Sandy Brooks: A 69-Year-Old Female With Left Hip and Groin Pain

Learning Objectives

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Learn the common causes of hip pain.
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Develop an understanding of the unique anatomy of the hip joint.
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Develop an understanding of the causes of avascular necrosis of the hip.
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Learn the clinical presentation of avascular necrosis of the hip joint.
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Learn how to use physical examination to identify pathology of the hip joint.
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Develop an understanding of the treatment options for avascular necrosis of the hip joint.
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Learn the appropriate testing options to help diagnose avascular necrosis of the hip joint.
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Learn to identify red flags in patients who present with hip pain.
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Develop an understanding of the role in interventional pain management in the treatment of hip pain.

Sandy Brooks

Sandy Brooks is a 69-year-old retired teacher with the chief complaint of, “My left hip hurts whenever I walk.” She volunteered that her left hip had been bothering her for the last couple of years, but she hadn’t realized how bad it had gotten because, until her pulmonologist upped her prednisone dose, her breathing had been so bad that she was primarily staying in her recliner all day long. “Doc, whatever you do, don’t smoke those coffin nails! They did me in, and I don’t want that to happen to you. Dealing with this oxygen 24 hours a day is no picnic.” I reassured Sandy that I never smoked and had little intention of starting now, and she patted my hand and said, “Thank God!” I asked her, “Other than prednisone and breathing medicines, have you tried anything else to help the pain?” Sandy said she had “tried rubbing on the Australian Dream and took some Tylenol, but I guess the pain was just down too deep for them to work.” Sandy also noted that she had to stop using her heating pad because she fell asleep with it on and she accidently burned herself. “Doc, I just don’t have any strength anymore. I’ll have you know that I was quite an athlete when I was younger. Now, it’s all I can do to get up and go to the ladies’ room.”

I asked Sandy if she had ever injured her left hip before and she thought for a moment, and said, “You know, when I was 5 or 6 years old, I got hit by a car when I ran out into the street to get my ball and had a dislocated hip. I can’t remember which one—it was so long ago. It’s a wonder I remember my own name any more.” I gave her shoulder a squeeze, smiled, and told her that she was doing great and that we were going to figure out what was wrong with that hip and do what we could to get it better.

I asked Sandy to point with one finger to show me where it hurt the most. She pointed to the front of her left groin and said, “Doc, it hurts way down deep, and it really gets my attention when I try to bear weight on it. I really dread having to get up to go to the ladies’ room. It really hurts, but I don’t want to have an accident.” I asked, “Does the pain go anywhere?” and Sandy noted that sometimes it radiated to the side of her thigh. Sandy denied any gynecologic symptoms or blood in her urine.

On physical examination, Sandy was afebrile and dyspneic at rest. Her respirations were 22. Her pulse was 88 and regular. Her blood pressure (BP) was normal at 112/76. In spite of the recent increase in her prednisone dose, Sandy did not appear cushingoid, but she looked like she had lost a little weight since I had seen her for her flu shot. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her thyroid examination. Her cardiopulmonary examination revealed diminished breath sounds with prolonged expiration and a few wheezes. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. I did a rectal and pelvic exam, which were both normal other than mild atrophic vaginitis. Visual inspection of the left groin and hip revealed no cutaneous lesions or obvious hernia or other abnormal mass. The area overlying the left hip was cool to touch. Palpation of the left hip revealed mild diffuse tenderness, with no obvious effusion or point tenderness. There was mild crepitus and I thought I detected a click with range of motion. The overall range of motion was decreased with pain exacerbated with active and passive range of motion. I had Sandy walk down the hall and noticed that she had a positive Hopalong Cassidy sign for antalgic gait ( Fig. 2.1 ). The right hip examination was normal, as was examination of her other major joints, except for some mild osteoarthritis in the left hand. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

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A history of a recent increase in prednisone dose to treat an exacerbation of chronic obstructive pulmonary disease (COPD)
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A questionable distant history of acute trauma to the left hip/dislocation after being hit by a car
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A several-year history of some left hip pain with a recent acute exacerbation after an increase in prednisone dosage
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Increase in pain with weight bearing
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No fever or chills

The Physical Examination

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The patient is afebrile
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Normal visual inspection of hip
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Palpation of left hip reveals diffuse tenderness
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No point tenderness
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No increased temperature of left hip
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Crepitus to palpation during range of motion of left hip
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Click sensation during range of motion of left hip
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Positive Hopalong Cassidy sign on the left (see Fig. 2.1 )

Other Findings of Note

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Normal BP
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Normal HEENT examination
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Normal cardiovascular examination
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Abnormal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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No groin mass or inguinal hernia
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No CVA tenderness
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Normal pelvic exam
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Normal rectal exam
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Normal upper extremity neurologic examination, motor and sensory examination
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Examinations of joints other than the left hip were normal

What Tests Would You Like to Order?

The following tests were ordered:

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Plain radiograph of the left hip
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Magnetic resonance imaging (MRI) of the left hip

Test Results

The plain radiographs of the left hip revealed sclerotic changes of the femoral head consistent with advanced avascular necrosis ( Figs. 2.2 and 2.3 ).