Lateral Thigh Pain Research Articles

Does patient-reported perception of pain differ based on surgical approach in total hip arthroplasty?

Whether patient-reported pain differs among surgical approaches in total hip arthroplasty (THA) remains unclear. This study's purposes were to determine differences in pain based on surgical approach (direct anterior (DA) vs posterolateral (PL)) and PL approach incision length. This was a retrospective investigation from two centres and seven surgeons (three DA, three PL, one both) of primary THAs. PL patients were categorized for incision length (6 cm to 8 cm, 8 cm to 12 cm, 12 cm to 15 cm). All patients had cementless femoral and acetabular fixation, at least one year's follow-up, and well-fixed components. Patients completed a pain-drawing questionnaire identifying the location and intensity of pain on an anatomical diagram. Power analysis indicated 800 patients in each cohort for adequate power to detect a 4% difference in pain (alpha = 0.05, beta = 0.80). A total of 1848 patients (982 DA, 866 PL) were included. PL patients were younger (59.4 years, sd 12.9 vs 62.7 years, sd 9.7; p < 0.001) and had shorter follow-up (3.3 years, sd 1.3 vs 3.7 years, sd 1.3; p < 0.001). DA patients reported decreased moderate to severe trochanteric (14% vs 21%; p < 0.001) and groin pain (19% vs 24%; p = 0.004) than PL patients. There were no differences in anterior, lateral, or posterior thigh, back, or buttock pain between cohorts (p = 0.05 to 0.7). PL approach incision length did not impact the incidence or severity of pain (p = 0.3 to 0.7). A significant proportion of patients perceive persistent pain following THA regardless of approach. DA patients reported less trochanteric and groin pain versus PL patients. PL incision length did not influence the incidence or severity of patient-reported pain. Cite this article: Bone Joint J 2019;101-B(6 Supple B):31-36.

Pulsed Radiofrequency Ablation after One Block for the Treatment of Meralgia Paresthetica

Meralgia paresthetica describes a condition in which impingement of the lateral femoral cutaneous nerve (LFCN) causes anterolateral thigh numbness, and often pain. Treatment options include conservative care with nonsteroidal anti-inflammatories, local anesthetic nerve blocks with corticosteroids, radiofrequency ablation of the LFCN, and surgical interventions, such as neurolysis and neurectomy. When a left femoral cutaneous nerve block is used to treat meralgia paresthetica, it is typically repeated before advancing to pulsed radiofrequency ablation (pRFA). We hypothesized that a single trial of a LFCN block, which relieved pain, but for only a short duration was sufficient to advance to pRFA . Our patient was a 55-year-old woman with right anterior lateral thigh pain for 1 year, which made activities of daily living difficult and was resistant to conservative treatment which included nonsteroidal anti-inflammatories, an antidepressant, and an anticonvulsant. Diagnosis of meralgia paresthetica was established by physical exam, nerve conduction study, and electromyography. A LFCN block under ultrasound guidance was successful in resolving 100 percent of the pain for approximately 2 weeks duration, at which time the pain and paresthesia returned to original intensity. The patient was deemed an appropriate candidate for pRFA of the LFCN, which resulted in complete resolution of symptoms as of her 9 month follow-up visit. To our knowledge, this is the first report of the use of pRFA after a single LFCN block providing faster resolution of symptoms and return to activities of daily living. Key words: Pulsed radiofrequency ablation, RFA, pRFA, meralgia paresthetica, lateral femoral cutaneous nerve, LFCN

Right Distal Thigh Pain - Water Polo

HISTORY: A 15 year old male experienced spontaneous onset of distal lateral thigh pain during his water polo season without preceding event. Symptoms, including an ache and hypersensitivity, responded to activity modification but recurred immediately upon activity resumption, with knee extension even against gravity. He noted no mechanical symptoms, swelling or discoloration. Patient had been receiving physical therapy for presumed distal quadriceps tendinosis but was soon unable to tolerate even topical treatments to the region. PHYSICAL EXAMINATION: Exam revealed tenderness localized to the superior pole of the patella and the vastus lateralis-retinacular interface without nodularity. No knee effusion was present, and all provocative maneuvers of the knee were negative. Give-way weakness of the right quadriceps was present as was skin hypersensitivity. DIFFERENTIAL DIAGNOSIS: 1. Proliferative synovial disorder 2. Vascular malformation 3. Chronic musculotendinous strain of the vastus lateralis-retinacular region 4. Malignancy TEST AND RESULTS: Femur radiographs were negative but contrast MRI of the distal thigh revealed a T2 hyperintense lobulated mass deep to the vastus lateralis and quadriceps tendon, separate from the suprapatellar recess. CT guided biopsy showed benign fibrovascular tissue consistent with an arteriovenous malformation (AVM). FINAL WORKING DIAGNOSIS: Slow flow arteriovenous malformation TREATMENT AND OUTCOMES: The patient underwent percutaneous sclerotherapy with 2cc of absolute alcohol. He reported complete resolution of pain within 1-2 weeks and returned to all previous competitive activity.Figure

