Clinical Reasoning Case

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    • February 7, 2018 at 9:09 am #6061
      Laura Thornton
      Moderator

      Hey guys – here’s an interesting differential diagnosis case that recently presented to our clinic. I thought this might be a great opportunity to discuss clinical reasoning, based on subjective, then objective findings:

      A 66 year old male, owner of small business in Richmond, mostly desk work. Referral for bilateral hamstring stretching.

      CC 1) bilateral posterior thigh, knee, and calf pain of shooting, electrical quality. Can be bilateral, or unilateral. Sometimes pain will just in the posterior thigh, or just the calf, or the entire route.

      CC 2) numbness and sensitivity to touch in the right lateral thigh (in oval-shaped area below greater trochanter to above knee joint)

      CC 3) central low back pain (not his primary concern, has been present for years)

      Aggs (leg pain): static standing for more than several minutes, sit to stand transfers, and walking. Pain will not improve during standing or walking until he rests in sitting. After sit to stand transfer, pain will take 1-2 minutes to resolve in standing. Eases: sitting, lying down. He is currently not performing his regular walking program due to pain.

      Aggs (paresthesia in R lateral thigh): constant, non-variable. When he touches area, he will feel tingling, but otherwise can forget that it’s numb.

      Aggs (low back): been present for years, can ache after sitting for long periods of time or after exercise, but does not stop him from activity.

      PMH: bilateral anterior approach total hip replacements in the past year (left in July 2017, right in November 2017). Paresthesia started several days after surgery, started with intense pain in same area as numbness, prescribed Gabapentin, which resolved the pain but numbness is still present.

      Pain in legs started gradually over the next several weeks after first THR. He was followed by surgeon, who did not prescribe him PT after home health, just had him on a regular walking program. Pain gradually started in the legs, did not improve in months prior to the second THR. No change in symptoms (both paresthesia and pain) after second THR. Referral for MRI of lumbar spine and cortisone injections for L4-S1, no improvement in symptoms. Referral for TPDN throughout hamstring and calf musculature, no improvement in symptoms. Referral for bilateral hamstring stretching to our clinic.

      SUBJECTIVE ANALYSIS:
      1) Based on the above info, what is on your differential diagnosis list?
      2) Do you see any pattern of symptoms that lead you to believe this is not hamstring inflexibility?
      3) What other questions would you have asked during the subjective examination?
      4) Do you see any potential red or yellow flags that would warrant referral to another health care professional?
      5) What tests/measures would you prioritize on the objective examination?

    • February 7, 2018 at 10:10 am #6062
      Laura Thornton
      Moderator

      Here is the body chart for reference.

      Attachments:
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    • February 7, 2018 at 9:52 pm #6066
      Sarah Bosserman
      Participant

      -Would want to rule out UMN, vascular causes. neuro exam would be high on my list.
      -Lateral thigh numbness: could be lateral cutaneous nerve? (L2-L3, courses through lateral border of the psoas major and iliacus, h/o anterior hip THA)
      -Lumbar radiculopathy L4-S1 (leg pain), stenosis…seems load sensitive.
      -Would want to continue to assess hamstrings, glutes, deep hip rotators, iliopsoas, etc…curious what his hip mobility looks like for sure as it could affect mechanics (with walking/steps/transfers)/peripheral nerve entrapment.
      -Curious a little more about the nature of his leg symptoms…is one side different from the other (did the pain start first on one side, earlier onset with activity R vs L, intensity?)
      -Yellow flags due to patient reporting he has stopped walking program and has few ways to decrease his pain. Surgeries have lead to decreased quality of life.
      -Definitely curious to hear more about his objective exam!

    • February 8, 2018 at 12:36 pm #6069
      Tyler France
      Participant

      Primarily, I would want to rule out any UMN disorders or vascular causes, as Sarah noted. The lateral thigh numbness sounds like it could be related to meralgia paresthetica/LFC entrapment, especially since it began soon after hip surgery. I think that spinal stenosis could explain his leg pain, especially since he has had a history of central LBP and since his leg pain is aggravated by extension-based activities and relieved by sitting and unloaded positions. I’d definitely want to get a good picture of his hip mobility, particularly into extension. If he is no longer getting any hip extension, then it would make sense that he is extending his lumbar spine more irritating some neural tissue. I’m curious if you asked what approach they took for his hip replacements and whether or not he is still observing his post-op precautions. I’d also be interested to see results of his slump and SLR testing.

