Patient is a 60 year old police officer who had seen us 6 years before for long standing significant lower back pain (LBP). The patient was not a surgical candidate and we sent him for rehabilitation. He continued with manageable LBP. He came back to the office 5 years later with new onset lateral right hip pain, mild groin pain with increased lower back and sacroiliac pain after helping a motorist change a tire. The pain in the hip was increased with sleep and would awaken him at night. This pain was tolerable during the day but increased with standing and prolonged sitting.
Physical examination noted normal gait and stance. He could heel walk and toe walk without difficulty. Patient had right lower back pain with flexion 4” to floor and no pain with extension. Extension with right rotation caused right lateral hip pain. Motor strength and reflexes were all normal. Sensation was decreased over the right upper anterior thigh only. The log roll test was normal. Femoral stretch test was negative.
Differential diagnosis:
The patient has known long standing lower back pain from multilevel degenerative disc disease(DDD). He has new onset of right lateral hip pain and increased low back pain from lifting a tire. The common thought would be that he simply aggravated his lumbar DDD as pain from the lumbar spine can refer pain into the hip region or groin especially from the L4-5 disc. The hip can also cause pain from a labral tear.
Pain with standing could be from a disc but normally, standing pain originates from a stenotic condition (narrowing) of the spinal canal. This patient had a normal log roll test for hip symptoms which doesn’t rule out hip pathology but puts it lower on the differential diagnosis scale.
There is one clue here of the potential pathology. The sensory exam noted decreased sensation in the right anterior thigh. Of course, this could be meralgia paresthetica (compression of the lateral femoral cutaneous nerve in the groin) but this area is also the dermatome of the L1 or L2 nerve.
A herniated disc (HNP) at L1 can affect the genitofemoral nerve and refer pain into the hip, groin and sacroiliac joint. Looking at the history of bending and lifting with new onset of pain makes a herniated disc more likely. HNPs can also cause more pain at night from positional swelling of the nerve root. See the MRI to note the HNP at the L1-2 level.
