Case Study 23 –..

A 63-yr-old female presents with a 2-week history of right groin discomfort. She was initially evaluated by a physician and referred for radiographs of the hip, femur, and lumbar spine. These radiographic studies demonstrated osteophytes of the right acetabulum, facet arthritis at the L3-4 and L5-S1 levels, and disk space narrowing at L5-S1, but vertebral alignment was noted to be satisfactory. The patient was then referred for an MRI scan of the right hip to eliminate avascular necrosis (AVN), as her initial history revealed a 1-year history of steroid use for underlying rheumatoid arthritis. The MRI scan of the right hip was interpreted by the radiologist as being consistent with early AVN. The patient was made non-weight-bearing, a steroid taper was started, and she was referred for orthopedic consultation. The consulting orthopedic surgeon was not convinced of AVN based on the MRI scan, but in light of the patient's history of steroid use, he recommended a course of physical therapy to address the hip pain.

Given this brief history, do you have a working hypothesis?

This is a complicated case, although it is not unusual to be presented with a patient who has a number of issues occurring simultaneously when working in OP orthopedics. The difficulty with such patients is being able to narrow down the important findings from the less important findings in the history. This patient’s history is likely to produce a number of working hypotheses. The imaging studies indicate both a right hip and a lumbar spine involvement, but the orthopedist seems to feel that the hip may not be the most significant cause for the patient’s symptoms. So the question is whether both the hip and knee are involved or whether one or the other is involved.

Groin pain can result from both local and referred sources.

The physical examination revealed the following findings:

• The patient's gait had a normal heel-to-toe pattern, with an increase in right hip flexion and knee extension.
• Lumbar range of motion was significantly limited in extension, side-bending, and rotation secondary to pain. Flexion was pain-free, without reversal of lordosis.
• Strength testing revealed: 4/5 for hip flexors and adductors on the right and 5/5 for all other muscle groups, including the left side.
• Sensation was intact for light touch and pinprick.
• Straight leg raise was negative, whereas reverse straight leg raise on the right side reproduced the patient’s symptoms into the hip and radiated pain down the anterior thigh.
• Deep tendon reflexes were 2/4 throughout the bilateral upper and lower limbs.
• Palpation revealed moderate tightness diffusely in the paraspinals.
• Motor nerve conduction studies performed on the R tibial and R peroneal nerves were found to be of normal latency, conduction velocity, and amplitude. Sensory nerve studies were performed on the R ...

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