Bone cement dry prosthetic with internal fixation treat senile osteoporotic femoral fractures

Objective: To explore the treatment of senile osteoporotic femoral fractures after using internal fixation of bone cement dry prosthetic. Methods: Twelve patients aged from 74 to 94 years with mean age of (84.0±2.5) years with internal fixation of bone cement dry prosthetic surgery who were treated at Department of Orthopaedics in Nanjing Medical University Affiliated Wuxi Second Hospital between May 2013 and May 2015 were retrospectively analyzed. There were 8 male and 4 female, 10 cases of tumble and 2 cases of traffic injury. The fracture types with AO type included 1 case of A1 type, 5 cases of A2 type, 3 cases of A3 type, 1 case of B1 type, 2 cases of B2 type. The steel plate internal fixation with bone cement dry prosthetic method was chosen to treat senile severe femoral fracture. Postoperative observation of postoperative pain assessment, hip joint activity and walking ability were evaluated. Paired simple t test and Wilcoxon rank sum test were used to compare the differences of pain score and the ability to walk. Results: Twelve cases received an average of (16.0±3.6) months follow-up. The average hospitalization days are (9.0±1.4) days and average of intraoperative time was (68.0±10.6) minutes. Intraoperative blood loss compared to normal was (106.0±24.2) ml. Patients began walking load and activities in two weeks. The gait and joint activities gradually restored and there were no obvious deformity and no loose internal fixation. All of the patients didn't have fracture shift with breaking plates or screws deformation and have no bone cement reaction. The walking ability was (4.1±0.9) points, the hip joint activities were 98.5°±7.7° and pain scores were 1.22±0.58 by Holden grading standards. The differences of walking ability (Z=-3.126, P<0.05) and pain scores (t=23.047, P<0.001) between pre- and post-operative were statistically significant. One patient had contralateral hip pain, 2 patients had lateral thigh pain, 10 patients returned to preoperative level of activity. Postoperative function recovered satisfactorily, there were statistically differences. Conclusion: The treatment of severe osteoporosis fractures by internal fixation with bone cement dry prosthetic is a new and effective method, making patients less pain, improving joint function and walking ability.

Acetabular Revision with Bone Grafting and Cementation for Aseptic Loosening after Primary Charnley Low-Friction Hip Arthroplasty with Structural Bulk Autografts

To review the outcome of acetabular revision with bone grafting and cementation for aseptic loosening after primary Charnley low-friction hip arthroplasty with structural bulk autografts in 15 patients. Records were reviewed for 3 men and 12 women aged 31 to 72 (mean, 53) years who underwent acetabular revision with bone grafting and cementation for aseptic loosening at a mean of 12.4 (range, 6.6-20.3) years after primary Charnley low-friction hip arthroplasty with superolateral structural bulk autografts from the femoral head for dysplastic hip (n=14) or bone loss secondary to acetabular fracture (n=1). After a mean follow-up of 6.7 (range, 1.1-14.5) years, the mean Merle d'Aubigné and Postel score improved from 8.55 to 16.5. Bridging trabeculae was noted in 10 hips and graft remodelling in 5 hips. Five hips had ectopic ossification of Brooker grade 1 to 2. The mean hip centre of rotation was 21.6 (range, 16.2-30.6) mm. Two women required re-revision for aseptic loosening of the acetabulum after 8.5 and 6.6 years. The first one underwent re-revision with solid allograft for superolateral deficiency of the acetabulum. The second one underwent re-revision with solid and morselised bone allografts for loosened acetabulum. One patient had superior migrationof the acetabulum for 9 mm at year 2, but it was asymptomatic. One patient had a dislocation that was reduced with manipulation under anaesthesia. Threepatients had trochanteric non-union and presented with lateral thigh pain and tenderness, but no further surgery was performed. The medium-term outcome of acetabular revision with bone grafting and cementation is satisfactory. Repeat bone grafting is required to restore the anatomic acetabular position and bone loss secondary to acetabular loosening.

