Chronic pelvic pain (CPP) is a widespread phenomenon experienced by an estimated 4-27% of women in the United States. CPP is also responsible for numerous surgical procedures, which oftentimes lead to disability and depression. Untreated, CPP can be debilitating and significantly impair one’s quality of life. Most providers who practice pelvic medicine are versed in treating the organ-based pain specific to their subspecialty. However, outside of those providers, there is a huge learning gap in the set of diagnostic and interventional skills that are needed to accurately diagnose and treat neurologically mediated pain. A physical examination can generally reproduce the patient’s pain with hip end-range motion. If the findings are positive, it is safe to assume that the etiology is from the hip region.

A video screening exam was created for non-orthopedic surgeons to recognize the inter-relationships between the hip and the pelvis in order to screen for hip-spine-pelvis and core pathologies of chronic pain. This exam is aimed at examining the anatomy and biomechanics of the hip-spine-pelvis through maneuvers demonstrable through physical examination. The maneuvers are conducted in the standing, sitting, supine and lateral positions, with each maneuver in each position aimed at revealing the pathology causing the pain.

Primary intra-pelvic pathology such as neoplasias, and endometriomas lay directly on the piriformis or surrounding nerve roots and vascular structures causing piriformis syndrome and unilateral pain. Extra-pelvic pathology such as abnormal hip mechanics, piriformis irritation causing piriformis syndrome or obturator nerve compression can cause a secondary generated pelvic pathology that can cascade inwardly.
The standing exam begins with a gait assessment with both normal and long stride. Reproductions of pelvic pain with this can indicate pathologies such as torsional femoral anomaly, posterior CAM profunda wall abutment, and ischiofemoral impingement. The patient can then be asked to extend their arms and rotate their torso to both sides. Reproduction of pain in this position indicates further spinal evaluation.

The seated exam begins with a straight leg raise. This can test for radicular neurological symptoms. A sensory examination of the legs can be done to assess proper sensation in the L4/L5/S1 dermatomes. Deep tendon reflexes should also be assessed in this position. Next, the lower extremity in the seated position (hip at 90 degree flexion, knee at 90 degrees) is internally and externally rotated to assess kinematics and torsional femoral alignment of the hip. Decreased femoral torsion is indicated by increased external rotation and decreased internal rotation. Increased femoral torsion is indicated by increased internal rotation and decreased external rotation. A seated slump test is performed to reveal spinal contributions. 

Flexion, adduction, and internal rotation of the leg in the supine position causing pelvic pain can indicate a premature osseous abutment (CAM) deformity. A supine flexion, adduction, internal rotation test can be used to determine internal hip impingement. The FABERS (flexion, abduction, and external rotation) can be used to screen the ligament of teres function, femoral anteversion, SI joint or some pubofemoral ligament contribution.

Passive hip extension causing pain may indicate premature osseous abutment. Improper hip mechanics may cause extension to be limited, which can pull on the pelvis and recreate the pain.

A brief hip exam focused on pain at end-range motion can identify patients with orthopedic contributors to pelvic pain. Correct diagnosis allows for physical therapy interventions including stabilization and accommodation and, if necessary, orthopedic consultation, targeting the etiology. The patient can learn to adapt to new ways of positioning their body in movement to avoid exacerbation. Patient education on hip kinematics can empower them to avoid positions that create secondarily generated problems of the subsequent layer.

Continence 12S (2024) 101640
DOI: 10.1016/j.cont.2024.101640