hip pain during gait.

Progress over the period was slow but knee and groin pain both began to decrease. The level of muscle func- tion improved but was still not optimal. The patient felt she would be able to continue working on her own and was discharged with a home exercise program (HEP), and asked to keep in touch regarding her progress.

The patient persisted with the HEP but did not make any further progress. She visited a rheumatologist who took blood tests that revealed elevated levels of thyroid stimulating hormone. She was subsequently diagnosed as suffering from Grave's disease. This was treated with medication to inhibit the thyroid gland, and within 1 month of taking this medication, remaining knee and groin pain disappeared. After 6 months the patient remains pain free.

COMMENT

Grave's disease is a disorder caused by the action of excess thyroid hormone (DeGroot et al 1996). It is caused by an auto-immunity to thyroid antigens causing hyperthyroidism. Common symptoms include signs of

Manual Therapy (1998) 3(3), 159-161 © 1998 Harcourt Brace & Co. Ltd

Grave's, gravity and the groin 161

hyperthyroidism such as weight loss, weakness, dysp- noea and tremor. Additional signs relate to the sympa- thetic nervous system (whose action is inter-related with that of the thyroid hormone) including tachycardia and sweating. Ophthalmic phenomena are common such as swelling of the lids, infrequent blinking and a wild star- ing expression.

The muscle system is affected by hyperthyroidism and weakness and atrophy of the proximal muscle is common. These changes are probably related to an alteration in concentration of normal metabolites. The causes of this condition are unclear and there seems to be some hereditary factor. In addition there is often a history of unusual emotional stress prior to the initial symptoms (DeGroot et al 1996).

This patient did not display any ophthalmic symp- toms. However, her resting pulse rate was about 100 beats per minute and she exhibited a tremor at rest (e.g. trying to hold the hand steady) or whilst performing exercise that was thought to be simply due to fatigue. These signs were not considered relevant during the period she was treated, but in retrospect were important clues to the underlying disease process.

The interesting aspect of this patient was the rela- tively rapid resolution of the hip and knee pains follow- ing medication. The patient attributed this to an increased general strength in her leg muscles. Joints that function without the benefit of normal muscle support and protective reflexes are liable to mechanical trauma if normal range of joint motion is exceeded, leading to cartilage degeneration (O'Connor et al 1985). In this case the normal range of internal rotation may have been exceeded due to lack of normal muscle control.

Joints without muscular protection may be more sus- ceptible to impulse loads. These loads occur at heel strike and in animal models have been demonstrated to lead to rapid cartilage deterioration (Simon et al 1972). Muscle lengthening under tension is considered to be an important mechanism to attenuate (i.e. spread out) such forces (Radin & Paul 1970). Other researchers have demonstrated that the impact of the heel strike may be attenuated by motion of body segments and changes in muscle forces (Cole et al 1995).

It is likely that the Graves disease in this patient reduced the ability to attenuate the heel strike, and lead to the development of the hip pain. Mathematical modelling of the pelvis has shown that stresses in the

acetabulum are increased at heel strike without muscle support. When muscles are included in the model, the load is transferred across the hip to the sacroiliac joint along the line of the gluteus maximus muscle (Dalstra & Huiskes 1995). It could be argued that the excessive internal rotation was the key precipitating mechanical event, but this is unlikely as even when using an orthotic, which reduced the amount of internal rotation, the hip pain remained the same.

In conclusion, this case study discusses an unusual musculoskeletal presentation of an endocrinological disorder. The clinical signs that were under weighted were the increased resting heart rate, the tremor during exercise, and the description of weakness. In retrospect these signs gave significant clues as to the presence of an underlying disease process. It is also clear that too much emphasis was placed on the role of the biome- chanical faults in the development of the patients symp- toms. The correction of these faults lead to some improvement but did not significantly change the patients pain. This emphasises the point that when treat- ment does not produce the expected outcome the clini- cian should always be prepared to re-evaluate the diag- nosis and treatment approach.

References

Bullock-Saxton J 1994 Local sensation changes and altered hip muscle function following severe ankle sprain. Physical Therapy 74(I): 23-37

Cole G, Nigg B, Van de Bogert A, Gerritsen K 1996 Lower extremity joint loading during impact running. Clinical Biomechanics 11(4): 181-193

Dalstra M, Huiskes R 1995 Load transfer across the pelvic bone. Journal of Biomechanics 28(6): 715-724

De Groot L, Larsen P, Hennemann G 1996 Grave's disease and the manifestations of thyrotoxicosis. In: The Thyroid and its Diseases, 6th Edn. Churchill Livingstone, New York, Ch 10, pp 371-416

McConnell J 1995 Lower limb biomechanics. Course notes. McConnell Institute of Australia

Mulligan B 1996 Mobilisations with movement for the hip joint to restore internal rotation and flexion. Journal of Manual and Manipulative Therapy 4(1): 35-36

O'Connor B, Palmoski M, Brandt K 1985 Neurogenic acceleration of degenerative joint lesions. Journal of Bone and Joint Surgery 67-A(4): 562-572

Radin E, Paul ! 1970 Does cartilage reduce skeletal impact loads? The relative force attenuating properties of articular cartilage, synovial fluid, periarticular soft tissues and bone. Arthritis and Rheumatism 13(2): 139-144

Simon S, Radin E, Paul I, Rose R 1972 The response of joints to impact loading- II. In vivo behaviour of subchondral bone. Journal of Biomechanics 5:267-272

© 1998 Harcourt Brace & Co. Ltd Manual Therapy (1998) 3(3), 159-161