Hip Pain - Cycling

Abstract

HISTORY: A 31 year-old male presented with a long history of bilateral hip pain. He initially developed right hip pain 4–5 years ago, and then developed similar pain in his left hip 2–3 years ago. He described his pain as sharp and located “in the groin” and “deep in the joint”. He previously was quite active in cycling, but had to stop secondary to the pain. He had no history of trauma or pediatric hip problems. No back pain, fever/chills, radicular pain, bowel/bladder changes, or numbness/ tingling. The pain was worse with cycling, hiking up hills, and prolonged sitting. Prior imaging studies included plain X-rays of the pelvis and both hips, multiple bone scans, MRI of the pelvis, and MRI of the hips with gadolinium. All of these studies were read by the radiologists as “normal”. The patient had tried extensive physical therapy and numerous pain medications with little improvement. Intra-articular steroid injections were initially quite helpful, but more recently provided minimal relief. PHYSICAL EXAMINATION: Gait was slightly antalgic. Lumbar ROM was normal and non-painful. There was slight anterior hip joint tenderness to palpation bilaterally, otherwise no focal areas of tenderness. Lower extremity strength testing was non-painful and revealed full strength in all major muscles bilaterally. Reflexes and sensation were normal. Straight leg raise and reverse straight leg raise tests were normal. Stinchfield and FABER tests were positive bilaterally. Passive hip flexion/ internal rotation/adduction resulted in severe pain bilaterally that reproduced the patient's symptoms. DIFFERENTIAL DIAGNOSIS: Femoroacetabular impingement Labral tear Early hip osteoarthritis Upper lumbar radiculopathy Iliopsoas bursitis Nerve entrapment Chronic muscle strain/tear TEST AND RESULTS: Plain X-rays of the pelvis and hips -read by radiologist as negative -on close examination, oblique views revealed a deformity at the superior femoral head-neck junction MRIs of the right and left hips with gadolinium -read by radiologist as normal -on close examination, a prominent bony deformity at the superior femoral head-neck junction was seen bilaterally FINAL WORKING DIAGNOSIS: Femoroacetabular impingement TREATMENT AND OUTCOMES: Referred to orthopedic surgeon for offset procedure to improve the contour of the femoral head-neck junction, thus resulting in improved hip joint clearance. The patient initially had a right offset procedure performed, with almost complete resolution of symptoms. Six months later the patient had a left offset procedure and labral repair with equally successful results. He has since returned to full activities including cycling.