American Journal of Physical Medicine & Rehabilitation:
From the Departments of Orthopedics (JRP) and Diagnostic Imaging (DS), Warren Alpert Medical School of Brown University, Providence, Rhode Island.
All correspondence and requests for reprints should be addressed to John R. Parziale, MD, Brown University Medical School, University Rehabilitation, 450 Veterans' Memorial Parkway, East Providence, RI 02914.
A 60-yr-old man with osteoarthritis, lumbar degenerative disc disease, and left total hip arthroplasty presented with right groin and buttock pain for several months. There was no history of rheumatoid arthritis or known precipitating event or injury. Aching pain was increased with weight-bearing activities. Unsuccessful previous treatment included nonsteroidal antiinflammatory drugs, chiropractic adjustments, and physical therapy. Physical examination demonstrated an endomorphic male patient with a reduced lumbar range of motion, and the results of the neurological examination were normal. Flexion Abduction External Rotation test on the right reproduced low-back and buttock pain. The x-rays of both hips in weight bearing demonstrated severe osteoarthritis of the right hip and a stable left hip total arthroplasty.
An initial diagnostic consideration was right sacroiliac joint inflammation, and treatment included weight reduction, an exercise program, and a corticosteroid injection of the right sacroiliac joint. This procedure and a subsequent fluoroscopically guided corticosteroid injection of the right hip joint were ineffective. Magnetic resonance imaging of the right hip and pelvis demonstrated a large periarticular thin-rimmed cystic lesion centered anterior to the right femoral head within the iliopsoas muscle and extending inferiorly along its tendon, consistent with iliopsoas bursitis (Fig. 1). The iliopsoas tendon was intact, and there was no evidence of avascular necrosis of the femoral head.
Aspiration of the cyst was performed using ultrasonography guidance, withdrawing 25 ml of serous fluid (Fig. 2) followed by injection of methylprednisolone and bupivicaine. Within 48 hrs, his pain level had dropped from a score of 5 to 2 on a visual analog scale. At 3 wks after the procedure, he had partial return of his symptoms, and a repeat aspiration/corticosteroid injection was performed with resolution of his groin pain.
Pain in the region of the groin and anterior hip in a patient with advanced osteoarthritis involving both the hip and spine may pose diagnostic and therapeutic challenges. Differential diagnosis includes lumbosacral radiculopathy, hip joint pathology, inguinal hernia, appendicitis, gynecological pathology, femoral artery aneurysm, and other causes. Risk factors for iliopsoas bursitis include rheumatoid arthritis. Pain is increased with weight-bearing activities, putting on socks and shoes, or arising from a chair.
Blood tests are not usually indicated but may help in assessing for a rheumatological disorder. The results of hip radiographs are normal in cases of iliopsoas bursitis. Diagnostic ultrasonography may demonstrate bursitis or tendinitis but can be operator dependent. Magnetic resonance imaging is the current imaging standard for evaluation of painful conditions of the hip and pelvis. The most commonly reported magnetic resonance imaging appearance of iliopsoas bursitis is a thin-rimmed, homogeneous cystic fluid collection.
Treatment may include antiinflammatory medications and stretching of the hip flexor muscles followed by a strengthening program. Aspiration and corticosteroid injection of the bursa should be performed for persistent pain symptoms. Communication with the hip joint may occur in up to 15% of cases, and repeat injection may be required. Surgery is rarely indicated.
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