Hip And Buttock Pain - Runner

Abstract

HISTORY: A 50-year-old female presents 10 days pre-marathon with gradually increasing right hip, back and buttock pain for 5-6 weeks, worsening to where she is hardly able to run. She has increased her weekly mileage to 30 miles, with her longest run 22 miles. She has pain in her right anterior and posterior thigh. Her hip pain radiates to her groin and antero-medial thigh. Her posterior thigh pain radiates from the buttock to the knee. She reports her pain is 20% back and 80% leg. She denies weakness, neurologic or systemic symptoms. PHYSICAL EXAMINATION: Gait is antalgic. Hop test positive for hip pain. Hip ROM is slightly restricted on right side. Quadrant test and log rolling of the hip mildly painful. No palpable tenderness. Straight leg raise reproduces her index posterior thigh pain. Power, sensation and reflexes were normal. DIFFERENTIAL DIAGNOSIS: Lumbar radiculopathy Sciatica Femoral stress fracture Hip osteoarthritis TEST AND RESULTS: Radiographs: Standing AP pelvis, supine frog leg: No evidence of femoral stress fracture or periosteal reaction. Slightly increased femoral neck offset consistent with FAI, and early degenerative changes. Standing AP, lateral of LS spine No acute bony abnormality. MRI pelvis and right hip were ordered, and performed 5 days later: No evidence of femoral neck or shaft stress fracture. Reactive edema of the proximal hamstring origin on the ischial tuberosity, consistent with grade 1 strain and partial avulsion. MRI lumbo-sacral-spine: Right-sided lateral L3-4 disc impinging on exiting L3 nerve root. FINAL / WORKING DIAGNOSIS: Hip pain secondary to L3 radiculopathy Posterior thigh pain secondary to hamstring insertional tendonitis TREATMENT AND OUTCOMES: Day-0: Advised to stop all impact activities until MRI results available. She was advised to do non-impact activities and pool running Day-5: Following the MRIs, fluoroscopy-guided selective right L3 nerve root block, provided significant relief of hip and anterior thigh pain. Day-6: ESWT to the hamstring origin on the ischial tuberosity provided immediate pain relief in her posterior thigh. Day-10: able to walk/run marathon without much difficulty. Day-13: Second ESWT provided additional pain relief in her posterior thigh. Day-14: Hop test negative. Normal nerve tension. Hip and anterior thigh pain improved.