“Hi Ms. D.,” I said. “Nice to see you. You can come
on back.”

“OK, but you might have to help me,” she replied, struggling to rise from the chair.

“What in the world happened?” I asked. After helping her to my treatment room, she began to relay the whole story.

“My son just purchased his first home, and I volunteered to help him remodel, starting with removing some very old wallpaper. We had rented a steamer, but even that didn’t help. Mostly, I had to use muscle power to pull it off the wall. Not long after we were done, I started to have this deep aching pain in my hip, which kept getting worse as the night went on.”

“Where do you feel the pain is centered? Did the pain come on suddenly, or did it slowly develop afterward?”

“The pain is really mysterious, unlike anything I have had before. Most of the pains I have had are really easy to point to, but this is a deep ache that I cannot locate. I feel pain into the groin, but not in the way that a groin pull would feel. I feel a real tightness here (pointing to the pectineus area), but it isn’t exactly painful when I press on it. At the same time, it hurts above my waist, all the way up in here (she pointed to the anterior superior iliac spine area), but again, it doesn’t really hurt when pressed on. I thought I was being so careful. I even sat down most of the time and didn’t do any of the high work above my head.”

“Describe the motion of removing the wallpaper,” I said. “I want to visualize your exact motions.”

“I was only doing the lower part of the wall, and this paper seemed cemented on the drywall. To avoid hurting my back, I sat pretty much the whole time. I was grabbing the wallpaper at about shoulder height and pulling downward toward the floor. It was slow going the whole time, but I worked for hours. Not long after returning home, the pain began. I couldn’t lift my leg; getting up from a chair was almost impossible. My husband had to help me in the bathroom, and I slept in a recliner because lying on the bed was out of the question. I barely slept. Now, I can hardly stand up, but once up, I can slowly adjust to the position. Moving my leg forward while walking is very painful.”

Helping her onto my table, I mentally ran through some potential possible causes.

My first thought was to lift her leg to create passive hip flexion. As I did this, she winced in pain. If passive movement created pain, that could indicate intra-joint pathology. Or …

“Completely relax and allow me to lift your leg,” I said. “I will go slowly and we can do it several times if you’d like.”

Indeed, as she relaxed, the pain during passive hip flexion disappeared. In all likelihood, the muscles of the joint were hypersensitive to length changes and fired reflexively. This was defense, not defect. I did this at first with her knee straight, then with the knee flexed. Movement was fine until somewhere around 90 degrees of hip flexion, when she felt a pinching pain in her groin.

“Describe the position you were in again. You were sitting in a chair and forcefully pulling down and forward correct?” I asked, demonstrating this action to her.

“Actually, most of the work was to my left, so I was leaning that way while I was pushing my right leg outward (abduction) a bit for stability.”

At that moment, the muscle that took the brunt of the strain became very clear. I suspected that the muscle was a hip flexor; possible culprits were the psoas, iliacus, and tensor fascia latae. Unfortunately, I could not use resistive testing to differentiate them; when such irritation exists, every muscle tests positive. Of the aforementioned muscles, the iliacus was the perfect functional match, as it creates pelvis on femur flexion, where the psoas creates femur on pelvis flexion. Because Ms. D. was sitting, she was forcibly creating pelvis on femur flexion for hours. In addition, the iliacus, unlike the psoas, is very sensitive to abduction, which she was doing with her right leg to stabilize movement to the left.

After carefully treating the iliacus, Ms. D. was surprised to discover that getting up from my treatment table was much easier. She gingerly took a few steps, finding them less painful than expected. I encouraged her to alternate sitting and standing often in the next day or so. Improvement was rapid indeed, with a relatively good sleep in her own bed on the first night. In about two days, the pain was completely gone, and so was the wallpaper.

Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars and president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois. His clinic, seminars, and research endeavors explore the science behind this work. Visit www.nmtmidwest.com or email him at doug@nmtmidwest.com.