WHEN DOES IT BECOME AN ETHICAL ISSUE TO REFER ON…
by John Gibbons BSc (OST), Sports Osteopath/Therapist, and Lecturer in Sports Medicine at the University of Oxford and St Mary’s University

I have been lecturing in the field of Sports Medicine for eight years. During this time I have come to recognise that many physical therapists commonly treat where the patient presents with ‘pain’ rather than considering if this is the actual ‘cause’ of the problem or if it is merely a ‘symptom’, especially with regard to patients who present with groin pain.
I would consider pain in the groin as one of the problematic areas for a specific diagnosis, even though we are only hypothesising as to what the actual tissue is that is causing the pain. This is because we generally refer for a scan, once a treatment plan has been administered, and if we were unsuccessful with our treatment we would then consider an alternative plan of action.
I was having my haircut a few weeks ago and overheard a conversation between the receptionist and a hairdresser. The receptionist was saying how frustrated she was not being able to run for more than five minutes due to her groin pain. She said that she was having a massage treatment every couple of weeks and this had been going on for over a year.

Naturally it didn’t take long before I decided to join in the conversation. It was very interesting as we went through the history taking while I was having a haircut. I explained to this lady that since regular treatment to the symptomatic area was unsuccessful, should she come to my clinic for an initial consultation I would assess and treat her but not the area of pain. I told her that in my experience, her presenting pain was purely a symptom and not the cause of her being not able to run. Two days later I received a phone call from the lady in question. So the challenge was on!
History
The patient as briefly explained above is a 49 year-old female working for many years as a receptionist. Before the onset of her injury, she was running approximately 4 xs weekly for about 45min per session. About 18 months ago she was toning her abdominals by doing bilateral leg lifts off the end of the bed. During this exercise she felt a sharp pain in her right groin and stopped exercising immediately.
She rested for a few days and when most of the pain had disappeared she went for a run and was very surprised to have immediate groin pain within a few minutes. This went on for a few weeks e.g. she would rest, and then run and pain would come on, causing her to stop and rest again for a few days.
Walking up and down stairs was painful and she particularly had pain at night notably when shifting from side to side, which involved lifting her right leg up (abduction). She finally went to visit her GP and was given an x-ray of her hip, which proved negative. Subsequently she was put on the waiting list for physiotherapy.
After a few weeks she tried running again but the pain reappeared within a few minutes. Eventually she went to see a physiotherapist and was given some exercises to do but she felt this exacerbated her condition. She followed up the physiotherapist appointment two weeks later and was given 5 minutes advice, which she felt was inadequate and a complete waste of her time.
Having gone back to her GP my client was referred to have an ultrasound scan, which showed tearing of one of her adductors at its origin on the pubis. Nothing else was said or done so she paid to continue sports massage every two weeks for the next sixteen months. The treatment she received from the massage therapist was very painful although at the time she felt it was of some benefit.

As a lecturer of Sports massage I try to explain to my students that generally the Adductors as a group tend to follow the trait of becoming shortened, hence tight. They do benefit no doubt from manual therapy techniques to help normalise the hypertonicity within the affected muscle groups. I try to emphasise to my students if the area is painful and you continually treat the area of pain, then there is a likely hood of exacerbating the symptoms. There is a possibility that this patient could have improved without being continually massaged – as nature is a great healer. There has to come a time where we consider that the treatment we are giving has no effect on their symptoms. It is not a matter financially but more ethically to our patients, the patient has to have least a feeling of improvement if we are to continue to treat them. This lady and the massage therapist I feel are both to blame, as they both encountered into a vicious cycle i.e. she would have a treatment, be tender to the area for a couple of days then it would ease off and then would try and run, and this is how it continued. I do understand how easy it is to treat patients with sports massage on a regular basis as I have done it myself and still do, however if we are treating patients with an ‘injury’ then our thought process and clinical reasoning has to continually change as the patient progresses or at times regresses.
Examination
As part of the objective history it is important to find out what tissue/tissues are causing the patient’s pain. Obviously the ultrasound scan showed some tearing of one of the adductors, however, when I asked the patient to point to the location of pain, it seemed to be very close to the ischial tuberosity and I considered it to be either the adductor magnus or possibly one of the medial hamstrings.
So let’s revisit the presenting complaint. We know that her pain comes on within a few minutes of running and is particularly painful on the stance phase of gait leading to heel lift to toe off.
If one understands the musculature involved during the gait cycle then one can hypothesise as to why the adductor magnus is becoming reactive rather than proactive. If the posterior chain muscles are inhibited for some reason then other muscles naturally have a compensatory role.
In my opinion and experience treating athletes I find it common practise to see the following. And this was the case for the patient in question.
• Short hypertonic psoas, rectus femoris and adductors
• Over active hamstrings and ipsilateral erector spinae with consequential inhibition of the gluteus maximus (Gmax)
• Gluteus medius (Gmed) weakness, especially the posterior fibres
If we look at the above dysfunctions, a shortened hip flexor group can potentially cause an inhibition weakness into the antagonistic muscle i.e. Gmax, because of the restriction to hip extension caused by the psoas hypertonicity. This would cause an over activity of the hamstrings and erector spinae, but more importantly the vertical fibres of the adductor magnus would be utilised during extension of the hip.

