May Journal Club Case – Bonus Addition

[August Winter]

Hey all, I am doing a journal club for our clinic so I am posting the case and article here so that my coworkers can look at it, but look over it and comment if you get a chance (deference to Katie’s post coming soon).

Outcomes measures:
LEFS: 30
NPRS (current/best/worst): 2/0/7

Subjective: Pt is a 68 yr old male presenting following a L THA with posterolateral approach on 3/20/16. The pt had an uncomplicated post-op course of home PT and OP PT in which he was able to perform the leg press, weighted step ups, and sled push. Pt began having lateral hip pain in August when he began decreasing the amount of NSAIDs he was taking. Pain is dull and aching, described as deep. Pain frequently radiates form the lateral hip down the leg as well as into the anteromedial thigh, but also can be present only distally. Patient also experiences some pain posteriorly at the ischial tuberosity. Patient denies back pain, weakness, numbness/tingling, weight loss, systemic fever/chills. MRI of the back revealed minimal degenerative changes. Multiple hip XR reveal components grossly stable. Pre surgical MRI no glute pathology found, op note reporting deep rotators and glutes successfully reattached. CSI to the L trochanteric bursa produced little to no relief locally.

– Aggravating factors: increased loading and then unloading on the LLE, turning quickly on the L leg (ER worse than IR), prolonged walking
– Easing factors: laying supine, sitting, activity modification, NSAIDs
– PMH: Psoriatic arthritis, MDD
– Medications: mobic, celebrex, cialis, triamcinolone, wellbutrin

Primary hypothesis after subjective: gluteus medius pathology (tendinopathy to partial tear)

Differential list: complete glute tear, TFL/iliopsoas/lumbar multifidi muscular referral, lumbar somatic facet referral (instances of lateral pain), L3/L4 radicular pain due to foraminal stenosis

Objective:
– Lumbar clearing: rotation limited L > R but nonpainful when performed slowly, extension quadrant w/compression, OP, and hold non-provocative, CPAs/UPAs hypomobile throughout but non-provocative
– Slump and SLR reproduce nontypical posterior thigh pain, symmetrical minimal restrictions in knee ext and hip flexion respectively, improve with neutral cervical spine
– Dbl leg squat nonpainful, SL stance painful lateral and anterior thigh with unloading from L leg > initial loading. Gait not assessed on TM until visit 4, at initial eval pt demo’s L lateral trunk lean during L stance w/no hip drop noted
– MMT: hip ABD 4-/5 and reproduces lateral hip pain radiating down leg to knee. IR/ER in sitting nonpainful, hip flexion nonpainful
– Palpation: glute med palpation reproduces lateral hip into anteromedial thigh pain, TFL and piriformis min TTP locally
– L hip flexion 105 deg, IR 10 deg, ER 35 deg (assessed in supine). R 110, 20, and 45 deg
– Ober’s, 90/90 both moderately restricted on L > R

Severity: moderate (low LEFS, significant subj impact on recreational activities such as walking, gym weight machines)
Irritability: moderate (pain comes on easily but does not linger if the offending activity is ceased)
Stage: chronic
Stability: stable

Dx: L hip glute med partial tear

Treatment:
Visit 1: HEP provided of double leg bridge, prone heel squeeze, seated tb ER

Visit 2: Pt reports no change in his sx but that he did not have any pain with his HEP. Pt 30 min late to appointment prior to an evaluation so session consisted of reviewing HEP form, trialing the total gym and recumbent bike, both of which were pain free

Visit 3: SL stance produces 4/10 lateral mid thigh pain.
– Recumbent bike and total gym squat warm up
– Soft tissue massage to TFL and glute med
– Quadruped bent leg kick back alternating 3×12
– Wall squat w/5 second hold at bottom with glute squeeze

Visit 4: Subjective reports of decreased medial and anterior thigh pain, but continued lateral thigh pain, more so mid thigh versus proximal to distal in the past week. Objective testing: SL stance continues to reproduce pain mid lateral thigh, particularly w/loading into unloading. SL heel drop reproduces worst pain mid lateral thigh. Hip ABD MMT minimally reproduces lateral thigh sx. Femoral shaft fracture test negative. Gait: decreased ankle ER on L, significant lateral trunk lean to L during L stance.

While treating this patient during mentoring hours he mentioned that he also receives Remicade infusions for his arthritis. While not common, Remicade can result in decrease bone mineral density. In discussing this case and the patients pain pattern with Eric I have changed my primary diagnosis to L thigh pain d/t irritation at the femoral shaft component, with secondary gluteal pain.

– Gait training with a straight cane and mirror cues for increased ER of the L foot and decreased trunk lean
– Alternating forward lunges at a painfree depth 3×15

Visit 5:decreased severity and frequency of pain in the last week. Pt demonstrates decreased hip external rotation in prone and PA hip hypomobility.
– L hip PA in full ER
– Dbl leg bridge with tb around knees 3×15
– Standing tb hip ER 2×20
– Gait training with a straight cane and mirror cues for increased ER of L foot
– Alternating forward lunges at a painfree depth 3×15 (inc depth in this session)

Initial PICO: In an older patient with a possible glute med tear, would exercises targeting glute max versus a general lower body strengthening routine decrease pain and improve function?
Final PICO: What are the clinical features, risk factors, differential diagnoses and treatment options for a patient with possible femoral stem component pain?

Discussion questions:
1. How frequently do you see patients for lower quarter following THAs? What sort of deficits have you seen following that surgery and what strengthening interventions did you find most beneficial?
2. Follow up question: given the reported incidence of thigh pain following THA (1.9% – 40% per the article) have any of you had to work through this differential diagnosis before? This was something completely unknown to me and yet it seems to be fairly common.
3. If you are this patient’s PT, what is your next step for referral out for treatment/imaging/specialist assessment?
4. Lastly, this patient came in very frustrated with the lack of answers from his medical team, and talked for nearly 30 minutes. At this point in my career I have a hard time knowing what cues to use to help guide the conversation back to the exam, or even what cases it’s even worth trying as sometimes it can be therapeutic for people to express their frustrations without interruption. What things have you all found help you navigate this delicate situation?

First article I thought was just an interesting library addition if people had not already seen it, the second article will be the one discussed.

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