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Old 06-01-2012
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Rheumatology/Orthopedics Hip and Pelvic Pains!

A 54-year-old woman is evaluated for pain in the right posterior hip and pelvic area that she noticed upon awakening 3 days ago. She had been moving and lifting boxes the day before the onset of pain. She has experienced similar pain several times over the last 2 years, but it has never lasted so long. On physical examination, BMI is 30. The FABER test (Flexion, ABduction, and External Rotation of the hip) elicits pain in the right posterior pelvis. There is tenderness on palpation over the right posterior pelvic girdle. Flexing the hip is painful. There is no tenderness in the right groin, the right trochanter, or the right gluteal notch. Passive range of motion of the right hip reveals no pain. Straight-leg-raising test is negative, and deep tendon reflexes are normal. Which of the following is the most likely diagnosis?

A Osteoarthritis of the right hip
B Piriformis syndrome
C Right L5 radiculitis
D Right sacroiliitis
E Right trochanteric bursitis
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Old 06-01-2012
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Originally Posted by Novobiocin View Post
A 54-year-old woman is evaluated for pain in the right posterior hip and pelvic area that she noticed upon awakening 3 days ago. She had been moving and lifting boxes the day before the onset of pain. She has experienced similar pain several times over the last 2 years, but it has never lasted so long. On physical examination, BMI is 30. The FABER test (Flexion, ABduction, and External Rotation of the hip) elicits pain in the right posterior pelvis. There is tenderness on palpation over the right posterior pelvic girdle. Flexing the hip is painful. There is no tenderness in the right groin, the right trochanter, or the right gluteal notch. Passive range of motion of the right hip reveals no pain. Straight-leg-raising test is negative, and deep tendon reflexes are normal. Which of the following is the most likely diagnosis?

A Osteoarthritis of the right hip
B Piriformis syndrome
C Right L5 radiculitis
D Right sacroiliitis
E Right trochanteric bursitis
Piriformis syndrome
From exclusion
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Old 06-02-2012
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This patient is probably suffering from right sacroiliitis from strain. The sacroiliac joint is susceptible to strain injuries, particularly in overweight patients who do not routinely exercise. Pain in the posterior pelvic region when performing the FABER test (Flexion, ABduction, and External Rotation of the hip) with the absence of pain on passive hip rotation is fairly specific for sacroiliac joint pathology.

Hip pain from osteoarthritis usually presents as groin pain and occasionally radiates to the knee and localizes to the buttock. Weight bearing is often painful, and patients usually have evidence of osteoarthritis elsewhere. Osteoarthritis of the hip is also associated with pain during both passive and active range of motion, which is not present in this patient. Furthermore, the diagnosis of osteoarthritis, a chronic medical condition, is unlikely in a patient who presents with the acute onset of symptoms of 3 days’ duration.

Piriformis syndrome is a common source of sciatic nerve pain resulting from irritation and hypertrophy of the piriformis muscle. Pain is reproduced by applying pressure to the sciatic notch, a finding that was absent in this patient.

Most patients with a herniated disk and associated radiculitis will have a positive straight-leg-raising test, which is absent in this patient.

Trochanteric bursitis can be confirmed in patients in whom hip adduction intensifies the pain or in those in whom the examination reveals pain and tenderness over the bursa. The absence of lateral hip pain in this patient makes trochanteric bursitis unlikely.
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