Is the Direct Superior, Iliotibial Band-Sparing Approach Associated With Decreased Pain After Total Hip Arthroplasty?

BackgroundRecently, the direct superior approach (DSA) has been introduced in total hip arthroplasty (THA) with the goal of limiting soft tissue dissection. This study's purpose was to use a visual pain diagram questionnaire to determine the location and severity of pain in patients undergoing THA via a DSA vs miniposterior approach (MPA). MethodsThis was a prospective, Institutional Review Board (IRB)-approved investigation from 3 centers. Patients aged 18-70 years with a diagnosis of osteoarthritis were included. Two centers used the MPA, while 1 center the DSA. The DSA uses a 9- to 12-cm incision with its distal extent at the posterosuperior greater trochanter. Dissection into the iliotibial band is avoided, and the capsule at the inferior femoral neck is preserved. All THAs in both cohorts received a cementless, titanium, proximally coated femoral stem and a hemispherical acetabular component. ResultsA total of 42 DSA and 196 MPA THA patients were included. Overall, 43% of patients reported pain in at least 1 of the 8 anatomic areas assessed. There was no difference in the incidence of moderate to severe pain in any anatomic area of interest between the MPA and DSA cohorts (P = .1-.9). Specifically, the incidence of moderate to severe trochanter (17% MPA vs 17% DSA, P = .9), anterior thigh (15% MPA vs 17% DSA, P = .9), and lateral thigh pain (12% MPA vs 12% DSA, P = .9) was nearly identical in both cohorts. ConclusionThis study was unable to demonstrate a difference in the incidence of residual pain after use of a DSA or an MPA approach after THA.

Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part VIII: Lateral Hip and Thigh Pain.

Objective. This article presents an evidence-based algorithm to assist primary care providers with the diagnosis and management of lateral hip and thigh pain in older adults. It is part of a series that focuses on coexisting pain patterns and contributors to chronic low back pain (CLBP) in the aging population. The objective of the series is to encourage clinicians to take a holistic approach when evaluating and treating CLBP in older adults. Methods. A content expert panel and a primary care panel collaboratively used the modified Delphi approach to iteratively develop an evidence-based diagnostic and treatment algorithm. The panelists included physiatrists, geriatricians, internists, and physical therapists who treat both civilians and Veterans, and the algorithm was developed so that all required resources are available within the Veterans Health Administration system. An illustrative patient case was chosen from one of the author’s clinical practices to demonstrate the reasoning behind principles presented in the algorithm. Results. An algorithm was developed which logically outlines evidence-based diagnostic and therapeutic recommendations for lateral hip and thigh pain in older adults. A case is presented which highlights the potential complexities of identifying the true pain generator and the importance of implementing proper treatment. Conclusions. Lateral hip and thigh pain in older adults can contribute to and coexist with CLBP. Distinguishing the true cause(s) of pain from potentially a myriad of asymptomatic degenerative changes can be challenging, but a systematic approach can assist in identifying and treating some of the most common causes.

Clinical pattern recognition: hip and thigh pain.

