Regional Soft Tissue Pain

A 68 year-old female is evaluated for several months of left hip pain. She has multiple medical problems including diabetes, hypertension, coronary artery disease and osteoarthritis. She has known degenerative disease of her knees and has used a cane for ambulation for several years. Five years ago she underwent lumbar surgery for degenerative disc disease. She takes 2-3 hydrocodone-acetaminophen tablets a day for the back and knee pain.

The hip pain is new for the past 2-3 months. She localizes the pain to the upper outer thigh overlying the greater trochanter. The pain is particularly problematic when she lies on her left side and it interferes with her sleeping. She does not note any increased pain with walking. Her knee and back symptoms are unchanged. The pain does not radiate down the leg. She denies any numbness to the area of the pain.

What is the differential for hip pain that localizes to the lateral thigh/hip region?

The first step in the evaluation of musculoskeletal pain is attempting to localize the site of pain: articular, periarticular, regional (bone or muscle), and referred sources. Developing a systemic approach to the patient presenting with acute musculoskeletal symptoms is important, and several review articles offer excellent summaries on the approach of patients with regional and diffuse musculoskeletal complaints. [8, 9]

The differential of hip pain should include articular abnormalities of the hip, bursa and tendon disorders, neurologic disorders, referred pain from the knee, and bone disorders. Pain from disorders of the hip articulation such as osteoarthritis and avascular necrosis generally are noted in the groin but pain may be more diffuse. Trochanteric bursitis pain is localized over the greater trochanter with tenderness elicited in that area. Meralgia paresthetica causes paresthesias and numbness over the lateral thigh. The iliotibial band syndrome, a syndrome most commonly seen in runners, causes lateral but typically distal thigh pain. Lumbar spine disease with nerve root entrapment especially involving L2 to L4 may cause pain described as in the hip and thigh, while lumbar spinal stenosis typically produces bilateral leg pain with walking. Bone abnormalities including primary bone malignancies, metastatic bone lesions, occult fractures and Paget’s may present with localized hip and leg pain. Inter-abdominal abnormalities causing referred pain include abscesses, renal stones and hernias.

How does the positional nature of the pain aid in localizing the source of the pain?

Pain occurring with palpation or pressure over the greater trochanter would be most characteristic of trochanteric bursitis. Local bone abnormalities should also be considered. Unlikely in this scenario would be referred pain from an intra-abdominal or lumbar spine process.

On exam, the patient is 5’2’’ and weighs 180 lbs. She is stiff on arising and walks with a cane. There is no tenderness over her spine nor back. There is increased tenderness to palpation over the left greater trochanter but not on the right side. Rotation, flexion and abduction of the left hip are normal but she notes pain in her left lateral thigh with adduction of the left hip. On knee exam there is crepitus bilaterally but no effusion. Range of motion of the knee does not reproduce the pain. Neurologic exam of the lower extremities is intact and there is no loss of sensation elicited over the lateral left thigh.

A diagnosis of trochanteric bursitis is made on the basis of the history and exam findings.

Are any additional studies warranted at this time?

No further studies are warranted giving the typical nature of the history and exam findings.

What history and exam findings would have been characteristic for degenerative hip disease, radicular pain from degenerative back disease, metastatic bone pain, referred pain from the knee and meralgia paresthetica?

Degenerative hip disease would typically cause pain with weight bearing and ambulation, and be relieved with recumbency; pain is often reproduced with active or passive range of motion testing of the hip articulation. Radicular pain from the lumbar spine should not cause localized tenderness in the hip or thigh but would instead be associated with abnormalities on neurologic testing. Metastatic bone lesions classically cause constant pain which is not positional. Meralgia paresthetica causes numbness and paresthesia over the lateral thigh.

What other potential diagnoses are in the differential? What clinical and/or exam features make these less likely?

• Long-standing diabetes can be associated with a proximal neuropathic process called diabetic amyotrophy. It causes pain, and in some cases weakness, of the proximal thigh and hip-girdle muscles. Roughly 50% of cases are unilateral. The focal nature described by the patient, localized to a specific region of the lateral thigh, would not be typical of diabetic amyotrophy. In addition, the lack of weakness and absence of severe pain are reassuring for an alternative cause.
• Subtrochanteric femur fractures can present with deep thigh pain, and should be considered in patients with long-standing bisphosphonate use with unexplained hip/thigh pain. A detailed history should be obtained regarding osteoporosis/osteopenia and use of anti-resorptive therapy. Again, the focal quality of this patient’s pain is classic for trochanteric bursitis; if the patient failed to respond to typical therapy, radiographs of the hip and thigh could be considered, especially in the setting of long-term anti-resorptive therapy. The lack of increased pain with walking also makes a subtrochanteric fracture less likely.
• Improper use of assistive device (cane). A cane that is improperly fitted to a patient can result in pelvic tilting and subsequent strain on muscles and tendons in the pelvic girdle. In the standing position, the handle of the cane should rise to approximately the volar crease of the wrist.

What treatment options are available for trochanteric bursitis?

• Oral NSAIDs, ice
• Physical therapy or home exercises (with focus on stretching of the adjacent iliotibial band as well as the gluteus medius and minimus)
• Local glucocorticoid injection

Using sterile technique and 25 gauge 1 ½ inch needle, 2 cc of local anesthetic and 40 mg of injectable corticosteroid preparation are injected deep in the area of greatest tenderness overlying the left greater trochanter. Immediately following the procedure, the patient relates significant improvement in the pain when palpated.

• A 2 ½ inch spinal needle may be needed for steroid to reach the bursa in obese patients.
• The initial response to the local injection of anesthetic helps confirm the diagnosis of trochanteric bursitis and rule out other entities. The steroid injected may provide long term benefit.
• Recurrent symptoms would warrant other therapy including physical therapy and evaluation for precipitating factors (such as leg length discrepancy or hallux rigidus) or re-consideration of alternative cause (including gluteal muscle or tendon tears, or alternative conditions listed above)