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A 42-year-old male runner presented with an insidious onset of left buttock/hip pain and some left thigh pain that had been present for approximately 4 weeks. The patient's past medical and surgical history was unremarkable and the patient reported no problems with night pain unrelated to movement, bowel and bladder function, and no unexplained weight loss. The patient also reported no instances of groin pain but that bending forward at the waist caused an increase in his pain. The patient had no recent imaging studies.

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Is there anything in this history that should cause concern?

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The history is relatively unremarkable except for the insidious onset.

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What would be a reasonable working hypothesis at this stage?

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This has the hallmarks of a running injury – a possible gluteal or hamstring injury.

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Does the patient warrant a lower quarter scanning examination?

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This patient would appear to not warrant a lower quarter screening examination.

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The physical examination revealed the following findings:

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  • Gait analysis revealed a slight left-sided antalgic gait.
  • Tenderness was elicited with deep muscle palpation over the greater trochanter and the gluteus medius muscle on the left side.
  • Lumbar spine active range of motion was limited by pain at the end range for flexion, but was otherwise normal for all of the other directions.
  • Left hip active range of motion was flexion (50° with pain), adduction (20° without pain), abduction (5° with pain) and internal rotation was limited by 50% with pain. All other hip motions when normal as compared to the right hip. PROM of the left hip provided similar results. The loss of hip flexion remained the same whether hip flexion was tested with the knee extended (SLR) or with the knee flexed.
  • All the neurologic tests were negative.

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Which of all the findings in the physical exam should cause the most concern?

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The limited hip flexion range of motion.

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Do you think this patient would benefit from physical therapy?

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The most obvious diagnosis for this patient would be a soft tissue injury but because the neurologic tests, which include strength testing, were negative in the presence of pain with the active range of motion tests, the clinician should begin considering a non-musculoskeletal diagnosis. The limitation of hip flexion that remained unchanged with or without hip flexion is a classic ‘sign of the buttock’. Based on this finding, the patient was referred back to his primary care physician with a recommendation that imaging studies be performed. Pelvis and lumbar spine radiographs revealed a lytic lesion in the left ilium. The subsequent CT scan revealed findings ...

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