43-year-old attorney comes to the office because of pain in his right lower extremity. He is an avid tennis player, and lately, he has started to notice pain in his right groin area whenever he runs or jogs. The pain is described as a soreness that travels down his anterior thigh toward his knee. It is present with moderate activity and improves with rest. Lying on his right side does not affect the pain. There is no associated numbness or muscle weakness.
His temperature is 37.2 C (98.9 F), blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 12/min. His cardiac, pulmonary, and abdominal examinations are within normal limits. His hip examination reveals pain along the anterior hip worsened with internal and external rotation.
Which of the following is the most likely diagnosis?

Question

43-year-old attorney comes to the office because of pain in his right lower extremity.  He is an avid tennis player, and lately, he has started to notice pain in his right groin area whenever he runs or jogs.  The pain is described as a soreness that travels down his anterior thigh toward his knee.  It is present with moderate activity and improves with rest.  Lying on his right side does not affect the pain.  There is no associated numbness or muscle weakness.
His temperature is 37.2 C (98.9 F), blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 12/min.  His cardiac, pulmonary, and abdominal examinations are within normal limits.  His hip examination reveals pain along the anterior hip worsened with internal and external rotation.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Hip pain is most commonly caused by trochanteric and gluteus medius bursitis, femoral fractures, and osteoarthritis (most likely in this patient). Patients with osteoarthritis typically complain of morning stiffness and groin pain. The pain may radiate towards the knee, but does not extend beyond it. Rest tends to ameliorate the pain, but lying on either side would not affect the pain. Pain is often aggravated by movement (internal/external rotation) rather than by direct pressure, as in trochanteric bursitis. Plain x-rays (weight bearing AP pelvis) can confirm osteoarthritis by showing a decreased joint space, sclerosis of the joint space margins, and periarticular osteophytes. Treatment usually involves rest and NSAIDs. (Choice A) A hamstring injury would present with pain felt over the buttock area and may extend to the trochanteric bursa area, but would not be felt anteriorly in the thigh. (Choice B) Patients with meralgia paresthetica complain of burning pain, paresthesia, and diminished sensation over the upper outer thigh. The most common predisposing factor is obesity with an overlying panniculus and is caused by compression of the lateral femoral cutaneous nerve. (Choice C) Occult hip fracture typically presents with acute onset of severe pain after an injury. Patients have pain with any slight hip movement and difficulty bearing weight, neither of which was present in this patient. (Choice E) Trochanteric bursitis usually presents with pain/point tenderness over the greater trochanter that is worse when lying on the affected side. The most common cause of trochanteric bursitis is disturbance of gait from any cause (e.g., lumbosacral spine disease (75 %), leg length discrepancy (10 %), etc.). Examination of the hip is usually normal. Educational objective: Patients with osteoarthritis typically complain of morning stiffness and groin pain. The pain may radiate towards the knee, but does not extend beyond it. Rest tends to ameliorate the pain, but lying on either side would not affect the pain. Pain is often aggravated by movement (internal/external rotation) rather than by direct pressure, as in trochanteric bursitis. __________ References: Emerging ideas: Shared decision making in patients with osteoarthritis of the hip and knee. (http://www.ncbi.nlm.nih.gov/pubmed/21161733)

43-Year-Old Attorney Comes to the Office Because of Pain in His