OPD Case 1

CHIEF COMPLAINT:

A 40 yr old male presented with the chief complaint of right hip pain since 6-7 weeks (since March)

HISTORY OF PRESENT ILLNESS:

• H/o heavy exertion and weight bearing 2-3 weeks prior onset (early Feb)
• Severe gastritis and UTI around onset (March). Not associated with fevers, chills or redness.
• Distinct click is felt when pain is severe, slightly affecting ADLs (while walking only)
• Tender point 2 inches distally down from ASIS. It is palpable on right hip margin on left bending.
• Gastric correlation to level of pain till few weeks back.
• Relieving factors: Hip extension exercises, warm shower, ice, Volini.
• Weight gain of 6 kgs.
• No postural discomfort 
• No fever
• No constipation
• No bulge or cough associated pulses around groin
• No tingling or radiation

PROGRESS OF ILLNESS: (from oldest to latest)

• Pain in hip margin, piriformis and gluteus.
• Mild sciatic involvement (Mild pins effect running down the thigh. Pressing along nerve helps thigh pain)
• Anterior thigh tingling only
• Putting ice around piriformis led to tingling in gluteus region
• Localized tender points around lateral femoral cutaneous nerve.
• Few episodes of cramps in opposite side hand. (No tremors)

HISTORY OF PAST ILLNESS:

1. Predisposed to lymphomas/neurofibromas. 

• No brown patch, only lumps that move sideways and painful when they form.
• Used to be localized in T3-T6 dermatome
• Noticed 1 or 2 locally painful nodules in anterior of thigh in past few months

2. Cracked feet soles. Painful for few weeks (July 2021). Managed with salt water soaking . Sitz bath once/twice a week.

3. Severe injury (laceration) on toe in last week of January 2021. Betadine bandage for a few weeks. Buddy taping for a month. Pain subsided in 2 months. 

 

4. Hb was 17.5 in 2018. Based on CBP. Pt. does not remember if RBC was large or count was high. Regular follow up was suggested.

5. T4/T5 disk compression in 2009. Did not go for follow up as back pain was relieved.

PERSONAL HISTORY:

Occupation: Engineer.

Hobby: Rifle shooter. 2015-16 was last practice, on and off after that (Exercise regimen included swimming and posture correction).

Diet: Mixed. Sometimes skipped meals, due to busy schedule.

MEDICATION HISTORY:

• No medications for UTI
• Occasional Pantroprazole for gatritis.
• Single dose Albendazole 400mg for deworming. (Missed December cycle)
• Supplement of 60k D3 was taken. Second supplement was taken 3 days later (as he felt that it gave him relief). Presently continuing on D3.
• Tab. Ofloxacin & Ornidazole 500mg orally since 7th June BD morning/evening + Sporlac. Presently continuing on O2.
• A-Z supplementation at lunch

CURRENT STATUS:

• Lymph node swelling subsided
• Right side bending pain reduced. Still no full ROM
• Tingling pain mostly subsided

DISCUSSIONS:

Patient:  Right hip. Hopefully groin strain only. Been around 6-7 weeks. 

A fascitis or tendonitis? There is a distinct click while walking when the pain is severe (slightly affecting ADLs - while walking only. No postural discomfort otherwise). Not sure of a pain rating. Hip extension exercises and warm shower help. ROM is fine all directions except right side bending. Hip adduction by itself it fine. 

No fever. No constipation. No bulge or cough associated pulses around groin. No tingling or radiation. Only one tender point on pressing around the area: 2 inches distally down from ASIS. The tender point is palpable on the right hip margin, on left bending. Tendon over neck of femur?
Just want to be sure I am not ignoring something like a mild hernia or appendicitis. Actually, there is some gastric correlation and a little bit of history is that in early Feb (2-3 weeks prior to onset) there was a lot of exertion shifting residence.

Doctor 1: Yes the lifting heavy weights takes me closer to your hypothesis of tendon injury rather than an obstructive hernia.

