Case
- 67 y.o., pensioner
- Difficulty walking, causing pain in the lower back, R buttock & R groin
- Slight limp when the pain gets worse
- In the last month, has only been playing 9 instead of 18 holes
- Difficulty keeping w/ his friends & doesn't enjoy golf as much |
- Limbo-sacral area (R>L), R buttock R groin
- Lately been feeling pain in R knee
- Onset gradual over last 3 months
- Pain & stiffness
- 5/10
- Getting worse
- No clear pattern; depends on activity |
AF: pain & stiffness usually start after walking 2-3 holes, but gradually increase as he plays more holes
- RF: sitting after a round of golf diminishes the pain after a while
- AA: Lately sometimes struggles to finish 9 holes |
Extras
- Stopped smoking at 40 y.o. (previously 10-20 cigarettes / day for 20 yrs)
- 2 pints of beer / night
- Father: diagnosed w/ Parkinson's disease @ 74 y.o.
- Mother: diagnosed w/ RA & had knee replacement @ 84 y.o. |
Physical Examination Findingscal
Gait
- Slight limp on R |
ROM
- AROM & PROM Lx: slightly reduced flexion & rotation (R) w/ some discomfort in his lower back & R buttock @ end range
- PROM hips: internal & external rotation of R hip reduced by approx 25% compared to L, w/ pain felt in the R groin; hip flexion & extension slightly limited & painful on R |
R glut palpations: tender locally & reproduces some pain into R leg towards his knee |
Iliopsoas: tight bilaterally (R>L) |
SLR
- 65° bilaterally w/ some pulling at hamstrings |
Discussion
Working diagnosis
- Hip OA
- Associated w/ mechanical LBP & myofascial pain syndrome (compensation for the hip) |
- Sx aggravated w/ activity & relieved w/ rest
- Triage: mechanical / degenerative |
Hip joint
- Doesn't normally refer pain to low back ∴ unlikely cause of the back pain
- Can refer to the knee (& vice-versa) ∴ could be the cause of leg pain towards the knee
→ But pain was reproduced by palpation of gluteal muscles suggesting active trigger points |
Differentials
- Vascular claudication: pain in thigh, calf, or buttocks that happens when walking
- Inguinal hernia: most common hernia; swelling/lump in groin or enlarged scrotum
- Hip dysplasia: acetabulum is too shallow to support femoral head; females more affected
- Femoroacetabular impingement (FAI): extra bone growth of joint causing rubbing against each other
- Labral tears the hip: injury to tissue that holds hip joint together; pain, reduced ROM, sensation of hip locking-up |
Previous Hx
- LBP & R leg pain below the knee, worse eon sitting: suggest prior Hx of radicular pain or radiculopathy
→ Current presentation doesn't have the same pattern
- Radiculopathy due to disc herniation less likely: pain is relieved by sitting, no SMR findings & pain doesn't follow a dermatomal pattern |
What other exams could have been conducted?
- Respiratory exam: former heavy smoker for 20 yrs
- Knee examination: referred hip pain to knee, & vice-versa |
Learning Outcomes
Differentials for LBP w/ buttock pain
- Muscle strain: results from lifting heavy objects, poor posture, or sudden movements
- Sciatica: can cause sharp shooting pain from lower back through buttocks & down the legs
- Herniated disc: can cause localised pain as well as radiating pain into buttocks & legs
- Spinal stenosis: narrowing of spinal canal; can cause LBP w/ buttock & leg pain that worsens w/ walking or prolonged sitting
- SIJ dysfunction: (or inflammation) can cause pain in lower back & buttocks
- Piriformis syndrome: tight or spasms, it can compress sciatica nerve; can cause buttock pain that may radiate down the leg
- Spondylolisthesis: forward displacement of one vertebra over another; can cause lower back pain as well as buttock pain & may be accompanied by leg Sx if nerve roots are affected
- Inflammaotry conditions: e.g. ankylosing spondylitis (type of arthritis affecting spine); can cause chronic LBP & buttock pain (particularly in young adults)
- Infection: e.g. osteomyelitis (bone infection) or disci tis (disc infection); can cause LBP w/ other Sx like fever & swelling |
Pathophysiology of OA
⏺ Mechanical stress:
- Repetitive mechanical stress causing micro trauma to cartilage & breakdown
- Abnormal joint mechanics, as above
⏺ Inflammation:
- Inflammatory cytokines can cause cartilage breakdown & joint inflammation
⏺ Age:
- Ability for cartilage to repair itself decreases w/ age
- More susceptible to damage & breakdown
⏺ Genetic:
- Predispositions of OA
- Gene abnormalities involved in cartilage metabolism or inflammation
⏺ Metabolic:
- Obesity
- Insulin resistance (diabetes) increases risk of OA (through release of inflammatory mediators & oxidative stress) |
Understand all about OA (cartilage breakdown):
⏺ Presentations:
- Hip pain: deep achefekt in groin or buttock area; worse when weight-bearing; improve w/ rest
- Hip stiffness: especially in the morning or after prolonged inactivity
- Decreased ROM
- Cracking or popping sounds
- Weakness of hip muscles: affecting walking, stairs, etc
⏺ Diagnosis:
- (w/o imaging): +45 y.o AND have activity-related pain AND morning stiffness for 30+ min
⏺ Management:
- Local muscle strengthening, general aerobic fitness
- Doing regular & consistent exercise, though may initially cause pain/discomfort
- Manual therapy alongside therapeutic exercise
- NO acupuncture |
Referral patterns for trigger points in muscles of the buttock
- Gluteus medius: lateral hip, thigh, & buttocks
- Gluteus maximus: posterior thigh & lower leg
- Piriformis: down posterior thigh & into calf
- Quadratus femoris: hip joint, groin, & knee
- Obturator interns: hip joint & groin |
Guidelines for the management of OA, especially hip OA
- Hip is 2nd most common OA location
- Therapeutic exercise & weight management (if appropriate)
- Provide information & support
- Exercise, little & often
- Manual therapy: massage, exercises, ROM & strengthening
- Hydrotherapy is beneficial |
Referral guidelines for imaging in a pt w/ suspected OA
- Don't require imaging for diagnosis of OA: medicalHx & examinations will suffice
- Imaging findings don't always correlate well w/ the pt's Sx (particularly in early stages of OA)
- No gold standard
- Considered if OA severe, underlying condition or for monitoring
- Possible: X-ray, MRI, & ultrasound |
Learning outcomes
Looks like hip OA from Hx and physical examination
- Walking differently causing myofascial problems
- Knee examination SHOULD HAVE been done((nl))- Hip OA management
- imaging not necessary (no imaging for osteoarthritis unless daily activities are affected) |
KNOW REFERRAL PATTERNS FOR MYOFASCIAL TRIGGER POINTS - TRIVAIL AND SIMONS |
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