The Gmed posterior fibres have a control for external rotation alongside the gluteus maximus. The Gmed is incorporated in the lateral oblique sling pattern and its function is to control pelvic alignment. Due to the weakness of the glutei group, when the patient adopts a one - leg stance the adductor group become the dominant control, which causes a subtle adduction and internal rotation of the hip. This in turn causes the adductor group to become hypertonic.

Hip Extension Firing Pattern Test
Muscle Activation Sequence

Muscle Activation Sequence
1. Hamstrings

Either group
may activate first
2. Gluteus maximus
3. Contralateral lumbar extensors
4. Ipsilateral lumbar extensors
5. Contralateral thoracolumbar extensors
6. Ipsilateral thoracolumbar extensors

The picture indicates the correct firing pattern of hip joint extension  (Jerome M. True 1995)
 
 
 

Hip Abduction Firing Pattern Test
Hip Abduction Firing Pattern Test

The Quadratus lumborum muscle is palpated with the Gluteus Medius and Tensor fascia lata, during abduction of the hip. The correct firing sequence should be Gluteus Medius, followed by TFL and finally QL at around 25 degrees of pelvis elevation. If QL or the TFL were to fire first, this would indicate shortness.

Gluteus Medius Anterior / Posterior Fibres Strength Test
Gluteus Medius Anterior / Posterior Fibres Strength Test

The patient is asked to resist the pressure of the therapist as a downward movement to the hip is applied. If the patient can resist the movement then the muscle is graded normal. By rotating the hip into slight extension and external rotation the posterior fibres of the Gluteus Medius can then be tested.

Treatment Plan
As research has shown us in regard to inhibition, if we lengthen the antagonistic muscle, which is held in a shortened and tight position, then we can have an immediate effect upon the muscle tone of the inhibited muscle. However, in my experience it never seems to be straight forward, especially with patients with long standing chronicity.
As part of the treatment I lengthened the psoas and rectus femoris using muscle energy techniques (METS) but I decided to leave the adductor group alone for the time being.
Muscle energy techniques (MET) and Proprioceptive neuromuscular facilitation (PNF) is very similar, in that they are used to help correct muscle imbalances. MET has derived from the Osteopathic profession and PNF from the Physiotherapy profession. The theory with both techniques is that if you contract a muscle for 10-12 seconds it induces a relaxation period, which then allows you to lengthen the muscle. In Osteopathic terms this is known as Post isometric relaxation (PIR) and in Physiotherapy it is known as Contract relax (CR)
I also advised the patient to perform Gmax re education exercises to promote the correct firing sequence of hip extension and in addition some functional exercises for the Gmed to help control pelvic and hip alignment.
To initially activate the Gmax, I asked my patient to adopt a supine position and to perform a pelvic lift but with the focus on squeezing the Gmax to lift the hip into extension. This is a very good exercise to do to help re-educate the firing of the Gmax. Another exercise I showed my client to do was fitball squats – I asked my patient to place ball against the wall and to place their lumbar spine against the ball. The patient was then asked to perform a squatting motion and on the concentric phase (up), the patient had to be very focussed on squeezing the Gmax with a subtle pelvic lift at the end of the movement.
For the Gmed I always try and be functional i.e. weight bearing. I explain to my patients the function of this muscle so they have a better understanding. I explain that basically any movement on one leg would hopefully activate the Gmed but the patient has to focus on where the muscle is and how it feels when it is activated. I show them an exercise off the end of a step, in which the patient is standing on one leg with the other leg lowered down so that the pelvis is seen to lower on that side. They then are advised to lift the pelvis back to the normal position by activating the Gmed on the weight bearing leg, if they can slightly externally rotate the hip as they perform the exercise, this will help activate the posterior fibres of the Gmed.
I told her to do 12 repetitions and repeat 2x daily increasing to 15-18 reps 3-4x over the next 10 days. and return for a follow up appointment 10 days later. On the follow up I reassessed the muscle imbalances shown to me the previous week and was pleasantly surprised to find a major improvement. Her night pain had also reduced enabling her to sleep better.

Subsequently, I was able to ask my patient to go out to the running track and run for 7 minutes. The patient was understandably apprehensive about doing this but agreed it was necessary in order to assess progression. After running for seven minutes she was ecstatic because she had no pain and felt so much stronger to the point she wanted to carry on.
Continuation Treatment Plan
I advised this lady to run with two-minute increments every other day starting with seven minutes and to continue the exercises previously given on a daily basis for ten days. I advised using some light weights (2-5kg) in each hand for the squatting exercise using the ball. All the other exercises shown previously were to continue as normal.
Then after ten days she was to perform her functional exercises for the Gmax and Gmed on the rest days i.e. dropping back to doing the exercises every other day.
Present Day
Every four weeks I go for my routine haircut and I am updated on her progress. She is now running forty minutes at a time with no pain during exercise or at night. To help continue and motivate her to run she has now joined back to her original running club, which she enjoys very much both from a physical and social point of view.
Conclusion
This is where the difficulty lies in being a Sports Therapist. The reason I say this is because in the past, as a practising Sports Therapist myself, I would have initially treated the area presenting with pain without taking into consideration any other relevant areas which might have been contributing to the complaint. I am not saying that you have to be an Osteopath to identify the cause of the pain. What I am saying is that if you have a good understanding of the 'functional' anatomy of certain muscle groups, it is possible to consolidate all of your objective tests and formulate a realistic plan of treatment.