Doctor 1:  Without any pertinent history as to age of patient, chronic or acute, any known trauma, profession of patient ( what he/she does), whether an X-ray was taken etc., a clicking hip joint mostly with walking brings in mind possibly of coxa saltans (ileopsoas tendinitis), usually seen in athletes. Treatment is rest and pain meds, then stretching ROM exercises and maybe PT if needed.  Sounds like tendinitis/ synovitis. Other D/D include other ileotibial issues like labra tear, iliotibial band syndrome, ileopsoas snap, arthritis, etc. Along these lines rather than SCFE, Perthe’s etc. involving hip joint.

Patient: 

40 yr old. Male. 

Pain is acute (7 wks?). Xray not taken. 

Profession - Engineer

Used to be physically active (sports shooting) - implies fairly well toned muscles for standing posture. Exercise regimen included swimming and posture correction. Rifle shooting leads to prolonged (2-3 hrs) sideward facing posture. 

Minor sports injuries including muscle / tendon pain but non in the right hip. 

Last 18 months or so - very sedentary. Lockdown effect. Only physical activity are domestic chores (sweeping etc) and some gardening. 

Patient: Why would it affect me after 2-3 years of not visiting the range. 2015-2016 was last active practice. Maybe on and off after that.

Patient:  Hip stretching exercises are tough without help. Most pain sprays have diclofenac. Is it safe for topical use in covid times?)

Doctor 1:  I am assuming that there are no systemic symptoms like fever, weight loss etc? Or weight gain, which is more likely due to activity restrictions from the pandemic. As with any hip issue at this age, X-ray would be the first choice to r/o any bony issues including degeneration, and then take from there. If X-ray is normal, sometimes ortho will get an US if they suspect bursitis/ tendinitis or an MRI for intra articular causes if they are thinking along those lines. I would also recommend CBC/ESR/CRP (inflammatory markers). 7 weeks is chronic, and more importantly it is not benign painless clicking, so further evaluation is needed for sure. Resting, trying not to do activities that provoke the pain, icing as needed and taking anti/inflammatory meds while awaiting further work up. May also try to do stretches and ROM exercises to strengthen the ileopsoas band and muscles.

Patient: Gained around 6 kgs

Doctor 3:  Is a PA or AP view of hip needed? Also does any specific positioning of the leg during xray elicit better view in this condition?

Doctor 1:  A tender area distal to and below the ASIS is often a Sartorius strain. It is attached to that little notch below the ASIS. Also the lateral femoral cutaneous passes very close to this (of course no tingling etc., reported). The other muscle which originates there and from the exterior superior aspect of the acetabulum is the Rectus Femoris, which if stretched can sometimes show avulsion injuries with painful hip flexion. Of course the tensor fascia lata is big and strong and more lateral but can be related to clicks & pain. Somebody needs to stress these 3 in isolation.

Patient:  The pain had subsided with ice, Volini and some physio guidance. Hip margin started hurting yesterday. Today piriformis started hurting in the morning. Now gluteus. And there is a very mild sciatic involvement? (mild pins effect running down thigh... Pressing along the nerve helps the thigh pain. But anterior thigh tingling only?) Putting ice around piriformis started tingling in gluteus region. Pyriformis inflammation now? 
I am predisposed to lipomas / neurofibromas (no brown patch only lumps that move sideways and painful when they form). These were localized in T3-T6 dermatome earlier but past few months I had noticed one or two locally painful nodules in the anterior of the thigh. Many of the torso ones are possibly dissolving (so most likely lipomas only, but there is some nerve involvement). 
I had a T4 or T5 disk compression in an MRI during in 2009. Never followed up as back pain was relieved then. Is it ok to do an antibiotics course as a prophylactic?  I avoid NSAIDs but maybe I need now. On my pain scale it was slightly more today. Walking affected mildly.

Patient:  I will try to differentiate between the three likely affected muscles. Apparently, sartorial origin seems to be the case. Meanwhile, I see benefits from hip extension while pressing the tender point with a finger - unlocking the contraction. I will try to schedule a session with some physiotherapist for a exercise regimen.

