June 6, 2019 at 9:19 pm #7587
I am hoping to do JC discussion board a little differently this month. I have posted just the pt background and subjective data to this case. I wanted to show you how this case was presented to me from a clinical standpoint throughout the evaluation process and subsequent visits. I am hoping it will be a little more conversational therefore I have purposefully omitted all information in hopes for some questions, feedback, etc. Sunday I will post the rest of the information for this case, followed by the article on Monday!
June 8, 2019 at 8:04 pm #7589Matt FungParticipant
Hey Casey, I just have a few clarifying questions that I may have asked during my subjective questioning to hopefully better guide my objective examination. Did you happen to clarify which position he prefers to sleep in/ what position give him his pain? Getting into and out of his car did his symptoms change if he was getting into the drivers side or passengers side? Additionally did he have hip symptoms initially when he had this most recent episode of LBP, does his LBP and hip symptoms have similar aggs and eases? Has he had treatment for his low back in the past? When he says stepping wrong over-striding/under-striding, side stepping? What did he do for work in the past/did that lead to his initial onset of LBP?
With this being said my diff Dx is as follows:
– Lumbar stenosis w/ dural irritation
– R hip OA
– Lumbar discogenic referral L3-4
With this information I would probably start by assessing his L/S and a through neuro screen. Based on what information I am able to gather there I would move towards his hip and see exactly what sleeping positions seem to be provoking his symptoms.
– Completely stopped daily routing and working out due to fear
– Unable to tolerate sleeping in bed
– “pulling his back out” with no MOI
I am definitely curious to see what everyone else thinks and how you approached the rest of your evaluation.
June 9, 2019 at 12:02 pm #7590Cameron HolshouserParticipant
List your top 3 differential diagnosis after the subjective?
– Lumbar referral (degenerative disc/lateral stenosis)
– Hip OA
– Glute min/med tendinopathy
How is would this information drive your objective exam?
– Try to differentiate whether this is primarily hip or lumbar driven, knowing that it could have a component of both (If hip, is this intraarticular (joint) or extraarticular (glute tendon)
– Clear SIJ
– Also want to make sure this is a mechanical MSK pain producer
Yellow or red flags?
o Non-MSK referral: prostate, GI/GU, cancer – low on my list
o Stopping gym routine
o Stress about upcoming trip?
Other subjective questions I have:
– What sleeping position
– Which direction when turning (hip IR/ER or lumbar rotation?)
– Standing, stairs – hip related questions
– Non-MSK special questions (CA,GI,GU)
– Prior trauma or injuries?
– What is his exercise routine?
– Stenosis questions – walking in flexed positions vs extended positions (shopping cart/up hill),
– When does he get the leg pain?
June 10, 2019 at 10:24 am #7592
Anwsering the questions!
Did you happen to clarify which position he prefers to sleep in/ what position give him his pain? -states just getting in bed was painful, states not being able to get comfortable….
Getting into and out of his car did his symptoms change if he was getting into the drivers side or passengers side? both but more getting out as the driver
Additionally did he have hip symptoms initially when he had this most recent episode of LBP, does his LBP and hip symptoms have similar aggs and eases? My understanding was some hip pain with his back pain but both usually went away together and now his hip was more intense with no back pain
Has he had treatment for his low back in the past? YES! Had PT for his back about a year ago, was given stretches which he does almost everyday. Help tremendously, not this time.
Stairs? “not bad” standing? didn’t seem to be too much of an issue as a aggravating factor, just less tolerance to walking his usually 10,000-15,000 steps.
Bringing on Leg pain? lateral hip into anterior thigh most prevelant, (feeling it at rest during evaluation), he states it was more painful with the aggs listed (SLEEP being the biggest), standing/stairs or lumbar flexion/extension questions did not seem to be huge contributor to his symptoms
Normal Routine? Gym 5x/week: back stretches, bike, weights, general UE and LE strengthening exercises; states since his normal stretches were not helping he stopped not so much because pain but because he didnt know if what he was doing was bothering his hip
I’ve also attached his p! drawing below. Does this change anything?
June 10, 2019 at 9:47 pm #7595Erik KreilParticipant
Hey Case, I dig the change-up in presentation style.
1. Hip OA > lumbar disc > myogenic referral pattern (iliopsoas, QL, glute med)
2. I’d be really interested in attempting to determine a relationship (or lack thereof) between his original back pain, current hip/ proximal leg pain, and his occasional sharp pain. For all I know, the distal sharp pain has always been there (knee OA, etc), and he’s just including it in his subjective report because he’s not really sure what’s going on anymore. If I can’t find a relationship, is it even mechanically driven?
