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Low-Back Pain?

Kortebein, Patrick MD

American Journal of Physical Medicine & Rehabilitation: June 2009 - Volume 88 - Issue 6 - p 523
doi: 10.1097/PHM.0b013e3181a0da50
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From the Department of Physical Medicine and Rehabilitation, Central Arkansas Veterans Healthcare System (CAVHS)/University of Arkansas for Medical Sciences, Little Rock, Arkansas.

All correspondence and requests for reprints should be addressed to Patrick Kortebein, MD, Department of Physical Medicine and Rehabilitation, CAVHS University of Arkansas for Medical Sciences, Little Rock, AR 72205.

A 73-yr-old woman was referred for evaluation of generalized lower lumbar and gluteal region pain. These symptoms had been present for 5 yrs, and the patient had undergone two lumbar spine surgeries for this pain with no significant relief. This pain was only present with standing and walking, and she required a cane or walker to ambulate. She denied radicular symptoms, including weakness, numbness, or tingling of the lower extremities. Recent computerized tomography myelogram of the lumbar spine demonstrated mild multilevel degenerative disc changes without any significant central/foraminal stenosis or neural impingement.

The patient’s physical examination was notable for essentially normal lumbar spine range of motion with no tenderness to palpation of the lumbar, gluteal, or greater trochanteric regions bilaterally. Bilateral hip range of motion was significantly limited in all planes, and this prevented positioning for FABERE’s sign (flexion, abduction, external rotation, and at the completion of the test, extension). Stinchfield test (resisted hip flexion while supine) performed bilaterally elicited significant pain in the ipsilateral lateral hip and gluteal region. The lower extremity neurologic examination was normal, including strength, sensation, and reflexes, and gait examination with a walker was notable for short step lengths because of markedly reduced bilateral hip flexion.

Radiographs of the pelvis (Fig. 1) demonstrated severe bilateral hip osteoarthritis with mild femoral head collapse indicative of avascular necrosis (the patient had no known risk factors for avascular necrosis). At follow-up 4 mos later, the patient was significantly improved after left total hip arthroplasty and was scheduled for a right-hip arthroplasty.



There are multiple potential etiologies of pain in the low back and gluteal region. Hip joint osteoarthritis typically presents as inguinal or groin pain,1 however, as illustrated in this case, hip osteoarthritis should be considered in the differential diagnosis of patients presenting with pain in the low back or gluteal region. Because of this patient’s atypical presentation, she had undergone two lumbar spine surgeries without any significant benefit. This case highlights the importance of maintaining a broad differential in the evaluation of patients presenting with low-back pain.

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1. Hansen PA, Willick SE: Musculoskeletal disorders of the lower limbs, in Braddom RL (ed): Physical Medicine and Rehabilitation, ed 3. Philadelphia, Saunders/Elsevier, 2006, p 867.
© 2009 Lippincott Williams & Wilkins, Inc.