By William Thatcher, DC
Abstract: Objective: To examine the diagnosis and care of a patient suffering from concurrent lower back pain with radiation into the hip and medial thigh. The patient also complains of lateral hip pain and pain in the inner groin with a clicking sound in the right hip joint. Diagnostic studies included Physical examination, range of motion, orthopedic, neurological testing, Radiological imaging, lumbar and hip MRI
Keywords: lower back pain, buttock pain, groin pain, lumbar disc degeneration, femoroacetabular impingement (FAI), spondylosis, facet arthropathy, disc bulge, degenerative spondylolisthesis, labrum, femoroacetabular joint
Introduction: On 09/07/2022, a 60-year-old female presented to our office for examination and treatment for the gradual onset of right-sided lower back and stiffness of four months duration. The pain was described as aching, throbbing, and tingling with radiation into her right buttock, lateral hip, and anteromedial thigh, with a rating of 8 out of 10 on the VAS (visual analog scale). The patient stated that her lower back was aggravated by yardwork, bending, lifting, and performing household chores. She also complained of right lateral hip pain and groin pain accompanied by a clicking sensation. She stated that this condition has also been present for approximately four months duration. This condition was rated as 6 out of 10 on the VAS (visual analog scale). She stated that this condition was aggravated by squatting, climbing stairs, prolonged sitting, and prolonged walking, which would worsen her condition, at which point she would rate her symptoms as an 8 out of 10.
Prior treatment: Orthopedic care with radiographs of the right hip. The patient was diagnosed with Right hip femoral acetabular impingement. Physical therapy on the right hip is eight weeks in duration with limited response. Subsequent Orthopedic re-evaluation Radiographs of the lumbar spine were performed; patient was diagnosed with lumbar degenerative disc disease and recommended continued Physical therapy with added instructions of physical therapy to address the lumbar spine condition. She continued with Physical therapy for an additional four weeks, at which point she felt her symptoms were worsening, and she presented herself to my office for evaluation.
Prior History: Multiple sclerosis 20 years duration
Family and Social History: The patient is retired.
Vitals: age 60, height 5’9”, 200lbs, BP 125/80 mm/Hg left arm in the seated position, pulse 63bpm, Temperature Taken with a skin surface scanner 97.9 degrees Fahrenheit
Appearance: visibly uncomfortable and concerned, difficulty changing positions
Gait and Station: normal gait and normal balance
An evaluation and management exam was performed. The exam consisted of a Visual inspection of the lumbar spinal ranges of motion and right hip, digital palpation, manual testing of muscles, deep tendon reflexes, and orthopedic and neurological findings. The lumbar exam showed the following decreased motion on the visual exam in flexion, extension, and right lateral flexion. All the above motions produced pain. Decreased motion with pain was elicited with right hip flexion, adduction, abduction, and internal and external rotation. Visual inspection of the lumbar spine and right hip revealed no gross deformity or skin changes.
When digital palpation was performed in the lumbar spine, there was a mild spasm noted bilaterally in the lumbar paraspinal areas, with moderate tenderness noted on the right. There was tenderness laterally over the right greater trochanter.
Orthopedic/neurological testing: Kemps test was positive for pain and tingling sensation in the right buttock and lateral thigh. Heel walk was positive on the right 4/5 for mild weakness which the patient stated had been present for 10 years. Fabere /Patrick test was positive on the right. The patellar and Achilles reflexes were 3+ and bilaterally symmetrical.
Due to the examination findings, persistent symptoms, and limited response to her previous care a lumbar and right hip MRI was ordered to obtain a more definitive diagnosis.
An initial radiographic study of the lumbar spine and right hip was conducted by the orthopedist.
Lumbar radiographs in the A-P and lateral projections revealed a mild left lumbar curve with the apex at L2-L3. Degenerative disc disease L2-L3 through L4-L5 more pronounced at L2-L3 and L3-L4. Anterior and posterior osteophytic spurring L2-L3 through L3-L4. Mild anterolisthesis of L4 on L5. Posterior joint arthrosis L2 through S1.
Right hip radiographs in the A-P and frog leg projections revealed osteoarthritis of hip joint with acetabular spurring.
