End-Stage Disorders of the Hip Presenting With Posterior Pelvic Girdle and Lateral Thigh Pain: Two Case Reports

Abstract

CASE 1 A 44-year-old white man with an 8-year history of low back, posterior pelvic girdle, and posterior thigh pain presented to a physiatrist with the recent progression of pain to bilateral posterior thighs. Eight years before his presentation to the physiatrist, his medical history included a diskectomy of an L5–S1 disk protrusion and a short period of physical therapy with symptom improvement. He continued to have some pain into the left posterior pelvic girdle and posterior thigh to the knee but without associated paresthesias. During the next 7 years his pain and functional decline continued. During that time he was seen by several neurosurgeons, chiropractors, and a neurologist. For pain modification he was prescribed multiple anti-inflammatory medications, antidepressants, and antiseizure medications. The anti-inflammatories did give him some relief. Three additional magnetic resonance imaging (MRI) scans of his lumbar spine were performed during the intervening years that showed moderate-to-severe degenerative changes of the intervertebral disks at L4 –L5 and L5–S1 without significant central or neuroforaminal narrowing. He was offered spinal fusion by one surgeon, but the patient declined. He went for a second surgical opinion and was prescribed lumbar epidural injections. The lumbar epidural injections were performed but failed to relieve his symptoms and caused severe discomfort. Finally, 8 years after his initial presentation he was seen by a neurologist who referred him to physical therapy. The physical examination performed by the physical therapist by using the movement system impairment syndrome [1] method of examination is summarized in Table 1. The physical therapist then referred the patient to a multidisciplinary hip clinic at the same university. At the time the patient was seen in the multidisciplinary hip clinic by the physiatry service, he reported being unable to walk greater than 100 yards without having to stop. He was having difficulty performing his job responsibilities as an environmental engineer, which often required him to walk over uneven terrain. He had stopped many activities that he previously enjoyed, including riding horses and motorcycles. The physical examination revealed an alert pleasant man who indicated his area of maximal pain to be across the posterior pelvic girdle. He ambulated with a wide based gait and had a positive Trendelenburg on the left. He was unable to do a single-leg stance on either side without pain and loss of balance. Strength testing of bilateral lower extremities for hip flexion, knee extension, ankle dorsiflexion, and extension of the great toe was 5/5. Hip abduction was 3/5. Hip extension was 2/5. Reflexes were 1 at the patella and hamstring. Hip range of motion (ROM) is listed in Table 1. Passive ROM reproduced his posterior pelvic girdle pain and lateral thigh pain bilaterally. His pain was also reproduced with log roll and resisted straight leg raise. He had some groin pain bilaterally with end range hip flexion but the patient stated that this was not the pain he experienced outside of the