A 64-year-old man comes to the office due to increasing pain in the right groin for the past several months. The pain increases with activity, is relieved with rest, and sometimes radiates to the upper thigh. The patient has no history of trauma or falls. There is no associated fever, weight loss, or change in appetite. He has a history of lumbar disk herniation but has no back pain currently. Medical history is notable for type 2 diabetes mellitus and hypertension. Vital signs are normal. Height is 168 cm (5 ft 5 in) and weight is 95 kg (210 lb). BMI is 34 kg/m². Examination shows pain on passive internal rotation of the right hip, but there is no focal tenderness on palpation of the groin and hip region. Reflexes are 2+ in the lower extremities symmetrically, and there are no sensory deficits. Muscle bulk, tone, and power are normal. Dorsalis pedis and posterior tibial pulses are 2+ in both legs. Which of the following is the most likely cause of this patient's hip pain?

Question

Quizplus · Accepted Answer

11ec25c8_d50f_c488_bc81_d155ded4787a_MD0003_00 This patient with slowly progressive pain relieved by rest has degenerative joint disease (osteoarthritis) of the hip. Osteoarthritis is the most common joint disorder and is characterized by progressive destruction of the articular cartilage. Predisposing factors include age >40, obesity, and diabetes mellitus. Osteoarthritis most commonly affects the interphalangeal joints of the hands and the large weight-bearing joints of the lower extremity. The pain of hip osteoarthritis is typically felt in the groin, buttock, or lateral hip (trochanteric) region and can radiate to the lower thigh or knee. Patients may have mild pain and brief stiffness with prolonged rest, but the worst pain usually occurs with activity and weight bearing. Examination findings often include decreased rotational range of motion, but synovitis (ie, redness, warmth) is absent. Common x-ray findings include loss of joint space, osteophyte formation, and subchondral sclerosis. pain of hip osteoarthritis (Choice A) Aortoiliac atherosclerosis can cause lower extremity pain with activity. However, the pain is typically in the entire leg (buttock, thigh, and calf) and the distal pulses would be diminished. (Choice B) Meralgia paresthetica is caused by compression of the lateral femoral cutaneous nerve at the waist. It causes burning pain and paresthesias at the lateral thigh. Symptoms are unaffected by motion. (Choice D) Osteonecrosis is characterized by reduced perfusion of the femoral head and collapse of the periarticular bone. Like osteoarthritis, it can present with groin pain and reduced hip range of motion. However, most patients have nocturnal or rest pain, and almost all have a history of glucocorticoid use, sickle cell disease, or heavy alcohol use (diabetes is not a significant risk factor). (Choice E) Greater trochanteric pain syndrome (formerly trochanteric bursitis) is caused by friction of the tendons of the gluteus medius and tensor fasciae lata over the greater trochanter of the femur. Pain is localized to the lateral hip and is worsened by direct pressure. (Choice F) Impingement of the lumbar nerve roots can cause referred pain to the posterior hip, thigh, and lower leg. Hip mobility is normal, but patients may have exacerbation of pain on flexion of the hip with the knee extended (straight leg raise maneuver). Educational objective: Osteoarthritis presents in adults age >40 with progressive pain that is worsened by activity and relieved by rest. The pain is typically felt in the groin, buttock, or lateral hip (trochanteric) region and can radiate to the lower thigh or knee. The joint is not tender, and systemic symptoms are absent. References: Pain distribution in primary care patients with hip osteoarthritis. (http://www.ncbi.nlm.nih.gov/pubmed/27538424)

A 64-Year-Old Man Comes to the Office Due to Increasing