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 one year ago out of the blue. The pain is exertional. It starts in the left anterior groin, and then gradually works its way down the whole leg until the leg feels dead. There is no pain at rest. 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.
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 is 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
