Resident physician UNC Health chapel hill, North Carolina, United States
Case Diagnosis: Left pectineus and adductor longus tendinopathy in a 39-year-old female with endometriosis, identified using diagnostic ultrasound in tandem with physical examination.
Case Description: A 39 year old female patient, with a history of endometriosis and persistent pelvic pain, despite laparoscopic excision for endometriosis and various physical therapies including trigger point injections, dry needling, cupping, home exercises, and hip strengthening PT. A detailed physical examination pinpointed tenderness at the left inguinal crease and over the left pubic symphysis. Subsequent diagnostic ultrasound confirmed tendinopathy in the left pectineus and adductor longus muscles. Targeted Botox injections into these areas resulted in a substantial reduction of her chronic pain.
Discussions: While endometriosis is a frequent source of pelvic pain, it often coexists with overlooked comorbid conditions. Several reports suggest musculoskeletal dysfunction, including muscle groups beyond the pelvic floor like the adductors, as potential culprits for chronic pelvic pain. This patient's persistent pain even after excision surgery necessitated a broader differential diagnosis. A focused physical exam coupled with diagnostic ultrasound localized the pain source, confirmed later as a tendinopathy through US-guided lidocaine blocks. Botox was selected for its superior longevity and efficacy over traditional steroids in chronic pain scenarios, including tendinopathies. This approach led to an almost total alleviation of pain in the subsequent 4 months after treatment.
Conclusions: A focused physical exam and diagnostic ultrasound create a versatile and inexpensive combination accessible to most patients and practice settings while also applicable to a vast selection of pathophysiologies. This case also highlights the uncommon therapeutic approach of using Botox for tendinopathies, and how unconventional treatments can also lead to significant pain relief when grounded in accurate diagnostic methods.
