Case Study: Instability-Induced Posterior Hip Pain

In such cases, an integrative approach is called for:

Our patient is a young, slender adult female reporting 7 months of severe posterior buttock pain. The pain radiated to her mid-posterior thigh and sometimes toward the rectal/perineal area. There was no numbness or tingling reported, and no clear patterns were found linking her pain to a specific nerve

The Challenge

The patient had already seen multiple orthopedic surgeons, pain specialists, and physiotherapists at major New York health care centers, and had undergone multiple spinal MRIs, with no major findings. She had been treated with epidural steroid injections and oral steroids, which failed to relieve her pain.

Our Diagnostic Process

Upon reviewing the patient’s health history, we found that she had never received a dynamic exam of her hip and pelvic region – the clinicians who treated her relied solely on static images that were not clinically relevant to her reported pain.

Clinical Exam

Our clinical exam revealed marked hip hypermobility, to the point of borderline Ehlers-Danlos syndrome. Her internal hip rotation at 90° flexion reached approximately 75°, consistent with capsuloligamentous insufficiency – a condition where the supporting joint capsule and ligaments become weakened, stretched, or damaged, leading to instability.

Ultrasound Exam

We used high resolution ultrasound to dynamically examine the patient’s hip and pelvis.
Our findings revealed:

• Severe hip micro-instability, with no nerve impingement.
• Abnormal femoral head translation during movement.
• Non-coaxial, turbulent rotation, as opposed to smooth, concentric movement around a stable axis, as seen in a healthy hip.
• Tearing of the anterior labrum, with no detachment. This was not a pain generator, but a sign of chronic joint overload due to instability.
• Reactive changes in the iliopsoas, indicating over-recruitment of the secondary stabilizers due to hip instability. The obturator internus muscle was hypertrophied and showed excessive active range of motion.
• The posterior femoral cutaneous nerve (PFCN) was thickened and hypoechoic, coursing over the hypertrophied obturator internus.
• We were able to reproduce the patient’s symptoms using sonopalpation – manipulation of the ultrasound probe.

We concluded that the patient’s hip instability was responsible for her pain symptoms, which explained why there was posterior thigh pain and occasional rectal pain with no paresthesia, and why epidural injections and oral steroids did not relieve her pain.

Our Treatment Protocol

We took the following steps to alleviate the patient’s posterior hip pain:

1. We treated the hip capsule and pelvis with prolotherapy and conducted hydrodissection of the PFCN nerve.
2. We used high intensity laser therapy to address neuropathic pain.
3. We used extracorporeal magneto-transduction therapy (EMTT) to decrease intra-articular inflammation.
4. Our physical therapy protocol focused on intrinsic hip and pelvic stability, and gait retraining.

Symptoms diminished by 30% after the initial prolotherapy injections, and by 80% after the second round. After completing targeted physical therapy, the patient was able to return to the gym, within four months of her first visit.

Discussion

In hypermobility-related hip instability, posterior pain does not indicate posterior capsule tightening – it reflects the failure of posterior structures to adequately compensate for excessive motion of the femoral head. In such cases, static MRI imaging is insufficient to identify the mechanisms behind the symptoms. Only when viewed with dynamic ultrasound were we able to identify the functional mechanisms of pain.

Our multifaceted treatment approach included orthobiologics, energy technologies, and customized physical therapy that helped to restore hip and pelvic stability and eliminate the compensation patterns that were the source of pain. Our integrative approach, backed by advanced imaging and therapeutic technologies, led to successful outcomes that could not be achieved with conventional methodologies.