Introduction

Low back pain is not a disease, it is a symptom. It can be defined as pain between the bottom ribs and the buttock creases(Dionne et al., 2008). Chronic low back pain patients are always asking about the cause of their pain(McPhillips-Tangum et al., 1998; Cherkin et al., 1998). A lot of people can experience it during their life. For instance, 6.3%–14.4% of people will experience their first episode of low back pain in any given year, while estimates for the incidence of any episode in any given year can reach 36%. In the general population, low back pain is thought to affect 23.2% of people within a month (Hoy et al., 2010). Its incidence also increases with age. By the age of 80, estimates of prevalence are as high as 40% in males and 35% in females (Hoy et al., 2014). True lumbar radiculopathy affects between 3% to 5% of the general population(Tarulli and Raynor, 2007). Although a herniated disc or spinal stenosis are the two most frequent causes of these symptoms, there are numerous additional potential explanations that resemble lumbar radiculopathy. It can be difficult to pinpoint a major pathology as the origin of a person’s back pain symptoms. Pathologies affecting the organs and tissues of the abdominal and pelvic cavities account for a sizable yet insignificant part of cases. One common condition is artery stenosis, which affects the aortic, iliac, femoral, or tibial vessels and may result in low back discomfort or altered sensations in the legs (Laslett M., 2000). It is advised to use red flags since they have historically been utilized to aid clinicians in spotting significant spinal abnormalities. However, recommendations vary regarding which warning signs should be considered when screening patients who are seeking treatment for musculoskeletal problems. Groin pain is a result of musculoskeletal and non-musculoskeletal problems. Groin area is considered a common area of referred pain, as it may arise from somatic pain generators and neurogenic problems, and may be presented as a sign of claudication. Groin claudication symptoms are clinically presented as temporary ischemic pain resulting (in mild cases, relieved by rest) from muscular activity demands exceeding the ability of arterial flow to oxygenate the area (Mahé et al., 2015). When the iliac artery stenosis is severe, the groin pain may even be felt while at rest. A patient with low back pain along with groin pain may be misdiagnosed since not all occurrences of iliac artery stenosis result in low back pain or groin discomfort, and the severity of symptoms might vary depending on the degree of artery constriction. To decide whether any action is necessary, clinicians must consider the context in which red flags exist and conduct a complete examination with a clinical evaluation of the relevance of the information received (Finucane et al., 2020). The first and most crucial measures in separating these illnesses from one another are diligent history-taking and a thorough physical examination(Grimm et al., 2015).

Case presentation

The case was 37-years-old female was referred for conservative treatment by orthopedic doctor she had a chronic low back pain. She had been suffering from low back pain for 5 years. She described the pain in the central lumbar area as it intermittent pain. 5 days before visiting her primary physician she felt intermittent right knee pain more than left, also she had an intermittent right groin pain. She was given a pain chart, in which she could draw the painful area by using specific color that indicated her pain as illustrated in figure below.

She had a history of physical therapy sessions before but without any effect. Her pain progressive and her condition regress over time. The chief complains of her the right groin pain she could described it as 8 out of 10 on numerical analogue scale (0 = no pain, 10 = the worst pain someone can imagine) after walking for long distance or doing her home duties. At the time of maxima pain. She experienced vague aching pain at right knee more than her left knee she added she had a throbbing pain at right groin area, she said her center low back pain minimally or overshadowed noticed while felling the pain in her both knee and groin area. The assessment of her function by verbal analogue scale (0 = no functional limitation, 10 = fully disabled), in the present episode the most significant disability was with walking and doing home duties, the verbal analogue scale rate her functional disability with walking was 9/10. Only walking and home duties produced the symptoms of pain in her right groin area and her knees pain but right knee more painful, the symptoms relief by stop walking. She had no problem with gait until the appeared of her knee and right groin pain. When she felt pain, she was forced to stop walking immediately until the pain was relieved. The patient’s general health was good, and she said no change in her body weight within the past 12 months, she had a good family history without any chronic diseases, about past surgery she had a previous history of complicated cesarean section. She was talking non-steroidal anti-inflammatory (NSAIDs) and muscle relaxant drugs on recommendation from the orthopedist. Medication had no effect on the symptoms, so she stopped taking them, but. No chronic medication.

