Long-time readers may remember that six years ago I wrote a newsletter on the subject of hip pain and how usually the problem is not in the hip. When the only physical finding is tenderness, it is often misdiagnosed as trochanteric bursitis. However, this term has fallen into disrepute as little evidence exists to support the presumed pathology.
In fact, hip pain is usually referred from somewhere else, commonly the iliolumbar ligament or a quadratus lumborum muscle trigger point. This month I would like to explore other presentations of hip pain, i.e. bilateral hip pain and pain presenting on the opposite side to the lesion. And perhaps draw out some principles that apply to other pain syndromes that lateralize or present on both sides.
Whenever pain presents in a specific location the clinician needs to determine if the pain is caused by something locally, or if it is referred from somewhere else. When clear‐cut physical findings are present, e.g. local swelling or restricted range of motion of a knee joint, chances are high that the pain is coming from the joint itself.
However, if the problem presents on both sides of the body, e.g. bilateral plantar fasciitis, my reasoning is that a local pathology is highly unlikely to present in two similar places on opposite sides of the body at the same time. There must be something central or systemic underlying such a presentation. This likely holds true for a similar problem occurring on the opposite side of the body at different times. (The one exception is the "cross‐over phenomenon" where signs and symptoms associated with an interference field can be mimicked on the opposite side of the body. See page 13 of my book.)
Bilateral hip pain is not a rare phenomenon. These people often say that they cannot sleep on either side. I believe that the reason bilateral hip pain is common is that there are so many potential midline interference fields. Perhaps the most frequent ones are the coccyx and the prostate, but bilateral hip pain can come from the anus, pelvic floor scars, the pubic symphysis, the urinary bladder or any midline abdominal surgical scar. Somatic dysfunction of the pelvic ring or lower lumbar spine can aggravate the situation.
Other bilateral pain syndromes include (at times) carpal tunnel syndrome. In addition to metabolic causes (hypothyroidism, hormone imbalances, inflammatory conditions) attention should be directed at the upper thoracic spine and especially the cervico-thoracic junction.
Unilateral pain can also be a puzzle, if the search for causes is limited to the same side. When I was first introduced to osteopathy 35 years ago from a MD background, I realized that osteopathy and conventional medicine had different approaches to diagnosing musculoskeletal pain. MDs were trained to start with the symptom and then search for the anatomical cause. DOs were trained to look for somatic dysfunction; the connection would be made by treatment which would usually correct the symptom wherever it had manifested.
These parallel approaches to diagnosis lead me to embark on a study of the symptoms associated with a common, but very significant somatic dysfunction ‐ an "innominate upslip" or a "superior innominate shear" (a superior displacement of the innominate bone relative to the sacrum at the sacroiliac joint). I simply recorded the location of the patient's pain and whether the pain disappeared when the somatic dysfunction was corrected.
I was not surprised to find innominate upslips were associated with pain in many parts of the body (e.g. head, neck, or chest) and not just the low back or leg. However, what was unexpected was that the pain was close to 50% ipsilateral and 50% contralateral at whatever level the pain presented. I published two studies of this phenomenon in the now defunct journal Manual Medicine (total of 125 patients) and although they are still referenced in the literature, I am not aware of any similar studies since.
Another common location of pain presenting on the opposite side to the lesion is anterior knee pain associated with tight hip adductor muscles and often asymmetry of the pubic bones (one slightly superior to the other). Knee pain of this nature is easily corrected by manipulation with the goal of releasing the tight hip adductor muscles. I have no data on this, but I find tight hip adductor muscles very commonly on the opposite side to that of the painful knee.
Many of the examples given above are osteopathic in nature and require some knowledge of manipulation to treat. However most somatic dysfunction can also be treated with procaine injections. If the tight muscles are identified, e.g. tight hip adductors, the neural therapy treatment is simply injection of procaine ½% as quaddles into the overlying skin. This technique, called "segmental therapy" will immediately relax the tight muscles. (See pp. 57-58 of my book.)
New neural therapy article (courtesy of David Vinjes at http://www.terapianeural.com/):
Robert F. Kidd, MD, CM