I’d also be mindful in how I examine him. He’s fearful of making it worse, and his pain can be 7/10 with an apparent big referral down to leg to a worse quality pain so I’d be modest with my approach initially.
(Side note: I’d continue to attack his MOI. Change in meds, anything new going on that week, etc)
3. Things that make me feel better about potential red flags: He lists Best pain as 0/10, he has aggravating/ easing mechanical-seeming factors…
Hey Case — his BMI being 31.3 — is he obese or really muscular? I’d like to get a good mental picture of the gent. And what body part did they look at? (radiograph, I’m assuming)
June 10, 2019 at 11:02 pm #7596
To answer your questions Erik
His occasional lower leg pain was brought to my attention as I asked if it every went past his knee. Lucky me, he said yes and it was a relatively new symptom of his. He states its very minor to his hip, and unable to put an aggravating factor and was minimal to not present during examination or during treatment session. I always had that symptom lingering in the back of my head however I agree I do not know how much of it was mechanical.
BMI: I would say he was somewhere in between your two descriptions.
Red Flags: his subjective did not scream red flags… his objective on the other hand
That being said good segway to objective information.
June 11, 2019 at 9:37 am #7599Jon LesterParticipant
From the Subjective:
List your top 3 differential diagnosis after the subjective?
– hip OA
– glute med/min tendinopathy
– lumbar referral (lateral stenosis/facet arthropathy?)
How is would this information drive your objective exam?
– Need to screen both the hip and lumbar spine and determine relation of posterolateral hip pain, anterior thigh, and lateral shank pain
– Determine relation of intra vs extra articular hip contribution with clustering of findings
– Neuro screen needed and should be multileveled due to varied location of symptoms
Yellow or red flags?
– I don’t see any red flags, but fear of activity, stopping exercise routine, and no MOI are worthwhile to write down and revisit later in the session as yellow flags.
From the Objective:
How does this information change your differential list? Any Concerns?
– The swelling is concerning and I would probe about this a little bit. History of this? TTP to the area and surrounding structures? How long has it been like this? History of trauma even prior to current onset of sx? History of cancer? This is just an odd place to have swelling that I haven’t seen before so maybe I’m overthinking.
– My DD list would be similar but I would add in dural tension. Hip OA might be a little bit less on my radar due to 130 deg of flexion prior to pain – still a possibility though with his limitations in other planes. Depending on the probing about the swelling I might add other DDs like fx, cancer, etc.
What would you have done differentially?
– Maybe try to influence the hip and lumbar spine positioning during lumbar screening (put foot on stool if he had pain with flexion and see if it changes symptoms for example)
– Neuro screen
– Lumbar spine joint mobility testing for hypomobility and referral down the leg/hip
– pubic percussion?? The swelling is concerning and I might be overthinking it just from reading the sheet but this might be beneficial in ruling out more sinister possibilities.
What would do day one?
– possibly mobilize hip (extension/IR) and/or lumbar spine (gapping) for pain relief due to his high irritability within session
– education regarding movement and relation of symptoms to dec in activity level
– exercises to improve lumbar mobility and tolerance to mobility based on response to MT (if gapping helped give gapping exercise, if hip extension mobilization helped give hip extension exercise, etc)
– all of these could change based on the other questions/answers I get and other objective findings that I listed as possibilities to look at (insert girl shrugging emoji)
June 11, 2019 at 1:53 pm #7602
June 11, 2019 at 8:33 pm #7604
June 12, 2019 at 8:33 am #7609Cameron HolshouserParticipant
Based on the objective, I am having a hard time differentiating my post-subjective hypothesis of: lumbar referral, hip OA, and glute med tendinopathy. Seems like the patient is too irritable for a true differential. I am curious to hear why gluteal tendinopathy was your primary diagnosis for this patient. I would actually lean more towards a synovitis in an arthritic hip as my diagnosis.
I think I would have tried to unload his spine and tried a quadruped position with quadruped rocking, to see if his lumbar motion increased. Quick neuro screen as well.
I might recommend a referral to ortho for a stronger anti-inflammatory due to his inability to sleep, high pain levels with minimal active and passive motion, and significant decrease in activity level. I would recommend isometrics (hip ER in supine) and potentially a bike for some active NWB exercise.
