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
- Heart failure with preserved ejection fraction
- Atrial fibrillation
- Coronary angiogram 3 years ago showing trivial coronary artery disease only
- 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
- He is still working at 70, retired 4 times. He does sedentary accountancy type work.
- 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 bring him back in for a vascular examination and ankle brachial pressure index (ABPI) measurement
- 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
Left distal CIA stenosis treated with 8mm Shockwave IVL and 9 x 59 Omnilink Elite stent
He is doing much better