Mechanical hip pain is difficult to diagnose due to its close proximity to the lumbar spine and pelvis. Lumbar spine pain prevalence is estimated to be 54-84% [1] in a lifetime. The diagnosis of somatic hip pain can be difficult as the lumbar spine can radiate pain and symptoms to the hip region. Konstantinou K et al [2]. found that those with low back pain were 2-42% more likely to report lower extremity radiant symptoms. Due to the potential for lumbar spine-based radiant pain into the lower extremity there might lie a bias towards prematurely diagnosing hip pain as a lumbar spine pathology [3]. Due to the difficulty in diagnosing hip pathology the lumbar spine and pelvis should be ruled out, along with any red flags [4] as potential pain generators prior to treatment. The purpose of this case report is to highlight (1) the clinical reasoning process and diagnosis of Greater Trochanteric Pain Syndrome (GTPS), specifically calcific tendinitis and (2) the positive effect of surgery and physical therapy on the patient’s function and pain.

Case Report

History

A 72-year-old female presented to physical therapy on numerous occasions over an 18-month period with a chief complaint of right lateral hip pain. The patient’s original mechanism of injury was repetitive swinging of a golf club and her initial pain was a dull ache and an occasional catching sensation at the hip’s dorsolateral greater trochanter. Her pain also included radiant tightness that extended to the distal lateral and dorsal thigh (Figure 1) with occasional extension of symptoms to the lateral foot [5]. After numerous secondary opinions (x4), one hip radiograph, three Magnetic Resonance Images (MRIs), one greater trochanteric bursal corticosteroid injection, three lumbar spine epidural steroid injections, and one gluteus medius/minimus tendon platelet-enriched plasma/stem cell injection [6] she was finally diagnosed post-surgically with calcific tendinitis of the gluteus medius/minimus tendon with the presence of a heterotopic ossification.

Examination

The patient had no previous medical history of right hip or lumbar spine pain. Her pain on the Numeric Pain Rating Scale (NPRS) at the time of the initial evaluation was 1/10 with 8/10 reported at its worst. The patient was taking prescription strength anti-inflammatories (Ibuprofen 800mg) as well as other existing prescriptions Synthroid, Lipitor, and Singulair. Lateral and dorsal hip structures visualization indicated gluteal atrophy. The patient demonstrated an antalgic compensatory Trendelenburg gait pattern and a positive single leg balance test that generated right hip pain in standing. Supine passive range of motion hip flexion, external rotation from 90° of hip flexion, and prone internal rotation from a 0° hip position were all painful with no deficits in motion. Resisted hip flexion, adduction from 90° of flexion, side lying abduction and prone internal rotation demonstrated normal strength grades with all causing lateral hip pain. Supine gluteus medius and maximus bursal testing through passive hip flexion, adduction and external/internal rotation generated lateral hip pain. Palpation of the gluteal tendon insertions (Figure 2) on the proximal dorso-lateral greater trochanter along with the ischial tuberosity were painful. The patient displayed numerous spinal and pelvic ring positive tests including a right lower extremity straight leg raise test [7] with symptom changes experienced with cervical flexion and ankle plantar flexion actions, sacroiliac dorsolateral and ventromedial tests, and a supine thigh thrust test. In prone on elbows position the L5 spinous process was more pronounced when compared to a prone position indicating a potential L5 retrolisthesis and lastly, the patient demonstrated right lower extremity altered dermatomal sensation in the S1 nerve distribution.