June 12, 2019 at 7:53 pm #7611jeffpeckinsParticipant
Hey everyone, sorry I’m late to the party.
Top Subjective Differentials:
– Hip OA
– Glute med/min tendinopathy
– Lumbar referred pain (DDD, discogenic)
– Lumbar radic (Difficult to say which level, esp after looking at pain diagram)
– I would start with a functional exam looking at gait, SLS, swing test, step-ups. Then I would rule out lumbar spine with APR exam. I would perform a neuro exam as he has LBP with lower leg pain as well. Then I would go to the hip.
– Completely stopped exercising (fear of making it worse)
– 20 year history of LBP
– Constant pain that is also painful laying in bed
– Some conflicting things here. Some things seems very glute med/min tendinopathy-like however location of symptoms is strange, and definitely wouldn’t expect back movement to reproduce this pain if this was just a tendinopathy. So I would think that hip OA would move higher towards my differential list with location, lack of hip mobility, and pain with WB.
– His fear and intolerance of WB is slightly concerning to me. Also somewhat concerning is that hip distraction increased his pain.
– I would have done a neuro screen (reflexes and myotomes at a minimum) and PAs to lumbar spine to assess for pain provocation. Also would have also done a traditional SLR. Since he had high irritability, these would have been good things to do to rule out while not aggravating his symptoms too much.
– Day One: I know this is really low-level, but I would probably go with some LTRs (lower trunk rot). It looks like he is not moving his lower back at all, so this could help improve some general mobility here while staying in a NWB position. I really like Cam’s suggestion of a stationary bike, as this would not likely increase his symptoms while giving him some sort of exercise he can participate in.
June 12, 2019 at 9:29 pm #7612Matt FungParticipant
How does this information change you differential list? Any concerns?
– After this objective information I think my differential list would remain the same with lumbar referral and hip OA being my two primary and glute tendinopathy cracking the top three due to reproduction of SLS, and hip ABD. With that being said as jeff mentioned he demonstrates signs and symptoms that makes me believe he might have two separate issues going on here that are resulting in his irritable state.
– The swelling noted on his R ilium raises a few concerns for me especially with no direct MOI. With that and his high irritability I would want to keep a close eye on how he may progress.
What would you have done differently?
– I would have performed a neuro screen especially w/ positing neural testing and further assessed l/s joint mobility to see if there may have been any reproduction of hip sx.
– Number one for me would be attempting to address his sleeping issues. If he is not able to get comfortable and sleep comfortably that is a big concern for me. If he is not sleeping well he is not giving his body time to shut down and recover. Talking through strategies w/ potential use of pillows and seeing if we can find a position of comfort could help calm down his system.
– Treatment wise I would probably attempt to address some of his L/S restrictions due to the irritably of his R hip examination and see if that changed any of his symptoms.
– HEP would have been on the conservative side as well due to his increased irritably during initial evaluation. I would likely lean towards gluteal isometrics and recommend the use of a recumbent bike to incorporate some cardiovascular component back into his regime if he could tolerate the hip flexion moment.
June 12, 2019 at 11:16 pm #7613Myra PumphreyModerator
Hey all – First, Casey – Way to get the discussion going! Good call.
A few quick thoughts –
Any other diagnostic tests that would be helpful here?
Any other things you can ask in subjective to help you differentiate hip from back or glut med from hip OA?
Considered irritable? Both back and hip irritable? Would you be willing to be more vigorous in some tests to help differentiate while being more cautious with others?
What do you think about lumbar extension causing pain while quadrant does not?
After out of car, does his pain ease after several steps, then increase as he continues to walk? Specifically which pain gets worse w/ walking?
If you point out the trendelenberg to the patient in a mirror, does this look like his typical gait or has he or a significant other notice a change related to timing of pain being more significant at the hip?
Anything you see in the literature relating hip OA and glut med pathology?
Which part of his pain is worse with sleep? Can you have him try different strategies with sleep position to help differentiate hip from back and mechanical vs. non-mechanical?
Do you consider these symptoms to be load sensitive? I know that distraction and lying down aggravate, but would there be a scenario where the problem would be irritable to both loading and unloading?
If so, are there ways in your exam you can differentiate from hip/back using loading?
June 13, 2019 at 4:23 pm #7615jeffpeckinsParticipant
Good job today. Looking at Myra’s post, and also in what we talked about today, can you post the article that you looked at that differentiated hip from back symptoms?
June 17, 2019 at 3:45 pm #7616
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