Differential diagnosis and early management of rapidly progressing hip pain in a 59-year-old male

Objective and importance

Rapidly progressing degeneration of the hip joint is an uncommon condition presenting to physical therapy. Differential diagnosis can often be difficult, as clinical and radiographic findings do not always coincide leaving clinicians with difficult decision making regarding course of treatment. The purpose of this case report was to describe the differential diagnosis and early management of a patient with rapidly progressing hip pain.

Clinical presentation

A 59-year-old male with a complicated medical history was referred with a diagnosis of severe bilateral hip osteoarthritis. Clinical presentation of insidious onset, severe bilateral groin and anterior thigh pain with rapid progression of functional decline lead to the differential diagnosis of bilateral avascular necrosis.

Intervention

The patient received seven manual physical therapy sessions over the course of one month.

Conclusion

During this time, the patient’s Lower Extremity Functional Scale score worsened from 33 to 21. The persistence of the patient’s painful symptoms and continued functional decline helped determine cessation of manual therapy and referral back to his GP for further diagnostic testing and eventual correct diagnosis. This case highlights the importance of monitoring patient prognosis using outcome measures leading to a change in patient management strategies.     

Application of a classification system and description of a combined manual therapy intervention: a case with low back related leg pain

Low back pain and leg pain commonly occur together. Multiple factors can cause low back related leg pain; therefore, identification of the source of symptoms is required in order to develop an appropriate intervention program. The patient in this case presented with low back and leg pain. A patho-mechanism based classification is described in combination with the patient’s subjective and objective examination findings to guide treatment. The patient’s symptoms improved marginally with intervention addressing primarily the musculoskeletal impairments and with intervention addressing primarily the neurodynamic impairments. Full functional improvements were attained with a manual therapy intervention directed at both mechanisms simultaneously. The approach described in this case address a mixed pathology utilizing passive accessory and passive physiological lumbar mobilizations in combination with lower extremity neurodynamic mobilization. The patient reported complete resolution of symptoms after a total of seven visits over a period of 6 weeks. While specific guidelines do not yet exist for treatment based on the classification approach utilized, this case report provides an example of manual therapy to address low back related leg pain of mixed pathology.     

Spinal dural arteriovenous fistula 8 years after lumbar discectomy surgery: A case report and review of literature

BACKGROUNDSpinal dural arteriovenous fistula (SDAVF) is an extremely rare vascular malformation of the central nervous system that is often confused with degenerative spinal disorders due to similar early symptoms and clinical features. Here, we report a case of SDAVF recurrence 8 years after lumbar spine surgery and summarize relevant literature.CASE SUMMARYA 54-year-old male was admitted to our hospital complaining of lower back pain, numbness in both lower extremities and intermittent claudication. Subsequent imaging identified lumbar spinal stenosis. Following surgical treatment, the patient’s symptoms significantly resolved, and he was able to perform daily activities. However, similar symptoms appeared 8 years later, followed by confirmation of SDAVF diagnosis. The patient underwent neurosurgery 7 mo after symptom onset. The follow-up period lasted 14 mo, and the patient remains with marginal neurological symptoms.CONCLUSIONThis case highlights the importance of prompt SDAVF diagnosis. Due to its nonspecific clinical presentation, the clinical experience of the surgeon and definitive imaging examination are indispensable. Additionally, timely neurosurgery is effective and may significantly improve patient outcomes.     

Acute brachial plexus neuritis: an uncommon cause of shoulder pain

Patients with acute brachial plexus neuritis are often misdiagnosed as having cervical radiculopathy. Acute brachial plexus neuritis is an uncommon disorder characterized by severe shoulder and upper arm pain followed by marked upper arm weakness. The temporal profile of pain preceding weakness is important in establishing a prompt diagnosis and differentiating acute brachial plexus neuritis from cervical radiculopathy. Magnetic resonance imaging of the shoulder and upper arm musculature may reveal denervation within days, allowing prompt diagnosis. Electromyography, conducted three to four weeks after the onset of symptoms, can localize the lesion and help confirm the diagnosis. Treatment includes analgesics and physical therapy, with resolution of symptoms usually occurring in three to four months. Patients with cervical radiculopathy present with simultaneous pain and neurologic deficits that fit a nerve root pattern. This differentiation is important to avoid unnecessary surgery for cervical spondylotic changes in a patient with a plexitis.     