Application last updated: 4 March 2015 Developer: Michael Wong Version: 1.2.2 Size: 350 MB Compatibility: Requires iOS 7.0 or later. Compatible with iPhone, iPad and iPod touch. This app is optimized for iPhone 5 and iPhone 6. Price: $19.99 Clinical pattern recognition is a series of applications dedicated to anatomical areas of the body including the hip/thigh, knee, ankle/foot and lumbar spine. It enumerates numerous clinical presentations of different disease processes with associated physical exam findings. It offers a variety of manual and therapeutic exercises for treating these conditions. This review focuses on the hip and thigh portions of this application series. The application is primarily a tool for physical therapist and patient education. On the opening index screen, one visualizes six selection screens including clinical pattern recognition, clinical practice guidelines, physical exam, manual therapy, therapeutic exercises and special tests. Upon choosing the clinical pattern recognition tool, the user is shown seven patterns of hip pain on a still-animation platform. These patterns include lateral thigh pain extending to knee, posterior gluteal pain, inner thigh pain, posterior knee pain, lateral thigh pain isolated to the greater trochanter and groin pain. After pattern selection, the application provides a differential diagnosis based on the location of the pain. For example, if posterior gluteal pain is chosen it will provide a differential of piriformis syndrome, hamstring strain and hip osteoarthritis. Each diagnosis is described with the prevalence, clinical findings, physical exam, interventions and outcome measures. Selecting the prevalence tab shows the occurrence of the condition, associated sporting activities, sex/age predominance and published references. Next, the clinical findings tab will provide a video showing a reenactment of a patient presenting with the selected condition. It will also describe a patient’s commonly associated symptoms and clinical history. The physical exam tab lists key physical examination findings, movement faults and associated physical impairments. Numerous clinical tests are provided for each disease process supported by thoughtful video demonstrations and reflections on conditional movement faults. The purpose of each exam is well described with a focus on the proper positioning of therapist and patient. In addition, many of the examinations are described with relevant statistics such as reliability, sensitivity, specificity and positive/negative likelihood ratio. Finally, detailed cues and related objective measures are made available with published references. The intervention tab is a resourceful tool that can be used for patient care. It offers high quality videos of therapeutic exercises and manual therapies to be used by patients and therapists. Written descriptions of the maneuvers are provided with associated cues and objective measurements. Further, several patient reported outcome measures are available to document and follow patient progress. There are limitations to note in this application. First, the program algorithm is based on location of pain to identify pathologic diagnoses. These symptom locations may not correlate with traditional presentations of diseases. For example, hip osteoarthritis is within the differential of the posterior hip and knee pain but may be atypical in a clinical setting. Second, the application has redundancies in different menus of the program. This simultaneous information may make user navigation confusing. Third, the greatest flaw in this program is the lack of association between lumbar spine pathology and clinical signs and symptoms about the hip joint. However, clinical pattern recognition does provide a separate lower back pain application for an additional purchase fee. In review, Clinical Pattern Recognition: Hip and Thigh Pain is a very informative application for both physical therapists and patients. It does not provided diagnostic or treatment modalities for lower back pathology that can often mimic hip pain; however, there is a separate application focusing on the lower back for an additional payment. Regardless, this application does an excellent job showing diagnostic exams and therapeutic modalities that can be used in clinic or by the patient at home.

Spontaneous Compartment Syndrome of the Thigh in the Absence of Trauma

BackgroundCompartment syndrome occurs when an increase in pressure results in vascular and functional impairment of the underlying nerve and muscles. Thigh compartment syndrome (TCS) is uncommon, but clinical suspicion warrants emergent surgical consultation and fasciotomy. Case ReportWe present a 42-year-old man evaluated for right lateral thigh pain, without a history of trauma, deep venous thrombosis (DVT), previous surgery, or intravenous drug use. He was febrile, tachycardic, with a mild leukocytosis, an elevated C-reactive protein level, and an elevated creatinine kinase level. Radiographs showed no abnormality and right lower extremity duplex ultrasound showed no DVT. A computed tomography scan of the right lower extremity was concerning for compartment syndrome. Surgical consultation was obtained, and the patient was taken to the operating room for fasciotomy. He was diagnosed with compartment syndrome intraoperatively. The patient was discharged on hospital day 10. Why Should an Emergency Physician be Aware of This?TCS is exceedingly rare, especially in the absence of underlying traumatic and nontraumatic etiologies. The diagnosis is challenging because more elastic fascia with larger space in the thigh allows for accommodation of acute increases in pressure. Consequently, there may not be the expected acute rise in compartment pressures; increased compartment pressure may only be a late sign, when underlying neurovascular damage has already occurred. TCS is complicated by high morbidity and mortality. Emergent surgical consultation should be obtained when there is a high clinical suspicion for TCS, and limb-saving fasciotomy should not be delayed. This case shows the importance of a high level of suspicion for TCS in patients with no identifiable etiology and no historical risk factors for development of compartment syndrome, because TCS may not present with classic symptoms.

