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Lumbopelvic Pain and Dyssynergic Defecation - Body Builder: 1125May 30 8:20 AM - 8:40 AM

Dugan, Sheila FACSM; Bernal, Rose

Medicine & Science in Sports & Exercise: May 2008 - Volume 40 - Issue 5 - p S138
doi: 10.1249/01.mss.0000322060.67909.44
E-18 Clinical Case Slide - General Medicine: MAY 30, 2008 8:00 AM - 10:00 AM ROOM: 122

Rush University Medical, Center, Chicago, IL.

(No relationships reported)

HISTORY: A 29 year old female competitive body builder presented with lumbopelvic pain and incomplete evacuation of stools, starting 2 years ago while she performed deadlifts and squats with increased resistance. Patient reports occasional stool impaction. Menarche was at age 15 with normal menstrual periods until 2 years ago when she became amenorrheic. She denied urinary incontinence or dyspareunia. She was a HS gymnast and presently engages in body building and running. She has seen a gynecologist and a gastroenterologist, and has tried different laxatives. She was referred to a pelvic floor physical therapist who noted hypertonic pelvic floor.

PHYSICAL EXAMINATION: Patient is well-developed and well-nourished. Ht 5′ 3″. Wt 116 lbs. BMI 20.5. There was full active range of motion of lumbar spine and hips. Bilateral hip flexors were tight with positive Ely maneuver. Scour test and slump sit were negative. There was minimal pain with palpation of the right gluteus medius, piriformis and proximal iliotibial band. Neurological exam was normal. Perineal exam revealed symmetric labia with no masses or scars and intact sensation. Palpation of the introitus and urogenital diaphragm was non-tender. Deep pelvic floor was minimally tender. Palpation through the rectum revealed moderate tenderness of the left greater than right levator ani muscle. No significant rectocele appreciated internally with Valsalva maneuver. There were trigger points noted in the left greater than right levator ani. Pelvic floor muscle strength was good with intact symmetry and good endurance. The coccyx is midline. No pain with pressure over the sacrococcygeus joint.

DIFFERENTIAL DIAGNOSIS:

  1. Pelvic floor dyssynergia
  2. Anismus
  3. Functional constipation
  4. Vaginal wall tear
  5. Gluteus medius strain
  6. Pelvic stress fracture

TEST AND RESULTS:

  • Plain x-rays - no bowel obstruction
  • Colonoscopy - normal

FINAL WORKING DIAGNOSIS:

  1. Pelvic floor dyssynergia
  2. Right gluteus medius strain

TREATMENT AND OUTCOMES:

  1. Intravaginal and intrarectal compound of lidocaine and nifedipine applied twice a day
  2. Pelvic floor physical therapy with focus on rectal soft tissue treatment, myofascial release, neuromuscular reeducation and biofeedback
  3. Dietary modification
  4. Modification of voiding habits and lifting habits
  5. Trigger point injection
©2008The American College of Sports Medicine