OMM # 28
Wednesday, October 08, 2003 2:00 p.m.
Jennifer Elmore
Dr. Gustowski Page 1 of 6
Inguinal Pain
Dr. Gustowski said to remember that we are responsible for the Kuchera reading
in syllabus (pages 123-145). It will be valuable to read through this.
A. T. Still
“The diaphragm surely gives much food to the one who would search for the
great whys of disease as reported causes seem to be far back in the fogs of
mystery. It may help us to arrive some facts if we take each organ and division
and make a full acquaintance of all its parts and uses before we combine it with
others”
Objectives
 Be familiar with the differential diagnosis of inguinal pain
 Be able to apply the following techniques to a patient with inguinal pain
 Techniques
o 12th Rib release
o Integrated NMS for innominates
o Iliolumbar ligament release
o Inguinal ligament Jones strain/ counterstrain
Case 1
 40 y/o male awoke c/o severe pain, which started in right flank and has
progressed to right groin. + N/V (nausea and vomiting), increased urinary
frequency, urgency, and dysuria. Pt is unable to find a comfortable
position
 PE- P 100, T 98.6, R 12, BP 136/84
 Right lower abdominal guarding and tenderness
Differential Diagnosis
Appendicitis
Urolithiasis
Diverticulitis
Prostatitis
Hernias
Intrinsic hip pathology
Femoral artery aneurysm
Peritonitis
Tumor
Iliopsoas tendonitis
Iliolumbar ligament syndrome
Adenopathy
Psoas abscess
Diagnosis is Urolithiasis (Kidney stone)
 80% Outpatient treatment
 20% Inpatient
o Intractable Pain
o Persistent Vomiting
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o
o
o
High Grade Fever
Obstruction with infection
Solitary kidney with obstruction
Urolithiasis
 Tests
o UA with C & S
o Blood chemistry, CBC with differential
o Imaging (KUB, IVP, US, Spiral CT)
 Management
o Pain control
o Hydration
o Strain Urine
o Urology referral
o Surgical Intervention
** Sympathetic Innervation (important) – this is partly responsible for the
viscerosomatic reflex, and knowing the reflex can help with diagnosis and
treatment.
o T10-L1= kidneys, ureters
o T12-L2= bladder
o Preganglionic fibers for kidney and upper ureters = superior mesenteric
collateral ganglion
o Lower ureters, bladder = inferior mesenteric collateral ganglion
The ganglions are another place to see sympathetic innervation, so you can also
treat these.
Sympathetics
 Increased sympathetic tone
o Vasoconstriction of afferent arterioles, decreases GFR
o Decreases ureteral peristaltic waves and may cause urospasm,
relaxes bladder wall
o Ureteral stimulation, (ie, ureteral stone) = kidney as target organ
for sympathetic discharge (so see increased sympathetic tone)
Parasympathetics
 Kidney and proximal portion of ureters = Vagus nerve
 Distal portion of ureters, bladder = Pelvic Splanchnic Nerves (S2-4)
 In ureters they maintain normal peristaltic waves
There was a slide from netter over sympathetic innervation.
** Lymphatics (very important)
 Renal lymphatics flow into the pre-aortic nodes before traveling up the
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thoracic duct to the subclavian vein
 Synchronous motion of the thoracic and pelvic diaphragms is
vital to lymphatic drainage from the urinary system. The thoracic
diaphragm actively helps with drainage by increased negative
pressure in inhalation to help draw in fluid and increase venous
return. The pelvic diaphragm passively helps with drainage.
If one is working and the other is not, can get a disruption of normal lymph
flow. Don’t have to treat both thoracic and pelvic diaphragms, but when
one is treated it will effect the other – remember synchronized motion!
Picture from Netter on lymph vessels and nodes of kidneys and urinary bladder
** Picture from Kuchera – ureteral irritation (might want to look this one
over)
Picture from Netter showing the Quadratus lumborum, medial arcuate ligament,
crus, and the lateral arcuate ligament.
Picture from Netter more detailed showing the 12th Rib, which is what we are
treating. We treat the 12th rib in order to treat the diaphragm to improve lymph
flow to pelvic organs and remove inflammatory products and wastes in diseased
tissue in order to return our bodies to homeostasis.
Motion of the 12th Rib: normally the 12th ribs are angled down and as we
breathe the lateral angles move out and up (they flatten). This is called pincer
type motion. In this disorder, the 12th rib is stuck in inhalation (flattened), so we
want to return it to a relaxed (exhalation) state.
Diagnosing the 12th rib: start at iliac crests and move up through the
quadratus lumborum until you get to the first bony prominence, this will be the
12th rib. Want to motion test the ribs and feel for tightness (restriction) on one
side (find the up and out positioned rib). You will treat the rib that is restricted!
12th Rib (Direct Myofascial Release) Correction! This is not Arcuate
Ligament Release – hand positioning is different in these two
 Patient supine
 Contact the 12th rib with guiding hand under palpating hand
 Palpate the tension in the lateral and medial arches of the arcuate
ligament of the diaphragm
t
h
12 Rib (Direct Myofascial Release) – we are indirectly treating the
arcuate ligament
 Distract the rib laterally and inferiorly (no anterior pressure!)