Symptomological diagnosis of discogenic low back pain and its neurological anatomic principle

Objective To analyse the symptoms in discogenic low back pain and their neurological anatomic mechanism, and to explore the theoretical basis of symptomatic diagnosis of discogenic low back pain. Methods From January 2010 to December 2013, 289 patients were primarily diagnosed as discogenic discogenic low pain in our department, of which 164 patients showing only single abnormal segment on MRI were enrolled, including 99 male and 65 female patients, averaging 42 years old. All patients underwent discography. All the symptoms conform to the neurological anatomic mechanism of lumbar disc, i.e. extensive low back pain, posterior ilium pain, lateral thigh pain, groin pain, low abdomen pain, were recorded postoperatively. Then the occurrence rate of each symptom with positive discography was calculated. The positive rate (equal to sensitivity of the symptom to the diagnosis of discogenic low pain) of discography when each symptom occurred and the negative rate (equal to specificity of the diagnosis of the symptom to the discogenic low pain) of discography when each symptom did not occur were calculated respectively. Results The discographies of 129 (78.7%) in 164 patients were positive, of these patients 95 (73.6%) had the symptom of extensive low back pain, 99 (76.7%) had posterior ilium pain, 58 (45.0%) had lateral thigh pain, 29 (22.3%) had groin pain, and 24 (18.6%) had low abdomen pain. The positive rate of discography in those with the symptom of extensive low back pain, posterior ilium pain, lateral thigh pain, groin pain and low abdomen pain was 89.6%, 90.8%, 90.6%, 90.6% and 92.3% respectively, i.e. the diagnostic sensitivity to the discogenic low back pain of the symptom of extensive low back pain, posterior ilium pain, lateral thigh pain, groin pain and low abdomen pain was 89.6%, 90.8%, 90.6%, 90.6% and 92.3% respectively. Conclusion The occurrence of the above-mentioned symptoms in the discogenic low back pain is conform to the neurological anatomic mechanism of efferent nerve of lumbar disc. These symptoms have great diagnostic significance for discogenic low back pain. Key words: Intervertebral disc; Low back pain; Diagnosis; Neuroanatomy

Use of Fascial Closure Needle Versus Staples for Mesh Fixation in Laparoscopic Transabdominal Preperitoneal Hernioplasty

Background Recently, it is being suggested in the literature that postoperative pain after TAPP is mostly attributed to the use of staples in mesh fixation .This study aims to compare the value and cost effectiveness of using facial closure needle versus the use of staples in the fixation of prosthetic meshes in laparoscopic tinguinal hernia repair (TAPP). Methods Sixty male patients suffering from inguinal hernia with a mean age 22.7 years ranging from 18 to 30 years were enrolled in this study mesh fixation using fascial closure needle was done in 30 cases and using staples in another other 30 cases. Full physical assessment for the patients was performed and any postoperative complications such as early or late post-operative pain or burning sensation, hyperesthesia, wound infection, seroma, hematoma or recurrence were recorded. Results he mean duration of intervention for fascial needle fixation cases was 43.4 minutes while for stapled cases the mean duration of intervention was 40 minutes. The mean recovery time to normal physical activity was 7.5 days for fascial needle fixation cases and was 9.1 for stapled cases. In stapled patients, one case of recurrence occurred, 2 cases showed hematoma and by the end of the 1st month after the operation, 2 cases had suffered lateral thigh pain, while at the end of the 6th month after the operation 5 cases had suffered chronic inguinal pain. In cases with fascial needle fixation no recurrence had occurred, while 1 case showed subcutaneous port hematoma and one case was reported with inguinal discomfort at the end of the 1st month after the operation and at the end of the 6th month after the operation, no cases had pain Conclusion From the above results, we can conclude that the use of fascial needle closure for mesh fixation in TAPP is better than the use of staples, not only because it is associated with lower incidence of postoperative complications (i.e. postoperative pain and recurrence) but also because its associated with lower costs allowing better availability for all patients

Incidence and Location of Pain in Young, Active Patients Following Hip Arthroplasty

Persistent pain following hip arthroplasty remains a concern, especially in young, active patients. Four hundred twenty patients less than 60years of age with a pre-symptomatic UCLA score≥6 (196 total hip arthroplasty [THA]; 224 surface replacement arthroplasty [SRA]) completed a pain-drawing questionnaire investigating the location, severity, and frequency of pain around the hip. At a mean of 2.9years of follow-up, 40% reported pain in at least one location around the hip. There was no difference in the incidence of groin pain between SRA and THA patients (32% vs. 29%, P=0.6), but THA patients had a greater incidence of anterior (25% vs. 8%, P<0.001) and lateral (20% vs. 10%, P=0.01) thigh pain. A high percentage of young, active patients experience persistent pain following hip arthroplasty.