Sever’s Disease of the Pediatric Population: Clinical,Pathologic, and Therapeutic Considerations

Sever’s disease is an underreported prevalent pediatric condition that causes heel pain in children worldwide. It is often described as an overuse injury that can present with either unilateral or bilateral heel pain. Even though the exact mechanism of injury is unknown, it is often thought it involves repetitive stress and pressure on the calcaneal growth plate. Diagnosing Sever’s disease mainly relies on a thorough clinical investigation and physical examination, with a positive squeeze test usually sufficient to establish diagnosis. Nevertheless, radiographic imaging can help exclude other differential diagnoses. Therapeutic options of Sever’s disease are mostly conservative, and these include rest, physical therapy, kinesiotherapy, and orthoses. Educating parents and coaches on the symptomatology and presentation of Sever’s disease is pivotal for the establishment of efficient preventive interventions and earlier diagnoses. This study presents a case of a pediatric patient with Sever’s disease and offers medical insight into the diagnostic, clinical, pathologic, and therapeutic characteristics of this condition, in light of the current existing literature.     

Aborder la perte auditive

ObjectiveTo provide family physicians with a practical evidence-based approach to the management of patients with hearing loss.Sources of informationMEDLINE and PubMed databases were searched for English-language hearing loss research, review articles, and guidelines published between 1980 and 2020. Most of the retrieved articles provided level II or III evidence.Main messageHearing loss is one of the most common sensory impairments worldwide and causes great detriment to a patient’s overall well-being by affecting physical health, finances, social inclusion, and mental health. A robust clinical assessment of hearing loss includes a history and physical examination that effectively characterizes the deficit as conductive, sensorineural, or mixed. Patients presenting with red flags (such as sudden unilateral sensorineural hearing loss) must be urgently referred to otolaryngology–head and neck surgery or immediately assessed in the emergency department. Many nonurgent presentations of hearing loss will also require referral for further audiological assessment, diagnosis, and management.ConclusionAs primary care providers, family physicians are well equipped to manage the psychological concerns associated with hearing loss and to reinforce conservative treatment strategies. Frequently, referral or urgent workup, including imaging, is necessary to confirm a patient’s diagnosis and initiate management in order to prevent further complications.     

Outcomes following plyometric rehabilitation for the young throwing athlete: A case report

The current literature offers limited evidence supporting sport-specific plyometric rehabilitation for young throwing athletes. The purposes of this case report were to 1) describe the focused differential diagnosis of a young throwing athlete with shoulder pain and 2) use previously validated, region-specific, health-related quality of life measures to describe clinical outcomes for a rehabilitation program that included sport-specific, plyometric training. The 13-year-old male patient presented in this case report experienced a sudden onset of right shoulder pain while pitching in a baseball game. On physical examination, this patient demonstrated shoulder pain, pain with palpation of the infraspinatus and teres minor muscles, decreased strength of the infraspinatus and teres minor with resultant impaired rotator cuff performance, and signs consistent with anterior shoulder instability. Early rehabilitation consisted of modalities for pain relief and therapeutic exercises to improve strength. In the return to sport phase of rehabilitation, the patient performed sport-specific plyometric exercises that were progressed in difficulty based on the patient's report of pain and muscle soreness. Health-related quality of life was assessed by using the Shoulder Pain and Disability Index (SPADI) and the sports module of the Disability of Arm, Shoulder and Hand (DASH) questionnaires. A standard error of measurement (SEM)-based criterion was used to determine if the patient demonstrated meaningful changes in outcome measures. The patient did not demonstrate meaningful improvement in pain or general disability with the SPADI. The patient did demonstrate a meaningful improvement in sport-specific function with the DASH. It is possible that sport-specific plyometric rehabilitation may have provided additional benefit for this athlete's ability to return to sport, but definite conclusions regarding treatment effectiveness are limited by the case report design. Properly designed studies investigating the benefits of sport-specific plyometric rehabilitation are warranted before the effectiveness of these techniques can be determined.     

Differential diagnosis of endometriosis in patient with nonspecific low back pain: A case report

BackgroundEndometriosis is one of the most widespread gynecological disorders and a very common condition amongst fertile women, thus it has to be considered one of the possible sources of lumbopelvic pain. Endometriosis is commonly related to low back pain (LBP) and therefore often mistaken for a musculoskeletal disorder.The purpose of this case report is to underline the primary role of clinical reasoning and assessment process, which led the physiotherapist to the differential diagnosis, considering endometriosis among the possible causes of low back pain.Case presentationS.C, 45 years old, complained to physiotherapist of lumbar spine and left buttock pain, spreading to the hypogastric, inguinal and left pubic areas. The patient's past medical history included gynecological visceral disorders, regularly monitored. Functional evaluation and clinical tests revealed a disorder referred to the lumbar spine and sacroiliac region. Initial physical therapy management included education, manual therapy and therapeutic exercise. Nevertheless, after five treatment sessions, the symptoms remained unchanged, and therefore the patient was referred to a gynecologist for a consultation. The patient underwent a laparoscopy for endometriosis eradication and the intervention resulted in complete abolition of symptoms, enabling the patient to return to work and to do physical activities.Conclusionsthis case report highlights the importance of a thorough clinical assessment and the identification of relevant findings from patient's medical history to be carried out by the physiotherapist. Those are of crucial importance to make an appropriate differential diagnosis and to screen amongst the possible causes of lumbopelvic pain also visceral ones as endometriosis, which often manifests with associated symptoms such as nonspecific LBP.     

