HIP PAIN IN A MIDDLE AGED MALE

Abstract

HISTORY A 50 year old white male presented to the office with a 3 month history of progressive right hip pain. He first noticed the pain when he was playing volleyball in a pool. The pain was located in the right lateral hip with radiation to the lateral thigh, anterior hip, and groin. These symptoms initially improved slightly, but worsened slightly with white water rafting and substantially after playing basketball. He denied any falls or direct trauma to the hip. He denied low back pain, paresthesias, weakness, and loss of bowel or bladder function. The pain was increased with cough and sneeze. He had no fevers, chills, night sweats, or weight loss. He had mild night pain associated with movement, but the pain did not awake him. No other joint problems. He had previously been diagnosed with referred pain secondary to lumbar radiculopathy. He had no relief with PT and Prednisone. An MRI of the lumbar spine was normal. He had no personal or family history of gout, lupus, or symptoms suggestive of inflammatory arthropathies. PHYSICAL EXAMINATION He ambulated with a marked limp. Flexion was to within four inches of the floor with restricted extension. Neurological exam, including straight leg raise, motor, sensation, and reflexes, was normal. Hip exam revealed marked pain with log rolling. Quadrant test was significantly positive. His ROM showed reduced flexion, internal and external rotation associated with marked pain. DIFFERENTIAL DIAGNOSIS Hip osteoarthritis Avascular necrosis Septic arthritis of the hip Trochanteric bursitis Occult hip fracture Malignancy TESTS AND RESULTS X-ray of the hip showed no acute bony abnormality or joint space narrowing. MRI showed a uniformly abnormal appearance of the bone marrow in the right femoral head, femoral neck, and inter-trochanteric region. This was a homogenous abnormality with diminished signal on T1 weighted images and increased signal on T2 images. There were no focal areas of marrow abnormality. Trace effusion. No fracture. Hip joint spaces were relatively well maintained. The left femoral head was normal in appearance. Adjacent soft tissues were normal. FINAL/WORKING DIAGNOSIS Idiopathic Transient Osteoporosis of the Hip TREATMENT AND OUTCOME Treatment is supportive with pain control and avoidance of provoking factors. The patient's symptoms are improving with indomethacin. Expect spontaneous resolution over a period of months.