Greater Trochanteric Pain Syndrome: Frequency and Associated Factors in Patients with Stroke

Background: Greater trochanteric pain syndrome (GTPS) is a common cause of lower extremity pain and is estimated to affect between 10% and 25% of the population. Despite all the research, there are no data in the literature about GTPS in the stroke population. Objective: The aim of the study was to determine frequency and related factors of GTPS in patients with stroke. Methods: Eighty-six patients with stroke were recruited from an inpatient rehabilitation department. Presence or absence of lateral thigh or hip pain was recorded. All patients with stroke (with or without self-reported pain) were examined using clinical criteria for the diagnosis of GTPS. Results: Lateral thigh or hip pain was reported on initial interviews by 29 of 86 patients. GTPS was diagnosed by means of structured physical examination maneuvers in 17 patients with stroke and self-reported pain and 11 patients with stroke without self-reported pain. Twenty-eight patients (32.6%) had GTPS. The following factors were significantly associated with GTPS: lower extremity spasticity, depression, and iliotibial band syndrome. No correlation was found between GTPS and age, sex, lesion localization, motor status, neglect, sensory loss, time since stroke, low back pain, knee and hip osteoarthritis, or health-related quality of life. Conclusion: In this study, we showed that patients with stroke have a high percentage of GTPS. Early diagnosis and treatment of pain from GTPS are important in this population, because GTPS may limit applicability of motor training and affect rehabilitation outcomes.

Chronic meralgia paresthetica and neurectomy

To understand the pathologic and clinical correlates of patients with chronic meralgia paresthetica (MP) undergoing lateral femoral cutaneous nerve (LFCN) neurectomy. A retrospective cohort approach was utilized to identify 7 patients undergoing LFCN neurectomy for intractable pain. Control autopsied LFCN was obtained. Clinical, radiologic, and electrophysiologic features were reviewed. In identified cases, preoperative symptoms included severe lateral thigh pain and numbness. The duration of symptoms prior to surgery ranged from 2 to 15 years. Body mass index (BMI) varied from 20 kg/m(2) to 44.8 kg/m(2) (normal-morbidly obese), with 6 out of 7 patients being obese. No patients were diabetic. Focal nerve indentation at the inguinal ligament was seen intraoperatively and on gross pathology in 4 of 7 cases. Multifocal fiber loss, selective loss of large myelinated fibers, thinly myelinated profiles, regenerating nerve clusters, perineurial thickening, and subperineurial edema were seen. None of these features were observed in control nerve. Morphometric analysis confirmed loss of large myelinated fibers with small and intermediate size fiber predominance. Five patients had varying degrees of intraneural and epineurial inflammation. Six of 7 reported improved pain after neurectomy, sometimes dramatic. Patients with chronic MP and intractable pain have an LFCN mononeuropathy with loss of nerve fibers. Pathologic and clinical study supports a compressive pathogenesis as the primary mechanism. Abnormal nerve inflammation coexists and may play a role in pathogenesis. These selected patients typically benefited from neurectomy at a site of inguinal ligament compression. This study provides Class IV evidence that patients with chronic MP LFCN neurectomy experience improvement in MP-related pain.

Cervical Spinal Canal Stenosis and Central Disc Herniation C3/4 in a Man with Primary Complaint of Thigh Pain

Purpose The purpose of this report is to describe the clinical course of a patient who had a primary complaint of isolated right lateral thigh pain 3 years prior that was nonresponsive to conservative measures. Hypoesthesia in the lateral side of the right forearm, deltoid and biceps, as well as triceps paresis, was also diagnosed. Results Immediately after surgery, the patient reported substantial improvement in his right thigh symptoms. The signs and symptoms associated with the right C6 and C7 radiculopathy did improve. Conclusion Although the presentation described in this case is somewhat unique, the eventual myelopathic signs and symptoms were not. It was these myelopathic signs and symptoms that led to cervical magnetic resonance imaging, the diagnosis of cervical cord compressive myelopathy, and surgical management.

