At a recent seminar, I was teaching how to correct the adductors. As I circumducted the supine patient's left hip joint, she experienced pain at the pubic ramus when the thigh was adducted medially and moved from superior to inferior.
The cartilaginous acetabular labrum creates a deeper well to hold the femur head into the socket and protect from bone-on-bone trauma. According to the Arthroscopy Association of North America (AANA), tears of the labrum cartilage are often the result of athletic activities that involve repetitive pivoting movements or repetitive hip flexion. The AANA Web site states that labral tears are usually caused by femoral-acetabular impingement, capsular laxity, dysplasia and trauma.1 The only definitive diagnostic tool is an MRI of the hip joint.
The patient was unable to identify a specific onset date or trauma, but revealed that she regularly rode horses. Since labral tears don't always have definitive signs and symptoms, that ruled out joint dysfunction from muscle dysfunction. We were still unable to confirm or deny the presence of a tear. So, what else could cause the uncomfortable pain and pressure during circumduction? I call it a pectineal pinch.
The pectineus muscle is the smallest and most superior adductor. It attaches at the lateral aspect of the superior pubic ramus and inserts inferior to the lesser trochanter of the femur. When the patient performs standing hip circles, a dysfunctional pectineus muscle will cause a locking, jerking motion in the anterior range of motion ipsilaterally. Circumducting the hip joint while the patient is supine will reveal pain and pressure as the thigh moves into the muscle origin.
Correction of the pectineus involves a lateral to medial thrust at the pubic ramus. Because this is such a sensitive region for patients, I recommend doctors use a knife-edge contact with gentle nudges or set their adjusting instruments to gentle force. The insertion can be corrected by creating external rotation of the thigh while maintaining a firm contact at the site of attachment. Retest the patient's circumduction to ensure that you have eliminated all pain and pressure.
After I applied treatment as described, the female patient responded with excellent results immediately. No more pain, pressure or tension when the hip was circumducted.
Next time one of your patients presents with a pectineal pinch, give them a one-two punch at the origin and the insertion. The patient will be amazed and thankful.
Reference
- Ranawat AS, Sekiya JK. Hip Labral Tears. Available on the Arthroscopy Association of North America Web site: www.aana.org/VideoEducationLibrary/Articles/HipLabralTears/tabid/130/Default.aspx.
Dr. Todd Turnbull, has authored online courses and articles about concussions, sports performance, soft-tissue diagnosis, rehabilitation and disc herniations. He is a 1991 graduate of Life University, a board-certified chiropractic sports physician, and maintains a private practice in Portland, Ore. He can be contacted with questions or comments via his Web site: www.drtoddturnbull.com/DCJournal.