Lumbar MRI Image #5 T2 sagittal Disc bulge is evident at the L2-L3 level. Image #6 T2 axial image at the L2-L3 level. Red arrow reveals narrowing of the right neural canal. Blue arrow is pointing to hypertrophy of the right zygapophyseal joint contributing to narrowing of the right neural canal and central canal stenosis. The green arrow reveals stenosis of the central spinal canal.
Right hip MRI image #7 coronal PD fat saturation red arrow is pointing to tendinosis with low-grade partial- thickness tearing of the deep fibers and mild peritendinitis at the distal gluteus medius insertion on the lateral greater trochanter. The blue arrows are showing moderate diffuse generalized chondral thinning at the weightbearing surfaces of the right femoroacetabular joint.
Image #8 oblique PD fat saturation view reveals partial tearing of the anterior superior labrum.
Treatment: After reviewing the patient’s clinical findings, radiographic and MRI studies treatment was initiated to the lumbar spine. The therapeutic goal was decompression of mid to lower lumbar spine to alleviate nerve impingement. Patient was treated utilizing Cox flexion/distraction, electric muscle stimulation and heat therapy, as well as a home lumbar strengthening and stretching exercises. The patient underwent six weeks of care with resolution of the throbbing and tingling into her anteromedial thigh. She rates her lower back and right buttock pain to be 1 out of 10 on the VAS (visual analog scale). The patient continued to have pain in the right groin and lateral hip exacerbated by prolonged standing and walking.
Patient was referred to her orthopedic surgeon for evaluation and recommendations. The orthopedist recommended interventional pain management due to her limited response to physical therapy.
Discussion: The diagnosis and management of concurrent hip and spine conditions can be challenging for the clinical practitioner. In this case the patient was initially managed for the hip pathology. Due to the persistent nature of her symptomatology a lumbar examination with radiographs was performed. The patient had twelve weeks of Physical therapy with limited response to care prior to presenting to our office for examination and treatment. Due to the patient’s duration of symptoms and clinical findings a lumbar spine and hip MRIs were ordered to obtain a definitive diagnosis of her conditions. The results of these tests enabled us to formulate a more accurate diagnosis to guide the appropriate treatment to her lumbar spine as well as referral to her orthopedist to manage her hip condition. The difficulty in diagnosing and managing patients with spine and hip pathologies can be attributed to similarities in their clinical presentation. Many of these patients can present with hip, buttock thigh, groin symptoms which create a diagnostic dilemma for the treating provider. A thorough history, examination and advanced Imaging can assist the clinician in obtaining a definitive diagnosis and treatment plan.
1.Groh, M. M., & Herrera, J. (2009). A comprehensive review of hip labral tears. Current Reviews in Musculoskeletal Medicine, 2(2), 105-117.https://doi.org/10.1007/s12178-009-9052-9
2. Wilson JJ, Furukawa M. Evaluation of the patient with hip pain. Am Fam Physician. 2014 Jan 1;89(1):27-34. PMID: 24444505.
3. DeFroda SF, Daniels AH, Deren ME. Differentiating Radiculopathy from Lower Extremity Arthropathy. Am J Med. 2016 Oct;129(10):1124.e1-7. doi: 10.1016/j.amjmed.2016.06.019. Epub 2016 Jul 9. PMID: 27401953.
4. Kruse RA, White BA, Gudavalli S. Management of Lumbar Radiculopathy Associated with an Extruded L4-L5 Spondylolytic Spondylolisthesis Using Flexion-Distraction Manipulation: A Case Study. J Chiropr Med. 2019 Dec;18(4):311-316. doi: 10.1016/j.jcm.2019.02.001. Epub 2020 Mar 9. PMID: 33408591; PMCID: PMC7774099.
5. Winter CC, Brandes M, Müller C, Schubert T, Ringling M, Hillmann A, Rosenbaum D, Schulte TL. Walking ability during daily life in patients with osteoarthritis of the knee or the hip and lumbar spinal stenosis: a cross sectional study. BMC Musculoskelet Disord. 2010 Oct 12;11:233. doi: 10.1186/1471-2474-11-233. PMID: 20939866; PMCID: PMC2958990.