English

Introduction Proximal lateral thigh pain is a common musculoskeletal complaint. Tenderness at the femoral greater trochanteric area is often diagnosed as trochanteric bursitis. This term is probably a misnomer because of evident non-inflammatory pathologies, particularly of the abductor tendons of the hip and is currently referred as the greater trochanteric pain syndrome. Although the clinical presentation seems straightforward it is important to differentiate this extra-articular source from an intraarticular or a lower back source of pain. Non-traumatic acute pain does not require the use of imaging modalities. Imaging of the lower spine and pelvis should be ordered in cases of prolonged pain or uncertain diagnosis. Non-operative treatment that involves modifying activities, physiotherapy, analgesics, steroid injections and shock wave therapy is usually helpful. Nevertheless, despite the above treatments about one-third of the patients suffer from chronic pain and disability. These patients may be candidates for operative intervention such as local decompression, bursectomy and suture of torn tendons. The aim of this review was to discuss trochanteric bursitis of the hip. Conclusion The differential diagnosis for greater trochanteric pain syndrome includes pathologies around the hip and lower back. Usually non-operative treatment that includes modified activity, physiotherapy, local injections and shock wave therapy is helpful. Introduction Greater trochanteric pain syndrome (GTPS) is a common clinical diagnosis. Typically, the pain is at the lateral side of the hip around the greater trochanter (GT) region, mostly in middleaged women and disturbs the activities of daily living. The pathophysiology is not completely understood. One of the earliest descriptions was published by Partridge1 in 1948 and was often termed the ‘great mimicker’ because of its similarities to other pathologies. The more familiar term ‘trochanteric bursitis’ that implies an inflammatory process is probably inaccurate. Recent histological2, radiological3 and surgical4 investigations showed tendinopathy and tears of the gluteal tendons around the GT with no significant inflammation of the bursae. Currently, the more acceptable term is GTPS5,6. This article reviews the anatomy, aetiology, diagnosis and updated treatment modalities of GTPS. Discussion Anatomy The gluteus medius, gluteus minimus and tensor fascia lata muscles are the main abductors of the hip joint and stabilise the femoral head inside the acetabulum during motion and weight bearing7. The pain in GTPS is related to various pathologies in these tendons with secondary involvement of the surrounding bursae. There are some similarities in function and malfunction between the hip abductors and the rotator cuff tendons of the shoulder8. The abductor muscles originate from the posterior aspect of the iliac bone and insert into the femoral GT. Specifically, the gluteus medius inserts into the superolateral aspect and the gluteus minimus into the anterior aspect of the GT. Bursa is a small fluid-filled sac that reduces friction between bone and soft tissue. Four bursae were described around the GT and deep to the gluteal muscles (Figure 1) while two are consistently found in most people9: the subgluteus medius bursa (between the gluteus medius and the GT) and the subgluteus maximus bursa (between the gluteus medius and gluteus maximus, lateral to the GT). The latter is the largest and often accused in causing the pain of ‘trochanteric bursitis’. There are other minor bursae that decrease the friction between gluteal muscles, tensor fascia lata and iliotibial band (ITB). The subgluteus minimus bursa is small and located superior and anterior to the GT while, the gluteofemoral bursa is inferior to the GT, adherent to the ITB at the insertion site of the gluteus maximus. Aetiology The aetiology of GTPS is variable. Direct injury to the proximal thigh or repeated irritation of the gluteal muscles and ITB against the GT can trigger symptoms. Limb length differences whether static or temporary (i.e. running on uneven surfaces) create mechanical imbalance that may influence the abductor muscles. Although sometimes there is no obvious cause, many related factors were found to be correlated with GTPS such as age, female sex, overweight, gait disturbances and lower back pain10. Schapira et al.11 found that GTPS was correlated with arthritis of the lower back or lower limbs in 91.6% of the cases. *Corresponding author Email: barak_haviv69@hotmail.com Arthroscopy and Sports Injuries Unit, Hasharon Hospital, Rabin Medical Center, Petach-Tikva,

Endoscopic Repair of a Gluteus Medius Tear at the Musculotendinous Junction

Abductor tendon tears are an increasingly recognized clinical entity in patients with lateral thigh pain and weakness. These “rotator cuff tears of the hip” typically result from chronic, nontraumatic rupture of the anterior fibers of the gluteus medius. Although the abductor tendon typically tears from the osseous insertion, the case discussed here ruptured at the musculotendinous junction. This is the first report of this abductor tear subtype and its endoscopic repair.