Abstracts: AAOMPT Conference, 2006

Abstract

This case report describes the effectiveness of mechanical diagnosis and therapy (MDT) in the management of a patient referred with a diagnosis of shoulder tendonitis. The patient was a 56-year-old male with a 3-month history of left anterior shoulder pain. Upon initial assessment, he presented with a positive open-can test, lift-off test, and Hawkins–Kennedy impingement test. A MDT assessment quickly ruled out cervical involvement and identified a loss of end-range shoulder mobility and pain during active shoulder movement. After the patient underwent a repeated movement examination and treatment based on responses to end-range movements over three visits, his shoulder pain was abolished and motion was fully restored. Despite having positive rotator cuff and impingement signs, this patient was effectively treated with repeated end-range movements over a short period of 2 weeks. This case demonstrates that treatment based on MDT sub-classification principles may be an effective way to manage shoulder pain as it is in the spine.     

Comparison of symptoms and clinical findings in subgroups of individuals with patellofemoral pain

Patellofemoral pain syndrome (PFPS) is one of the most common musculoskeletal disorders. However, no consensus on the definition, classification, assessment, diagnosis, or management has been reached. We evaluated symptoms and clinical findings in subgroups of individuals with PFPS, classified on the basis of the findings in radiological examinations and compared the findings with knee-healthy subjects. An orthopedic surgeon and a physical therapist consecutively examined 80 patients clinically diagnosed as having PFPS and referred for physical therapy. The examination consisted of taking a case history and clinical tests. Radiography revealed pathology in 15 patients, and scintigraphic examination revealed focal uptake in 2 patients indicating pathology (group C). Diffusely increased uptake was present in 29 patients (group B). In the remaining 29 patients radiographic and scintigraphic examinations were normal (group A). Knee-healthy controls (group D) reported no clinical symptoms. No symptom could be statistically demonstrated to differ between the three patient groups. Knee-healthy subjects differed significantly from the three patient groups in all clinical tests measuring pain in response to the provocations; compression test, medial and lateral tenderness, passive gliding of the patella, but they also differed in Q angle. Differences in clinical tests between the patient groups were nonsignificant. The main finding in our study on patients clinically diagnosed with PFPS is that possible pathologies cannot be detected from the patient's history or from commonly used clinical tests.     

Diagnosing suprascapular neuropathy in patients with shoulder dysfunction: a report of 5 cases

BACKGROUND AND PURPOSE: Suprascapular neuropathy, resulting in shoulder pain and weakness, is frequently misdiagnosed. The consequences of misdiagnosis can include inappropriate physical rehabilitation or surgical procedures. The purpose of this case report is to describe the differential diagnosis of suprascapular neuropathy. CASE DESCRIPTIONS: Five patients were initially diagnosed with subacromial impingement syndrome and referred for physical therapy. Physical therapist examination findings were consistent with subacromial impingement syndrome and suprascapular neuropathy. Subsequent electrophysiologic testing confirmed the diagnosis of suprascapular neuropathy in all 5 patients. DISCUSSION: The differential diagnosis of patients with suprascapular neuropathy includes subacromial impingement syndrome, rotator cuff pathology, C5-6 radiculopathy, and upper trunk brachial plexopathy. The diagnostic process and a table with key findings based on evidence and clinical experience is presented for differential diagnosis.     

Cervical radiculopathy

Cervical radiculopathy is a common clinical scenario. Patients with radiculopathy typically present with neck pain, arm pain, or both. We review the epidemiology of cervical radiculopathy and discuss the diagnosis of this condition. This includes an overview of the pertinent findings on the patient history and physical examination. We also discuss relevant clinical syndromes that must be considered in the differential diagnosis including peripheral nerve entrapment syndromes and shoulder pathology. The natural history of cervical radiculopathy is reviewed and options for management are discussed. These options include conservative management, non-operative modalities such as physical therapy, steroid injections, and operative intervention. While the exact indications for surgical intervention have not yet been elucidated, we provide an overview of the available literature regarding indications and discuss the timing of intervention. The surgical outcomes of anterior cervical decompression and fusion (ACDF), cervical disc arthroplasty (CDA), and posterior cervical foraminotomy (PCF) are discussed.     

Differential diagnosis and early management of rapidly progressing hip pain in a 59-year-old male

Abstract

Objective and importance

Rapidly progressing degeneration of the hip joint is an uncommon condition presenting to physical therapy. Differential diagnosis can often be difficult, as clinical and radiographic findings do not always coincide leaving clinicians with difficult decision making regarding course of treatment. The purpose of this case report was to describe the differential diagnosis and early management of a patient with rapidly progressing hip pain.