Clinical Findings

After getting written consent from the patient, the therapist started a physical therapy examination. The therapist observed that the patient had a slouched posture. During range of motion assessment from standing, He found minimal limitation in extension and pain in the central lumbar area. A mechanical evaluation was done based on McKenzie’s style of assessment. This style consisted of the specific sagittal plane, frontal plane, and combined movements, which are done singularly and then in repetitions up to 30 times, and before each tested motion, a therapist will note the changes in the symptomatic presentation (pain location and intensity) and the mechanical presentation (effect of repeated motions on a range of motion) (McKenzie, 2003). Based on force progressions and force alternatives, the repeated movement assessment did not indicate centralization, peripheralization, or abolition of symptoms and did not indicate any significant result (McKenzie, 2003). A spring test in the lumbar area does not produce familiar pain (Schneider et al., 2008). Seven Sacroiliac joint provocation tests (distraction, compression, thigh thrust-right and left, Gaenslen’s test-right and left, sacral thrust) (Laslett et al., 2005) failed to provoke familiar groin pain presentation. The hip joint examination did not indicate any limitations or provoke familiar patient pain. The patient does not meet any of Laslett and his colleague’s (Laslett, Aprill and McDonald, 2006) criteria for facetogenic back pain, which consist of specific variables (absence of centralization, positive extension-rotation test, three or more of the following: age greater than 5o years old, symptoms best when walking, symptoms best when sitting, onset of pain is paraspinal). The therapist performed the Straight leg raising test and the SLUMP test, which did not cause pain familiar to the patient(Berthelot et al., 2021; Nee, Coppieters and Boyd, 2022). The bedside neurological examination consisted of sensory examination (pain prick, cotton wool tests), myotomal, and lower limb reflexes (Sim et al., 2019; ERDİM, 2022). Mechanosensitivity (tension aspect of mechanosensitivity, which consisted of SLR, Femoral, and SLUMP test assessments) does not provoke familiar pain that were symmetrical (Castelli, Desai and Cantone, 2020; Lehmann et al., 2020). Also, pressure mechanosensitivity in sort of manual palpation of the femoral nerve at the proximal thigh, lateral to the femoral artery, inferior to an inguinal ligament) does not provoke any components of the patient’s groin pain. Coughing, sneezing, or straining did not reproduce symptoms, and bladder function was normal. Based on the previous findings, the therapist concluded that the patient does not fit any musculoskeletal classification for low back pain and took a different approach to the examination. The therapist generates a new hypothesis and assumes that the cause of pain is related to the vascular system. So, the therapist assessed the pulses at the popliteal and dorsalis pedis arteries and found asymmetry between the right and left sides that pushed the therapist to refer the patient to a vascular surgeon. The patient ordered artery ultrasonography (Doppler), which the patient obtained that week. Based on the ultrasound results illustrated in figure below the patient has Patent both deep and superficial venous system with no evidence of venous thrombosis.

Parner refluxing in deep veins from common femoral vein (CFV) and downward patent comitant saphenopopliteal junction (SPJ) and competent great saphenous vein (GSV) and short saphenous vein (SSV) . Finally, the surgeon diagnosed the patient with iliac artery stenosis.

