Case:Leg Pain 001

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

PMHx

Heart failure with preserved ejection fraction
Hypertension
Hyperlipidaemia
Atrial fibrillation
Coronary angiogram 3 years ago showing trivial coronary artery disease only
Gout

Medications

Aspirin 100mg daily
Dabigatran 150mg twice daily
Furosemide 40mg mane
Metoprolol 71.25mg daily
Lisinopril 40mg daily
Spironolactone 25mg daily
Atorvastatin 40mg daily
Allopurinol 300mg daily

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)

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.

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

Sagittal Median
Sagittal Paramedian left
L4-5 Transarticular

MRI Lumbar Spine Report

Five lumbar type vertebrae in normal alignment.
No central spinal canal stenosis
Mild disc disease with Schmorl's nodes are seen at L1/2 and L3/4 and L4/5. At L1/2 and L2/3 no focal disc protrusion neural compromise or foraminal narrowing is seen.
At L3/4 there is minor bulging of the disc annulus with a shallow left paracentral bulge but without neural compromise or foraminal narrowing there is mild facet disease.
At L4/5 left sided annular tear. There is left lateral recess stenosis with mild neural contact, but no neural compression. There are small facet effusions with mild facet disease.
At L5/S1 no focal disc protrusion neural compromise or foraminal narrowing is seen. There is moderate hypertrophic facet disease. No abnormal bone marrow or soft tissue oedema is seen.
The visualised SI joints are unremarkable.
Conclusion: L4/5 left lateral recess stenosis contacting the descending left L5 nerve root but no compression.

You bring him back in for a vascular examination and ankle brachial pressure index (ABPI) measurement

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	Left
Brachial	122	122
DP	110	96
PT	158	96
ABPI	1.29	0.78

You refer him to vascular surgery who organise an MRI angiogram

MRI Angiogram Report

There is a critical stenosis of the left iliac artery bifurcation.
The iliac artery above and below this is normal although the internal iliac artery is diminutive.
The femoral and popliteal arteries are essentially normally in calibre apart from mild irregularity and stenosis in the mid left superficial femoral artery.
There is three vessel runoff to each calf.
The high grade left iliac bifurcation stenosis would be amenable to endovascular treatment.

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

He is doing much better