Case Study #6

11 y.o. female with approximately 6-month history of R lower abdominal and upper thigh pain. Pain so severe that she needed help getting in and out of bed, on and off the toilet, and in and out of a car. Gait revealed a severe limp with her hands clutching of her R lower abdominal area. She had great difficulty changing positions on the treatment table to the point of needing physical assistance rolling supine to prone and vice versa. GI physicians had evaluated her with multiple CT and MRI, US, and no pathology noted. She underwent appendectomy as a last resort to see if it helped relieve the abdominal pain, and there was no improvement. This little girl’s life was severely impacted, as was the rest of the family’s. She was evaluated by a psychologist and had done some therapy without help. At the time of evaluation, the parents were prepared to check her into a residential center to see if intensive psychotherapy/counseling would help.

Careful history taking looking for possible incidents that could be implicated in the genesis of her situation revealed that the family was involved with horses…….we are in CO, after all. Evidently, there was a “fall” a couple of months before the onset of her symptoms. The “fall” involved sliding off the horse to one side, the L. The impact, as reported by the patient and Mom, was not severe.

Examination revealed severe ascending colon, cecum, R kidney ptosis and lateral/ER, and mesenteric root of the small intestine, R particularly the lower R. Evaluation of the osseous structures revealed normal R hip mobility in all planes, R ilia inferior shear, R inferior pubis. Lumbar segmental mobility was quite good.
Treatment was initiated with visceral release to the abdominal structures listed above as well as manual techniques, indirect largely, for the pelvic dysfunction. I also had to work with the patient on gait, exercise to re-engage the psoas and hip musculature and fear-based motion patterns. It took approximately 12 sessions to get her back to normal without any issues with pain and mobility. She is now playing Lacrosse and climbing on indoor walls. Mom has said that we have changed her family, and she is now a patient with long-term migraines. I evaluated her today, and it is an interesting case, maybe another case study for this group.

Takeaways: the “fall” off the horse most likely caused the R abdominal visceral strain and the inferior shear of the ilia. The slow fall probably happened with the R hip in abduction and a “drag” on the thigh, resulting in the inferior shear. Again, this resulted in a “loose pack” of the R SI joint with the ability of the R ilia to move inferiorly. The R’s lower abdominal pain was also from the visceral strain from this incident. The R inferior pubis also contributed to the adductor and rectus femorus strain. The R kidney ptosis works with the psoas as it is positioned on the anterior aspect of the psoas. There are several nerves that travel through the psoas that go to the genitals, medial knee, lateral thigh, etc. Kidney ptosis and dysfunction potentially irritate these nerves, and there can be implications more distally. This case highlights the importance of carefully going through the history and looking for trauma or potential physical strains that can give clues to the dysfunction’s genesis.

This case is a good learning opportunity for all. Remember that we ALL learn from our patients if we listen and look carefully. History taking is SO important. I have been doing this for nearly 39 years, and I learn every day. Humility is important in this work because if you aren’t operating in a place of confident humility, you bypass the breadcrumbs that give you clues to help your patients.