Discussion

This case study highlights the value of doing careful differential diagnosis when treating patients with chronic low back and groin pain in physical therapy practice. This case is a rare example of someone who first had symptoms that were maybe connected to a musculoskeletal problem but was finally found to have an unrelated ailment called internal iliac artery stenosis. It illustrates an unusual vascular source of severe groin pain that develop after walking and is accompanied by minor knee discomfort without the typical vascular symptoms & by examination it’s not related to lumbar spine. There are numerous conditions that might result in groin pain. It might be challenging to determine the origin of groin pain, even after a comprehensive physical examination and history-taking. Even for experts, identifying claudication with neurogenic and vascular origin has always been difficult for medical professionals (Haig et al., 2013; Jeon, Kim and Jung, 2014). A musculoskeletal issue was thought to be the underlying cause due to the nature of the symptoms and the lack of warning signs, such as acute trauma or systemic sickness. But despite a first round of therapy, the patient’s symptoms did not get better as anticipated. The physical therapist looked more closely at the process of differential diagnosis as a result of this lack of improvement. Only 5% of doctors are reportedly screening patients for red flags (Brown et al., 2004). Physical therapists must therefore be able to recognize the warning signs and symptoms of vascular issues that can resemble musculoskeletal presentations. The therapist will rule out frequent causes of persistent low back and groin pain, such as disc herniation and nerve root compression, lumbar spine stenosis, facet joint pain, sacroiliac joint pain, and hip joint referred pain, during the examination. Centralization, peripheralization, and direction preference rule out the mechanical discogenic component because there are no neurological problems. The patient’s complaint is unrelated to any sacroiliac joint or cluster of laslett provocation (Laslett et al., 2003), which rule out the patient’s complaint of sacroiliac joint pain. Upper lumbar spinal stenosis is a rare condition, and since the patient’s symptoms are not alleviated by changing their posture, this condition is also excluded. Hip discomfort is frequently referred to as groin pain. In 55% of individuals with hip pathology, groin pain was noted (Clohisy et al., 2009) According to reports, groin discomfort has a sensitivity and specificity of 84.3% and 70%, respectively, for hip dysfunction. On physical examination, patients suffering from hip problems are seven times more likely to limp and report groin pain, and 14 times more likely to have restricted medial rotation than those with lumbar spine pathology (Brown et al., 2004). Hip joint examination revealed no restrictions and didn’t trigger familiar patient pain; thus, it was ruled out. None of the criteria (Laslett, Aprill and McDonald, 2006) for determining positive response to facet joint block were met, thus the facetogenic source of the problem was also ruled out. Buttock claudication has been documented as a complication of internal iliac artery stenosis for example: two patients with buttock claudication caused by chronic internal iliac artery occlusion were described by (Adlakha, Burket and Cooper, 2009), a rare case suffering from severe groin and buttock pain as a result of chronic occlusion of the internal iliac artery was also described by (Chung et al., 2015). However, the techniques applied in the examination and diagnosis differ in this study. Despite there have been many reported cases of buttock claudication, there have been no reports of groin pain caused by internal iliac artery stenosis thus the importance of this case is to stay vigilant and open-minded throughout the entire diagnostic procedure and to emphasize the need of effective collaboration among healthcare practitioners who can minimize misdiagnoses and offer appropriate care for their patients by looking into a broader range of potential diagnoses and adopting a comprehensive examination. Although this case study illustrates the difficulties associated with misdiagnosing chronic musculoskeletal pain, it is crucial to acknowledge its limitations. First, the therapist who made the repeated movement testing was not McKenzie’s style of mechanical diagnosis and treatment certified. A study conducted by Deutscher et al found that when MDT principles were used in the treatment of low back pain, fewer therapy sessions were necessary when treatment was provided by a clinician with a McKenzie education level of part C or above. This suggests that clinicians who lack training may successfully adopt MDT principles, however, the plan of treatment gets lengthier(Deutscher et al., 2014) second, bicycle test (Dyck and Doyle, 1977) as an exercise test for claudication was not performed due to unavailability. Third, the used procedure for determining discrepancies between the two sides -pulse palpation- has a low sensitivity for diagnosing peripheral artery disease (Collins, Suarez-Almazor and Petersen, 2006). According to Armstrong DW, et al 2010, 1236 patients underwent PAD testing and a complete peripheral vascular physical examination (all dorsalis pedis and posterior tibial pulses palpated and auscultation for a femoral bruit), the sensitivity, specificity, negative predictive value, positive predictive value and accuracy for PAD were 58.2%, 98.3%, 94.9%, 81.1% and 93.8%, respectively (Armstrong, Tobin and Matangi, 2010). declaring that the emphasis in the detection of peripheral artery disease should be shifted towards a comprehensive physical examination rather than pulse palpation only. Fourth, follow-up of the patient’s condition was not possible due to lack of patient adherence and contact methods. Finally, the findings may not be universally applicable due to regional variations in the scope of physical therapy practice.

Conclusion

This case describes an adult woman who was referred for conservative treatment with complains of chronic right-sided groin pain as a main complain, low back pain and a recent intermittent knee pain. she was ultimately diagnosed as having internal iliac artery stenosis masquerading as a musculoskeletal problem. Failure of radiological services to report incidental findings -because a specific pathology is being sought- was misleading to the referring clinician. Although the patient presented musculoskeletal symptoms, evidence of an alternative diagnosis that sufficiently explained the patient’s symptoms encouraged the therapist to consider that line of investigation. This case highlights the crucial role of differential diagnosis in the field of physical therapy and the need to have a broad perspective and consider alternative diagnoses when facing odd symptoms. Prioritizing diligent history-taking and through examination are the first and most important measures in differentiating deferent pathologies from one another as mentioned before.

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