Clinical presentation

A 59-year-old male with a complicated medical history was referred with a diagnosis of severe bilateral hip osteoarthritis. Clinical presentation of insidious onset, severe bilateral groin and anterior thigh pain with rapid progression of functional decline lead to the differential diagnosis of bilateral avascular necrosis.

Intervention

The patient received seven manual physical therapy sessions over the course of one month.

Conclusion

During this time, the patient’s Lower Extremity Functional Scale score worsened from 33 to 21. The persistence of the patient’s painful symptoms and continued functional decline helped determine cessation of manual therapy and referral back to his GP for further diagnostic testing and eventual correct diagnosis. This case highlights the importance of monitoring patient prognosis using outcome measures leading to a change in patient management strategies.     

Trigger finger at the wrist caused by an intramuscular lipoma within the carpal tunnel: A case report

BACKGROUNDTrigger finger at the wrist, which occurs with finger movement, is an uncommon presentation. Few reports describing cases of trigger finger at the wrist have been published. Thus, we present a case of an intramuscular lipoma arising from an anomalous flexor digitorum muscle belly in a 48-year-old female patient causing painful finger triggering at the wrist and carpal tunnel syndrome (CTS).CASE SUMMARYA 48-year-old woman with complaints of a catching sensation during wrist motion and a progressive tingling sensation on the palmar aspect of the right hand for approximately 2 years was referred to our hospital. Triggering of the index to middle finger was evident with a palpable and audible clunk over the carpal tunnel during passive motion. Tinel’s sign was positive over the carpal tunnel of the right wrist with a positive Phalen’s test. Nerve conduction studies of the median nerve demonstrated a right CTS. Ultrasound examination revealed a 2.5 cm × 2.0 cm subcutaneous hyperechoic mass with no obvious blood flow at the wrist of the right arm. Surgical excision of the tumor and muscle mass led to a resolution of the patient’s symptoms, and any triggering or discomfort disappeared. The patient has had no evidence of recurrence at more than 1 year of follow-up.CONCLUSIONTriggering of the fingers at the wrist is rare. It must be noted that there are many possible causes and types of triggering or clicking around the wrist. Accurate diagnosis is mandatory to avoid inaccurate treatment of patients with trigger wrist. During the diagnosis and treatment of CTS, attention should be paid to the variation of tendon tissue in the carpal tunnel, to avoid only focusing on the release of transverse carpal ligament and ignoring the removal of anomalous muscle belly.     

Outcomes following plyometric rehabilitation for the young throwing athlete: a case report

The current literature offers limited evidence supporting sport-specific plyometric rehabilitation for young throwing athletes. The purposes of this case report were to 1) describe the focused differential diagnosis of a young throwing athlete with shoulder pain and 2) use previously validated, region-specific, health-related quality of life measures to describe clinical outcomes for a rehabilitation program that included sport-specific, plyometric training. The 13-year-old male patient presented in this case report experienced a sudden onset of right shoulder pain while pitching in a baseball game. On physical examination, this patient demonstrated shoulder pain, pain with palpation of the infraspinatus and teres minor muscles, decreased strength of the infraspinatus and teres minor with resultant impaired rotator cuff performance, and signs consistent with anterior shoulder instability. Early rehabilitation consisted of modalities for pain relief and therapeutic exercises to improve strength. In the return to sport phase of rehabilitation, the patient performed sport-specific plyometric exercises that were progressed in difficulty based on the patient's report of pain and muscle soreness. Health-related quality of life was assessed by using the Shoulder Pain and Disability Index (SPADI) and the sports module of the Disability of Arm, Shoulder and Hand (DASH) questionnaires. A standard error of measurement (SEM)-based criterion was used to determine if the patient demonstrated meaningful changes in outcome measures. The patient did not demonstrate meaningful improvement in pain or general disability with the SPADI. The patient did demonstrate a meaningful improvement in sport-specific function with the DASH. It is possible that sport-specific plyometric rehabilitation may have provided additional benefit for this athlete's ability to return to sport, but definite conclusions regarding treatment effectiveness are limited by the case report design. Properly designed studies investigating the benefits of sport-specific plyometric rehabilitation are warranted before the effectiveness of these techniques can be determined.     

Abdominal Cutaneous Nerve Entrapment Syndrome: The Cause of Localized Abdominal Pain in a Young Pregnant Woman

Background

Despite the broad differential diagnosis in any patient referring with symptoms involving the chest or abdomen, a small number of conditions overshadow the rest by their probability. Chest and abdominal wall pain continues to constitute a common and expensive overlooked source of pain of unknown cause. In particular, cutaneous nerve entrapment syndrome is commonly encountered but not easily diagnosed unless its specific symptoms are sought and the precise physical examination undertaken.