Strange case

[deleted875186]

Had a strange case the other day, curious what people think.

Patient had an injury, basically walking and got their right foot stuck behind them, they yanked their leg forward and fell, knee first onto their right knee, got up and immediately had pain going down the right leg.

comes in many months later after this injury, nobody can tell them what’s wrong. Pain goes down the posterior buttock And wraps around towards the anterior groin, no clear peripheral nerve or nerve root distribution tnothing below the knee. Parasthesias in the toes. On exam has pain over the right SIJ. SLR negative. Can’t even bend right leg up to do a piriformis stretch because the pain starts to be so painful.

lumbar spine mri completely normal
Pelvis mri normal
EMG normal

Had a piriformis injection, followed by an SIJ injection, no relief.

many ideas?

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[Laryngospasm]

Avascular necrosis of femoral head? Just brainstorming

 

[chudat]

Avascular necrosis of femoral head? Just brainstorming

You should see that on lumbar mri scout images

 

[Laryngospasm]

Doesn’t that depend on when the MRI was done?

 

[deleted875186]

I was thinking referred pain from the hip, but the pelvic mri was normal, I assume they would have seen something in the hip, although I’m not sure about the timing of the scan.

 

[callmeanesthesia]

I’ve seen several patients like this with a similar mechanism of injury (twisting/falling) - severe pain, severe loss of ROM. I posted a thread about it, but that would have probably been a year ago or more. Nothing ever helped - lots of PT, SIJ, lumbar MBB, intraarticular hip, GT bursa. One was WC, 2 Medicaid so there were confounding factors.

 

[Agast]

Could try an ultrasound-guided sciatic nerve block.

 

[callmeanesthesia]

Here is that thread:

https://forums.studentdoctor.net/threads/3-patients-with-severe-hip-area-pain-after-twisting-falling-injury.1391827/

 

[painfree23]

Could try an ultrasound-guided sciatic nerve block.

Really? Where? With what?

 

[painfree23]

Here is that thread:

https://forums.studentdoctor.net/threads/3-patients-with-severe-hip-area-pain-after-twisting-falling-injury.1391827/

Link didn’t work

 

[Agast]

Really? Where? With what?

I did it once for a lady with persistent sciatica type pain after a normal EMG/MRI and trying injections everywhere else I could think of. Yes I did piriformis. Since she was feeling pain in the sciatic distribution I figured it wouldn’t hurt to try. I used the posterior approach. When I injected (dilute bupivicaine and steroid) she felt pressure in the typical area of pain. Got about 60% better. I’m still not certain why she had so much irritation there but she has chronic foot problems too that might be altering her gait.

Sciatic Nerve Block - Landmarks and Nerve Stimulator Technique - NYSORA

Indications for sciatic nerve block include lower-limb surgery, combined with a femoral or psoas compartment block.

www.nysora.com

 

[studentologist]

Myofascial pain from iliopsoas?

 

[MD87]

Is there any legal stuff (lawsuit) going on related to the injury?

 

[Taus]

Is there any legal stuff (lawsuit) going on related to the injury?

Bingo. There’s your best explanation.

 

[deleted875186]

Is there any legal stuff (lawsuit) going on related to the injury?

Out on disability. No legal stuff as far as I know. Guy does seem actually motivated to try and get better.

anyone think scanning the thoracic spine for some sort of high disk problem is worth it?

 

[callmeanesthesia]

Out on disability. No legal stuff as far as I know. Guy does seem actually motivated to try and get better.

anyone think scanning the thoracic spine for some sort of high disk problem is worth it?

Nah, if it was hitting that area it would be at highest T11-12, and you’d probably see it on the lumbar MRI.
I had 2 more of these this week, both WC, falling/twisting injuries with severe hip area pain and decreased ROM. One had normal MRI spine so I ordered the hip. Other had no MRIs so I’m keeping fingers crossed for a disc herniation. Will update with results when they are back.

 

[lobelsteve]

Out on disability. No legal stuff as far as I know. Guy does seem actually motivated to try and get better.

anyone think scanning the thoracic spine for some sort of high disk problem is worth it?

Nope. Why is he on disability?


lumbar spine mri completely normal
Pelvis mri normal
EMG normal


MOA suggest hamstring or adductor injury. But it is not. basing that on MRI above.

It is a no shots, no meds, cuz no dx kind of case.

 

[Ligament]

Had a strange case the other day, curious what people think.

Patient had an injury, basically walking and got their right foot stuck behind them, they yanked their leg forward and fell, knee first onto their right knee, got up and immediately had pain going down the right leg.

comes in many months later after this injury, nobody can tell them what’s wrong. Pain goes down the posterior buttock And wraps around towards the anterior groin, no clear peripheral nerve or nerve root distribution tnothing below the knee. Parasthesias in the toes. On exam has pain over the right SIJ. SLR negative. Can’t even bend right leg up to do a piriformis stretch because the pain starts to be so painful.

lumbar spine mri completely normal
Pelvis mri normal
EMG normal

Had a piriformis injection, followed by an SIJ injection, no relief.

many ideas?

pudendal

 

[Taus]

While still most likely nothing wrong and medicolegal BS.... I’d send to either a good DC, DO or PT for manual therapy/manipulation. Preferably DO for OMT but they’re hard to find. I would have nothing else to offer. No role for procedures.

 

[Ferrismonk]

First thought would be innominate shear, maybe send to DO for OMT.

Second thought was maybe nondisplaced mild sacral fracture? Depending on when imaging was done (immediately after injury vs few day later) may have missed it, especially if they were looking at soft tissue vs bones.

 

[Ferrismonk]

Maybe try sacral TFESI if those don't work.

 

[painfree23]

When all of you say “try this, try that “ etc. do you consider the amount of steroid they are getting over the course of a few months with these injections? Or are you doing these with local only

 

[Ducttape]

Nope. Why is he on disability?


lumbar spine mri completely normal
Pelvis mri normal
EMG normal


MOA suggest hamstring or adductor injury. But it is not. basing that on MRI above.

It is a no shots, no meds, cuz no dx kind of case.

"I know a guy" that will stim next...

 

[deleted875186]

First thought would be innominate shear, maybe send to DO for OMT.

Second thought was maybe nondisplaced mild sacral fracture? Depending on when imaging was done (immediately after injury vs few day later) may have missed it, especially if they were looking at soft tissue vs bones.

What is innoninate shear?

 

[lobelsteve]

What is innoninate shear?

Voldemort syndrome

 

[Ferrismonk]

What is innoninate shear?

Basically the biomechanics/movement of the pelvis is jacked up due to the fall. It's an osteopathic diagnosis based on movement and position of the pelvic bones. If that's the diagnosis, maybe a DO that specializes in OMM/OMT can fix it with manipulation.

 

[10KHertz]

Reread the lumbar MRI yourself. Post axial/sag images. Look for a stealth subligamentous disc or HIZ. Symptoms would resolve in 4-8 weeks .how long has it been ?