The Paradox of Prevention—Bilateral Atypical Subtrochanteric Fractures due to Bisphosphonates in Osteogenesis Imperfecta

A 64-year-old woman with osteogenesis imperfecta type 4 was commenced on iv bisphosphonates after a low-trauma fracture of her ankle. After having received pamidronate for 3 years and zoledronic acid for 2 years, she complained of a 10-month history of right lateral thigh and groin pain. She was able to bear weight with only minimal discomfort, and there was no limitation of movement. Plain radiographs demonstrated an incomplete subtrochanteric fracture of the lateral cortex of the right femur (Figure 1A) and a similar finding at the mid-diaphysis on the left (Figure 1B). Nuclear medicine bone scanning with single photon emission computed tomography (CT) combined with CT revealed intense uptake in the regions corresponding to those identified on the plain x-rays (Figure 1, C and D). Further bisphosphonate treatment was withheld. Teriparatide, a bone anabolic agent, was commenced to promote fracture healing. Osteogenesis imperfecta is typically associated with frequent fractures in childhood and adolescence, but, with age-associated decline in bone density, patients may enter a second period of heightened fracture risk. Our patient had a genetic predisposition to fractures and was treated with bisphosphonates to ameliorate fracture risk (1, 2). Paradoxically, in this case, such treatment is linked to the evolution of bilateral incomplete subtrochanteric fractures (3, 4). Even in patients with unequivocally increased fracture risk (such as in osteogenesis imperfecta), close clinical scrutiny and follow-up are required when using iv bisphosphonates to provide individualized treatment. Careful and sequential reassessments of risks and benefits must be made when managing all patients with bisphosphonates.

Sciatica Caused by Pyomyositis of the Piriformis Muscle in a Pediatric Patient

Because the sciatic nerve leaves the pelvis through the greater sciatic notch underneath the piriformis muscle, any pathology of the piriformis muscle could result in entrapment of the sciatic nerve; this is widely known as piriformis muscle syndrome. Pyomyositis of the piriformis muscle may be a cause of piriformis muscle syndrome. Piriformis muscle syndrome caused by pyomyositis of the piriformis muscle in pediatric patients is rare. This article describes a case of sciatica caused by pyomyositis of the piriformis muscle in a pediatric patient. A 6-year-old boy presented with right buttock and thigh pain following a mild fever and sore throat. The pain worsened, and he became unable to walk. On admission, his temperature was 38.4°C. He reported severe right-sided buttock and lateral thigh pain. Positive Freiberg sign was observed. Laboratory examination revealed elevated white blood cell count and C-reactive protein level. T2-weighted magnetic resonance images of the pelvis revealed high-intensity changes of the piriformis muscle and iliosacral joint. Thus, piriformis syndrome caused by pyomyositis of the piriformis muscle was diagnosed. Oral antibiotics (10 mg/kg per day of cefdinir) were administered. Pain gradually decreased, and the patient was able to walk. Final follow-up examination at 6 months after symptom onset revealed no sciatic pain. Follow-up magnetic resonance imaging revealed normalized intensities of the piriformis muscle. The endopelvic fascia provides a route for infection from the pelvis to the piriformis. The pyomyositis of the piriformis muscle in the current case may have occurred secondary to the pyoarthritis of the sacroiliac joint. Endopelvic infections involving the piriformis muscle may mimic hip diseases in pediatric patients.

Trochanteric area pain, the result of a quartet of bursal inflammation

Bursitis is quite responsive to therapeutic intervention, once the afflicted area is accurately identified. This is especially notable for some hip complaints. Patients' use of the term "hip" can relate to anything from the low back to groin to lateral thigh pain. Trochanteric area surface localization of "hip" pain may afford an opportunity for immediate cure. Effectiveness of therapeutic intervention is predicated upon injection of not one or two, but all four peri-trochanteric bursa with a depot (minimally water-soluble) corticosteroid. The term trochanteric bursitis suggests that the inflammation is more focal than what is clinically observed. While easier to express, perhaps it is time to refer to inflammation in this area, naming all four affected bursae.