Patient: Hip margin as in iliac crest. It's tender to touch on ASIS. Not sure if significant, but in 2018 my haemoglobin was 17.5 and based on CBP visited TMC (rbc was large, or count was high don't remember). They cleared it and only mentioned regular follow up.

Doctor 1: Sounds like tendon inflammation to me. Fibromyalgia comes to mind.

Doctor 1:  I wonder if his sedentary lifestyle due to the pandemic is causing all his hip symptoms due to weakness of muscles leading to unsupported nerves? 

A few things are going on or being noticed by him-

1. Sciatic like nerve pain down his thigh, unilateral. Sciatic pains do not improve with exercise and good posture. So, should continue stretching and walking as tolerated and maintaining proper posture. Can certainly take NSAIDs as anti-inflammatory, as needed.
2. Painful nodules - Neurofibromas? Lipomas?
3. T4/5 disc compression 10 years ago, that had resolved, could be aggravated by general core weakness.
4. Hemoglobin of 17 is upper limit of normal in males, could also have been due to dehydration. Unlikely related to his current complaints. Would recommend repeating CBC when he gets a chance.
5. Not sure why he thinks he needs antibiotics, as prophylaxis for what?

Feel like he does have a myriad of issues bothering him physically and psychologically and I would recommend following up with his primary care doctor to address each issue, either in person or by Telehealth, to determine what studies he needs, blood work ( CBC, CRP, ESR), and imaging ( X-ray hip/ lumbar spine) to help his cause.

Patient:  Primary take away. Poor lifestyle during lockdown will show up!  Even I personally feel lack of regular exercise since lockdown last year is at the root. The antibiotics bit has a little background of gastritis - most likely misplaced as I have no fever or chills, no redness. Around the onset of the pain in March (at least marked difference in perception), I had a bout of severe gastritis and UTI. Both settled without antibiotics. Just in case the infection got round the corner. There was a gastric correlation to level of pain till few weeks back. That's when I first contacted you to rule out anything serious - appendicitis etc (I am trying to avoid hospital visits right now). The moving pain lead me to the hypothesis that the tendonitis could be moving among proximal ones. Initially there was no tenderness on the iliac crest! The mild sciatic involvement yesterday could be attributed to piriformis, and that was tender. Gluteal involvement could be along the sciatic path or through tendonitis around iliac crest. 

Looking for a way to get back up to speed, hence the prophylaxis thought was to prevent further spread of the infection, if any.

Doctor 2:  Interesting evolution. But why antibiotics? Has he got a connective tissue disorder, apophysitis, is he post viral? Are there any lumps along the Lateral Femoral Cutaneous Nerve? To me this feels like inflammation along his iliac crest which has sent his gluteus off kilter - hence possibly a struggling Pyriformis, hence perhaps an irritated sciatic nerve and with possibly coincidentally some meralgia paraesthetica - after all Lateral Femoral Cutaneous Nerve is never far and would account for that anterior thigh tingling. Lots of physio, core stability, pyriformis rehab, rest, ice , NSAIDS & CRP.

Patient:  Yes a few localized tender points around lateral femoral cutaneous nerve. Just an update on my hip pain. I experienced a few episodes of cramps in the opposite side hand! On an after thought I did deworming - had missed the December cycle in the thick of things. Single dose Albendazole 400mg. The other thing I did was, something I highly despise, took a single supplement of 60k D3, given the quality of food. I would normally not do this without a prescription but just gave it a shot. Of course not repeating. But there is an effective reduction in cramps! Placebo? Did I effectively fool my brain or could it have been owing to deficiency or worms?

Doctor 2:  Polyminimyoclonus? Folks consume Vit D as OTC. How likely is toxicity? 

Patient:  I tend to discount it, given that there are no tremors, even imperceptible ones. The left hand needs to provide stability to the rifle while being outstretched and bearing the nearly 7kgs weight. Right hand is used only for proper triggering. And it's repeated 60 times in a full set. Within a span of around 90 mins.