Today we are providing a good old fashioned case study. Most of the time, case studies are geared toward medical providers. TODAY it is meant for you! You can look for common similarities between you and the patient. Hopefully, identifying similarities will get you on the right road to recovery. Just some insight before we get going. The patient I am discussing had complaints of groin pain for two months. He sustained an injury while front squatting. It prevented him from spending time with his true love, the gym!
Today’s patient is a 36 year-old male. We will call him… Jon Snow. Only because of my new found love for Game of Thrones! Yes I know, I am a little behind. Most of my references will be SUPER outdated. Jon recently retired from the military. The U.S. military. Not the fictional military regime that protects the seven Kingdoms.
This gentleman previously sustained plenty of injuries while serving our country. However, he has not had any surgeries. Months earlier, we treated Jon in our clinic for a diastasis recti, which is an abdominal separation. It is more common in women who have delivered birth. Jon thinks he sustained it while carrying artillery during deployment. Either way, he did relatively well after a couple weeks of rehab.
Fast forward: Three months later I bumped in to good ol’ Jon Snow in the local gym. Crossfit is Jon’s passion. When he is not standing guard at the wall of course. Jon told me that he had injured the front of his hip while front squatting nearly two months ago. He has been unable to shake the pain and it has only gotten worse. It has prevented him from doing any lower body exercises or running for months.
Jon’s primary care doctor ruled out a hernia. She also had an MRI done that revealed a potential low-grade muscle strain at his hip flexor; not definitive. No changes were seen at Jon’s hip joint compared to earlier imaging.
Jon Snow’s Complaints
- Sharp pain adjacent to the left side of Jon’s groin. Felt with squatting and running.
- Despite attempts to stretch and refrain from lower body exercise he is not seeing any improvement.
- Tender to touch in adductor muscles near groin.
- Pain with body weight squat.
- Patient displays
posterior pelvic tilt (“butt-wink”) just after going below parallel. Same presentation when performing a lightly weighted front squat.
- Pain when I flex and extend his hip on the treatment table.
- Normal ankle motion on both sides.
- Negative testing for hernia.
- Negative testing for lumbar referral.
Spoiler Alert: This is not going to be one of those crazy stories where his toe was the true culprit of his pain. It also wasn’t referred pain from his back, neck or weird connection with his twin brother. Not to say we don’t see these cases. For the most part he was relatively mobile above and below his injury.
- Dry needling to the adductor muscles [pectineus, adductor longus, adductor magnus and gracilis.]
- Cueing with squat to avoid “butt-wink.” Encouraged bracing of abdominals during weighted squat to maintain alignment.
Patient returned seven days later reporting that he no longer had pain at his groin. Jon stated that he had returned to his previous exercise routine. He was able to front squat 225# without pain yesterday. Jon Snow is a happy camper.
- No tenderness to touch at adductor muscles.
- Pain free hip flexion and extension
- Pain free squat
The Big Takeaway
Jon made attempts to relieve pain local to the groin. He did all the right things. First, he took some time off from the exercises that aggravated his pain. He attempted to find relief through stretching and soft tissue work. When this was not working, he decided to see a medical provider. His medical provider ruled out any potential red flags. With the number one concern being a hernia. In the military, MRI’s are thrown out like candy. In civilian world he most likely would have been required to see me before insurance paid for an MRI. In the long run this would have saved him and the insurance company money (if he was a civilian).
We were able to make a significant change through dry needling of his adductor musculature. Did he have a tear in these muscles? According to his MRI he did not. Either way, we would expect a muscle strain in the hip region to have healed around two months assuming it was a low-grade strain. So why was he still having pain if the injury healed? We discuss in another article that tissue healing does not mean you will not have pain. Pain is a complex process that requires a brain. We see plenty of beat up tissues on MRI without reports of pain.
We do know that trigger points can send warning signals back to the spinal cord and then to the brain. By treating Jon’s trigger points, which were likely secondary to some irritation from front squatting with poor form, we were able to minimize those warning signals. Based on research, we also know that treating these trigger points helped restore the adductor musculatures ability to work optimally (strong and timely muscle contractions).
Interested in dry needling? Find a provider here.
-Dr. Mike Infantino, DPT