Worsening Hip Pain In A Golfer

HISTORY: A 59-year-old golfer presented for evaluation of intermittent right hip pain for three years, worsening over the past two months. Orthopedic Surgery had evaluated him three months prior and believed he had mild osteoarthritis; they deferred surgery and performed an intra-articular steroid injection. Pain was localized to the groin, buttock, and lateral hip with occasional radiation into the lower back and into the leg, not past the knee. Pain was exacerbated by swing follow-through and walking long distances on the golf course. In follow up with orthopedic surgery one month prior, it was felt that his pain was out of proportion to imaging; patient was referred to Rheumatology, who suspected ankylosing spondylitis and recommended Humira. He was referred to Sports Medicine clinic by his primary care provider for a second opinion before starting Humira. PHYSICAL EXAMINATION: Pelvis level, antalgic gait. Tender to palpation over right SI joint > right greater trochanter. Normal sensation and strength in lower extremities except for 3/5 in right hip flexors limited by pain. Intact reflexes. FADIR, FABER, Stinchfield’s, and side-lying hip abduction reproduce typical anterior hip and buttock pain. No exacerbation of pain with lumbar flexion or extension. SLR negative. DIFFERENTIAL DIAGNOSIS: 1. Femoroacetabular osteoarthritis 2. SI joint-mediated pain 3. Lumbar paravertebral muscle strain 4. Tendinopathy of hip flexors 5. Greater trochanteric bursitis TEST AND RESULTS : Right hip X-ray performed in Sports clinic: Flattening of the right femoral head, new since the previous exam 3 months prior, with severe joint space loss, subchondral sclerosis, and possible femoral head subchondral cyst formation. There is SI joint ankylosis. No other bone, joint, or soft tissue abnormality. FINAL/WORKING DIAGNOSIS: Rapidly progressive femoroacetabular osteoarthritis. TREATMENT AND OUTCOMES: 1. Plan for Orthopedic Surgery re-evaluation for total hip arthroplasty 2. Patient continued physical therapy for interim hip strengthening and gait improvement 3. Recommended to hold off on Humira until definitive resolution of right hip pain