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.
Left lateral hip and lower limb pain started easter last year out of the blue came on espcially with hills gradually worked its way down the whole leg, felt a "dead leg" got to the extent that couldn't do gym work anymore been seeing a physio. has an exercise bike. finds the exercises uncomfortable. finds is walking less. even walking around the supermarket. feels frustrated. no pain at rest. comes on after 30metres but it is inconsistent. if rests then goes away after 5-10 minutes. no current back pain. prolonged standing is normally ok still working, retired 4 times. accountancy type work.
O: gait normal spine range of motion grossly normal no lower limb wasting tone, power, reflexes, sensation normal straight leg raise negative no tenderness over the lateral hip abductors mild left groin tenderness bilateral hips internal rotation 10 degrees, external rotation 30 degrees anteroposterior springing over L5/S1 segment causes shooting pains down the right leg (contralateral limb to symptoms)
A: The clinical features are most in keeping with spinal stenosis Has mild hip OA but symptoms are not consistent with this.
P: xray referral orthopaedics for MRI scan and consideration of injection or operative treatment if diagnosis confirmed.
Review. 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
intentional 10kg weight loss
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
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
