Case:Leg Pain 001

From WikiMSK

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 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.

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.

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)

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