Complicated case

[100YardDash]

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Just wanted to discuss this complicated case and get schooled by the wise...

20 year old female complaining of hip pain for 1 year. She states that pain started when she was training for a marathon running 13+ miles/day. She says that pain radiates to the groin, is 7-8/10 pain scale, constant, somewhat relieved by standing, exacerbated by sitting. She denies any changes in her menstral cycle. Patient denies any numbness or tingling in the leg, denies any pain radiation down the leg, denies low back pain. She states that she saw multiple doctors who kept referring her until she was consulted by an orthopedic surgeon. She was given xray which was negative. Then MRI was negative. Then MR anthrogram showed POSSIBLE labral tear.

I'm just a student so I don't know much but my differential so far from least to most likely is gynecological, possible hairline fracture not healed, tear with calcification that is causing the pain. Any ideas on other differentials or tests that can be ordered?

 

[100YardDash]

Forgot to add that she had steroid injection with no relief. Sorry, the attending did the physical while I was in another room with a different pt. I came in mid physical and from what I remember the pain was elicited upon hip flex and palpation to the groin.

 

[cbest]

Can you specify location of the hip pain? Anterior with radiation to groin or lateral or post to buttock? Any provocative physical exam maneuvers reproduce her pain? How's her hip strength and flexibility? Any treatment pursued at this point?

Sorry 100 - you must have added as I was typing up my reply

 

[100YardDash]

Can you specify location of the hip pain? Anterior with radiation to groin or lateral or post to buttock? Any provocative physical exam maneuvers reproduce her pain? How's her hip strength and flexibility? Any treatment pursued at this point?

Sorry 100 - you must have added as I was typing up my reply

Sure, the pain is anterior w/ radiation to the groin. From what I remember hip flexion and internal rotation with hip abduction caused pain. Hip flexor was 4/5 but caused her severe pain. She stated that when the pain started 1 yr ago she continued to run, up until 6 weeks ago until it got so unbearable that she quit exercising. She has done a total if 12 weeks PT with no relief. Sorry, I know I'm not giving you much info to work with.

 

[100YardDash]

Let me ask a stupid question.... What about a hernia?

 

[DOctorJay]

Sounds like femoroacetabular impingement

 

[PMR2008]

Sounds like femoroacetabular impingement

Agree

 

[bedrock]

Forgot to add that she had steroid injection with no relief. Sorry, the attending did the physical while I was in another room with a different pt. I came in mid physical and from what I remember the pain was elicited upon hip flex and palpation to the groin.

Don't worry about whether she had relief from the steroid phase of a hip injection. The question is whether she had significant relief during the local phase (first hour). If she doesn't remember, just repeat the hip injection with lido only to confirm the hip joint is the pain generator. Once that's done you can work on your differential pain coming from the hip joint.

And yeah, femoroacetabular impingement is very high on her differential, but a very small labral tear can be quite irritating if you run 50 miles/week.

 

[DOctorJay]

bedrock's comment is an important point for you to learn early in your career. Patients often return saying "that injection didn't help at all". when you probe further and ask if it did anything for the first couple hours they'll typically say "well, yeah I had no pain at all for a couple hours but it didn't last so it didn't work".

it's important to review with patients that the purpose of the injection is both diagnostic and hopefully therapeutic. asking them to log their pain scores for a few hours after the injection and bring the information back on follow up which can be helpful in sorting things out.

take a closer look at that xray if you can looking for FAI. also find out if the injection was truly an intraarticular hip injection (was guidance used, ultrasound/fluoro) or was it a troch bursa injection?

 

[PMR 4 MSK]

Any chance you can post the x-ray? We can usually see FAI signs on x-ray.

 

[100YardDash]

Thanks for the responses. I don't know if I can post the X-rays since this is at an outpt clinic and the xrays were done by her PCP. I'll write down the radiology report as soon as I go tomorrow to the clinic.

 

[DrFreshair]

Thanks for shanring and the input from all doctors. It's very informative. 🙂Would like to see more case discussions here.

 

[RUOkie]

Thanks for shanring and the input from all doctors. It's very informative. 🙂Would like to see more case discussions here.

I stopped posting cases when Fozzy was the only resident/med student responding. If you guys want them, I see tons of pathology.

 

[cbest]

Ruokie,

I'm only an intern but I'd happily take breaks from all this Internal Medicine to look up various topics as they relate to MSK cases and other PM&R topics. Still find EDx stuff to be difficult to understand but I'll give it a go! Thanks in advance!

 

[fozzy40]

I stopped posting cases when Fozzy was the only resident/med student responding. If you guys want them, I see tons of pathology.

😍

 

[Sanchik]

I'd like some case discussions too.

 

[DOctorJay]

RUOkie, i'd like to see some more of your cases as well but post them here instead of the other thread for greater impact factor.

 

[RUOkie]

OK guys/gals, I'll find some good ones. Give me a few days.

/threadjack