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
The referring doctor previously organised the below x-ray of his pelvis and hips
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 Paramedian left
You bring him back in for a vascular examination and ankle brachial pressure index (ABPI) measurement
You refer him to vascular surgery who organise an MRI angiogram
Left distal CIA stenosis treated with 8mm Shockwave IVL and 9 x 59 Omnilink Elite stent
He is doing much better