    • February 9, 2018 at 8:51 am #6070
      Laura Thornton
      Moderator

      Thanks for responding guys!

      I agree on performing a full neurological examination and keeping vascular claudication on your differential list.

      Speaking of this, what are some key risk factors, quality of symptoms, and agg/ease factors that you can use to differentiate between vascular and neurogenic claudication?

      Sarah – the symptoms between the right and left LE are variable. He will at times have pain in both legs, sometimes in the right, sometimes in the left, and the intensity of the pain can vary from 1-2/10 to 5/10. Usually if he experiences pain in both legs at the same time, the pain will be in the same area (either posterior thigh, or posterior calf).

      I also agree with presence of yellow flags. His only exercise post-op was a walking program, but is unable to perform due to his pain, so you could imagine his frustration and desperation to get this taken care of. His only treatment approach so far has been passive treatments (cortisone injections, TPDN) without any improvement in symptoms. Quote from subjective, “all I want to do is get back into walking”. How would this direct your initial treatment or general POC?

      Remember – the paresthesia on the RIGHT lateral thigh started after the LEFT anterior approach THR. It’s interesting to think about this as both a differential diagnosis, but also for patient education to improve his understanding of condition.

      Tyler – He had an anterior approach on both hips and is not under any specific dislocation precautions at 10+ weeks post-op (right hip). My experience is that there is some controversy over precautions s/p anterior approach, however generally there is a lower risk of dislocation associated with the anterior approach THR. Each surgeon is different, but generally want to avoid forceful end range extension/ER.

      Any other thoughts before I post the objective examination findings?

    • February 20, 2018 at 8:58 am #6153
      Laura Thornton
      Moderator

      Here’s the objective findings from the evaluation on Day 1:

      Neuro screen:

      Myotomes – hip flexors 4/5 B, rest of LE myotomes 5/5
      Dermatomes – intact to light touch bilaterally expect for lateral thigh reports “tingling” to light touch (several inches below greater tuberosity starts, travels down to approx. 3 inches above knee joint)
      Reflexes – 2+ throughout
      UMN – Babinski negative, ankle and wrist clonus negative, Hoffman’s negative

      Sit to stand transfer: patient reported immediate pain in posterior thigh B upon transfer, immediately resolved upon standing after 5 seconds

      Static standing posture: increased lumbar lordosis, anterior pelvic tilt, hypertonic lumbar PVM

      Gait: wide BOS, right uncompensated trendelenburg, significantly limited hip extension B, denied pain during 30 second walking assessment

      Lumbar Flexion AROM: increased thoracic flexion, minimal reversal of lumbar lordosis. Fingertips reach ankle joint with knees in full extension. Posterior pelvic shift. Pain reproduced in bilateral posterior knees upon first 25% of range, then resolved into further flexion. Pain returns upon last 25% of extension into standing upright.

      Lumbar Extension AROM: 25%, minimal segmental extension through lumbar, most performed with anterior pelvic shift. Painfree, with the exception of twinge in posterior thigh B upon return to neutral. Sustained with overpressure into extension painfree.

      Lumbar Sidebending AROM: 50%, minimal segmental motion through lumbar, painfree with OP and sustained pressure B.

      Lumbar Extension Quadrant AROM: 50%, painfree B

      Slump Test: Negative for any reproduction of symptoms in full knee extension with slight Achilles tightness with added DF.

      Straight Leg Raise Test: Negative for reproduction of symptoms B

      Lumbar PPIVMs/PAIVMs: hypomobile into flexion PPIVM at L3-4, L4-5, L5-S1

      Hip Extension PROM: -40 degrees of hip extension (knees bent), -34 degrees of hip extension (knees straight)

      —

      1) Knowing the subjective and objective data, what are your conclusions about this patient?
      2) Anything particularly surprising or that does not fit your hypothesis?
      3) What would be your primary treatment objectives for day 1, inc. education?
      4) Would you have done anything differently or added more evaluation to what I did on the initial eval?

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