Case Study - 2 Years of Hip Pain
2 Years of Hip Pain
In this post, I’ll present a case study and explain how the patient was helped by understanding the basis of their pain and how they could reverse it.
This patient had a two-year history of right-sided hip pain where the onset was a tackle playing football a couple of years ago. He felt a sudden sharp pain as he tackled. He continued playing at the time, finished the game, and then had the pain afterward. The following day was a little bit worse, and then the pain subsequently stayed despite many different things that he tried. He’d seen quite a few other people; he’d ended up seeing a consultant. He’d had an arthrogram, an MRI scan of the lumbar spine and the hip, as well as an ultrasound scan and x-rays.
Numerous Tests
He had the whole range of tests, and nobody could find anything to explain his symptoms. Nothing was found on the scans. He had two incidental hernias that weren't causing him a problem and wouldn't give him that distribution of pain anyway. Because of those ongoing symptoms, he got a referral to try physio one more time.
So essentially, he'd suffered a soft tissue injury at that moment two years ago. Because it was two years ago, it's healed. It doesn't matter what it was; it’s healed. Fortunately, we know that everything was checked for anything that might have been sinister to cause those symptoms.
His pain was real. He couldn't run without pain, yet he continued to run, but he couldn't play football anymore. He had not been able to play for a couple of years, and he had a daily restriction with the things he wanted to do in his life.
Personality Traits
Interestingly he had some traits of just wanting to keep going despite not being able to, and he had to push past and carried on despite the pain. He would have pain during a run and do it anyway.
You could easily see he's a pretty driven guy, which is typical for many people who develop persistent pain.
He had no other options from an orthopedic point of view, and he thought he had exhausted his options. So he was giving physio one last chance. The only other thing he could do for himself was treating himself occasionally with a foam roller. This would help in the short term, but then the pain would just come back.
It was there all the time as a constant ache, and it would vary depending on what he did. When he was examined objectively, there were physical findings of pain with lumbar movements.
They were limited by about a quarter in different directions, and all reproduced his pain. If you've heard of the slump test or straight leg raise, they were also painful, and he had some muscle spasm on the right-hand side of his back.
So the physical findings that anyone can see whether you're a physio or not were that it hurt him to move. Structurally, the tissue already healed, but the pain represented that he was still in the fight or flight state regarding that pain.
Brilliant Assessments But Poor results
He had seen some brilliant people, had some fantastic tests, and the technology behind them showed them nothing. The more failed treatments you get, the more it pushes you further down the potential to get persistent pain. It becomes more stressful when you see someone you trust, and you think it's going to give you the results you want, then it doesn't. It’s disheartening.
It’s stressful, and that stress drives the mechanism behind the pain beyond the one initiated with a physical injury. In the time that the bodily injury is healing, which is about three months for everything. That analysis of the pain and the worrying about the pain increases. Then the failed interventions that start to happen and the failed tests that don't bring the answer start to create the cycle of stress and pain.
Challenge to Overcome
The challenge is getting the patient to understand they are safe. I explained to him that there was nothing sinister causing his pain and that he had undergone all the tests to confirm that nothing would kill him. I examined him too so that I could see his restrictions. I could see his pain if you like, and it's reality, but I told him that the basis for that is no longer the tissue damage that started it all.
It’s more to do with the fears around it. The mechanism how that persistent pain becomes dominated more by the emotions attached to the movements than actually the movements themselves.
We did no more than getting him to take four or five deep breaths through his nose and out of his nose, counting to five after reinforcing that message of safety. After re-examining him, his movement started to improve straight away.
The Speed of Change
It started to click behind why the pain mechanism had stayed, and it made some sense to him. Belief is a massive thing with any treatment, and I’m just another person telling him something different. It's difficult sometimes to challenge someone with a very different belief to the one they've held for so long about their pain.
But I think the easiest way to present this is to say that well, all those beliefs you've held or the opinions of the other people who have tried to help you haven’t helped change your pain so far. I said they couldn’t be right because you're not any better, so it's just getting the patient to buy into the possibility that this approach can help.
It's giving them thoughts that make sense. A viewpoint that can trigger optimism within them, showing them a breathing rate that’s calming and getting them to move after doing it.
It is essential to set the boundary for slight movement, and the feeling of the output from that breathing and movement combination can be compelling pretty quickly.
By the end of that first session, he was pain-free. Completely pain-free. Now the change isn't always quick like that. I simply told him he's safe, slowed his breathing, and asked him to move again.
I told him he was going to be okay. I told him there's nothing seriously wrong with him and said he's going to be okay.
New Language
Now those aren't words that he's been telling himself at all. Nobody else has been telling him in the last two years. Once he starts to hear them and almost repeats them unconsciously back to himself and engages in the thought pattern and breathing pattern that comes with it, the movements come automatically.
It’s crazy when you see it, and he left pain-free. When I reviewed him, a week after I’d first seen him, he came to the room he said, ‘Did you hypnotize me?’. I replied, ‘No, I simply told you that you were safe, you will be ok, and you’ll make a full recovery.’
He went back to running that distance a little sooner than I would have liked, but I could have predicted him doing that because people often chase the thing they’ve craved. They’re excited to get back to what they've always done, so there's a risk there that they kind of trigger the symptoms again through that enthusiasm.
He ultimately recognised that he needed to condition his body physically after not being able to run comfortably for a couple of years. He does have to take it easy.
He now runs the 5k that he's never been able to run pain-free for two years.
Learning to Feel Safe
It does create amazement in people how they can be constantly painful, totally dysfunctional, and within one session, in some cases be pain-free. So they’ve just got to be made to feel safe.
They’ve learned that they have control, that they have to accept the responsibility for it and maybe not get too excited about the rehab. They must reframe any return of that pain or sensations that come around that pain. They may have previously been frightened or frustrated by them, triggering a cascade of thoughts that keep bringing the pain back.
They have to control how they breathe, think, move and feel, and the output is always different.
If they repeat that enough and do that with the right kind of emotion, pain-free is possible.
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