 Follow this direction to feel the lateral arch release, continue until you feel
the medial arch release.
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 This technique can be continued to release the crus of the diaphragm
Integrated NMS for Anterior Pelvic Innominate
 Picture from Netter showing the relationship of the lesser trochanter,
ASIS, and inguinal ligament
 Patient is supine. Have patient reset pelvis (bend knees and lift buttocks
off table).
 Stand next to patient. Diagnose the inominates using springing and the
ASIS level to find which inominate is anterior.
 Place palms across ASIS bilaterally (cup them)
o Be sure to cover inguinal ligament and iliopsoas muscles
 Assess the pelvic obliquity
o positionally and functionally
 Barriers can be stressed both indirectly (moving inominate further
anterior) and directly (moving anterior inominate posterior) by
exaggerating the obliquity and moving the innominates toward the
opposite of the obliquity
 As barriers are approached, a sense of tension occurs – find where the
inominates feel balanced.
 Sudden firmness is felt if using direct method
 Softer pillow-like sensation is felt if using indirect method
 Hold against the barriers until releases occur
 Usually more than one release
 Asses for sequential tight loose changes in the ilioinguinal area
 Treatment is complete when positional tight-loose asymmetries are
resolved and a gentle internal and external rotation occurs
 The inominate bones are connected to the pelvic diaphragm and sacrum,
which has pelvic splancnic nerve (s2-s4) for parasympathetic innervation.
Case 2
 A 45-year-old male presents with low back and left groin pain. He denies
injury, but states that he was lifting heavy furniture all day yesterday.
 PE:
o neuro intact, motor intact (rules out herniated disk)
o left iliolumbar ligament tenderness
o L5 Rr Sr (NN – forward bent)
o Sacrum- right forward torsion
o Decreased flexion and rotation in Lumbar spine
o Decreased hip flexion bilaterally
Differential Diagnosis
Hernias
Iliolumbar ligament syndrome
Iliopsoas tendonitis
Urolithiasis
Peritonitis
Tumor
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Intrinsic hip pathology
Diverticulitis
Prostatitis
Femoral artery aneurysm
Psoas abscess
Appendicitis
Adenopathy
Diagnosis is Iliolumbar Ligament Syndrome
 Ligament attaches to the transverse processes of L4, L5, extends
to the iliac crest, and posterior and anterior regions of the SI
joint
 Tender point located 1 inch superior and lateral from the inferior margin
of the PSIS and in the lilolumbar ligament
 Becomes tender with low back pain, postural decompensation because
rotation of the 4th and 5th lumbar vertebra stretches the ligament and
causes scleroderma - radiating pain. “Referred pain” seen in lateral thigh,
inner groin, and in the inguinal area. (picture of this in powerpoints)
o It is the first ligament stressed with postural instability such as
short leg or scoliosis.
Anterior Inguinal Tender Point – located on the lateral border of the
pubic bone just caudal to the attachment of the inguinal ligament.
Find pubic symphysis and go lateral on pubic bone. Goal is to turn
tender point off to decrease nociception.
Anterior Inguinal Tender Point - Counter strain technique
 Stand on side opposite of tender point and put foot on table resting the
patient’s legs on your knee.
 The patient’s knee on the side of the TP is flexed 90 degrees and
crossed under the other leg.
 The physician’s caudal hand is pushing laterally on the ankle on the side
of the TP to produce internal rotation of the femur.
 Adjust the internal rotation of the femur and hip flexion in minute
increments until the pain is reduced by 70-100% (ask patient where pain
level is).
 Back off finger pressure (just find tender point and monitor)
 Hold for 90 seconds
 Return legs to table without Pt assistance
** Remember that strain/counterstrain affects gamma gain!
Iliolumbar Ligament diagnosis: palpate ligament on both sides and ask
which side is more tender – can also test for rotation and sidebending in L5 of
the lumbar vertebrae to get a clue about which ligament is tight.
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Iliolumbar Ligament Release (direct – myofascial type of treatment)
 Ligamentous articular strain technique
 Patient is lateral recumbent, knees and hips flexed, with affected
iliolumbar ligament up
 Physician stands behind the patient, facing the patient’s feet
 Contact the iliolumbar ligament near it’s attachment to the iliac crest
o Slightly medial and superior to the PSIS between the ilium and L4-5
(about 1 inch)
 Press anteriorly and inferiorly with thumb, maintaining balanced pressure
– press as hard as you feel the ligament pressing against you.
 Remember to test iliolumbar ligaments for tightness- treat the restricted
one!
 Continue to move anteriorly and superiorly to release the latissimus dorsi
(optional) – patient will often say they feel this in their shoulder.
 This is an essential area to treat when treating the lumbar and sacral
areas!
References
 Reading in syllabus
 Strain and Counterstrain, p. 71, Jones
 Ligamentous Articular Strain. Speece, Conrad.