Case:Leg Pain 001: Difference between revisions

Revision as of 13:44, 4 July 2021

70 year old man with a one year history of exertional left lower limb pain, referred to you for consideration of a left hip corticosteroid injection.

The pain started a year ago insidiously. It is exertional in nature with no pain at rest. It comes on after 30 metres but it is inconsistent. The pain starts in the left anterior groin and lateral hip, and then gradually works its way around to the back of the thigh but not buttock, and down the lateral aspect of the leg and foot. The lower limb also getting progressively more numb, and by 100 metres he has pins and needles in his foot. If he rests then goes away after 5-10 minutes. Prolonged standing is normally ok. The pain comes on especially with hills but even walking around the supermarket he isn't able to manage now.

He been seeing a physiotherapist for the pain who has been giving him exercises and go him going on an exercise bike, but he finds the exercises uncomfortable. He finds he is walking less. It has gotten to the extent that can't do gym work anymore. He feels frustrated.

He does not have any current back pain. He has also been getting dystonia in the bilateral hands and fingers over the past few months. He has had an intentional weight loss of 10kg

Previous Imaging

The referring doctor previously organised the below x-ray of his pelvis and hips

Pelvis and Left Hip Radiograph Report

There is slight cartilage space narrowing posteromedially in both hips not associated with any marginal spur formation. Cartilage space is preserved superiorly. Remainder of the bony pelvis and the sacroiliac joints are normal.

PMHx

Heart failure with preserved ejection fraction
Hypertension
Hyperlipidaemia

Social history

He is still working at 70, retired 4 times. He does sedentary accountancy type work.
Ex-smoker

Gait normal
Spine range of motion grossly normal
No lower limb wasting, tone, power, reflexes, sensation normal
Slump test and straight leg raise negative
No tenderness over the lateral hip abductors
Mild left groin tenderness
Hips: Internal rotation 10 degrees, external rotation 30 degrees, equal bilaterally
Springing over L5/S1 segment causes shooting pains down the right leg (contralateral limb to symptoms)

You refer him for an MRI of his lumbar spine to query spinal stenosis

MRI Lumbar Spine Report

L4/5 left lateral recess stenosis with mild neural contact, but no neural compression. There is no central spinal stenosis.

Here for ABPI measurement

symptoms deteriorating can only walk 50 metres if that.

vascular examination: - left side: unable to feel femoral, popliteal, DP or PT pulses - right side: weak femoral pulses, can't feel popliteal, weak DP and PT pulses

ABPI - right: 1.29 - left: 0.78 (symptomatic side)

ABPI data: Left brachial: 122/80 Right brachial: 122/60 Left DP: 96 Left PT 96 Right DP: 110 Right PT 158

A: Peripheral vascular disease

P: refer vascular surgery

MRI angiogram - severe stenosis left iliac artery

Left distal CIA stenosis treated with 8mm Shockwave IVL and 9 x 59 Omnilink Elite stent

Doing much better

@@ Line 2: / Line 2: @@
 year old man with a one year history of exertional left lower limb pain, referred to you for consideration of a left hip corticosteroid injection.
-The pain is exertional in nature with no pain at rest. It started a year ago insidiously. The pain starts in the left anterior groin, and then gradually works its way down the lateral hip and down the lateral aspect of the leg and foot. The lower limb also getting progressively more numb. it comes on after 30 metres but it is inconsistent. If he rests then goes away after 5-10 minutes. Prolonged standing is normally ok. The pain comes on especially with hills but even walking around the supermarket.
+The pain started a year ago insidiously. It is exertional in nature with no pain at rest. It comes on after 30 metres but it is inconsistent. The pain starts in the left anterior groin and lateral hip, and then gradually works its way around to the back of the thigh but not buttock, and down the lateral aspect of the leg and foot. The lower limb also getting progressively more numb, and by 100 metres he has pins and needles in his foot.  If he rests then goes away after 5-10 minutes. Prolonged standing is normally ok. The pain comes on especially with hills but even walking around the supermarket he isn't able to manage now.
 He been seeing a physiotherapist for the pain who has been giving him exercises and go him going on an exercise bike, but he finds the exercises uncomfortable.
 He finds he is walking less.  It has gotten to the extent that can't do gym work anymore. He feels frustrated.
-He does not have any current back pain.
+He does not have any current back pain. He has also been getting dystonia in the bilateral hands and fingers over the past few months. He has had an intentional weight loss of 10kg
 '''Previous Imaging'''
@@ Line 45: / Line 45: @@
 =Imaging 1=
-Review.
+You refer him for an MRI of his lumbar spine to query spinal stenosis
-Pain getting progressively worse
-Can walk, but can't go around supermarket shopping without having a break.
-pain comes on after 50-60 metres
-starts of around hip and radiates down the leg, not really in the buttock, but goes down the back of thigh, and into the knee. Pins and needles in feet after 100 metres.
-If not walking it is fine.
-also dystonia bilateral hands fingers since early this year
+{{Collapsible textbox
+|title=MRI Lumbar Spine Report
-intentional 10kg weight loss
+|text= L4/5 left lateral recess stenosis with mild neural contact, but no neural compression. There is no central spinal stenosis.
+}}
-MRI reported as normal but reading images myself possibly L4/5 left lateral recess stenosis with neural contact, but no neural compression.
-on exam left hip IR reduced 10 degrees
-neurological examination normal
-no spinal tenderness
 =Follow Up Visit=