A Shot At Relief: A Case Of Hip Pain

HISTORY: 39yo M with PMH of lumbar facet arthropathy, & PTSD reports R hip pain for 5 yrs, worse in past 4-5mo. Localized to R anterior pelvis, groin, & lower abdomen. Pain is constant, aching, intermittently radiating down R thigh with associated numbness and tingling. Severity 6-10/10. Worse with standing, sitting, squatting, laying on side. Notes temporary pain relief w/ po steroids and IM ketorolac. Failed OTC analgesics, heat/cool pack, tiger balm, PT, chiropractor, gabapentin, muscle relaxers. Sx affect ADLs. Unemployed. Admits GSW 5 yrs prior, bullet entered epigastrum, exited R flank. PHYSICAL EXAMINATION: Right hip: TTP over internal oblique, ASIS, origin of rectus femoris, & lateral femoral cutaneous nerve (LFCN). Antalgic gait w/ +Trendelenburg. ROM: flexion limited to 40° w/ pain actively, internal rotation normal w/ pain, external rotation normal w/ pain, extension limited to 10° w/ pain actively. Special tests: Negative log roll, FABER, FADIR, straight leg raise, slump test. Neuro: strength 5/5 for hip flexors, extensors, adductors, abductors. Sensation intact to touch b/l. Dorsalis pedis and tibialis posterior pulses intact b/l. Patellar & achilles tendon reflexes 2+, equal b/l. DIFFERENTIAL DIAGNOSIS: 1) Myofascial pain syndrome 2) Referred pain from chronic low back pain 3) Neuropathy 4) LFCN entrapment TEST AND RESULTS: X-Ray R Hip AP, Lateral (w/ Pelvis) R hip joint space maintained. Punctate os acetabulum presentXR Lumbar Spine AP, Lateral Preserved alignment. No fracture. Defect identified at the R iliac wing, probably corresponding to remote fracture. No degenerative changes. Soft tissues WNL MRI Pelvis w/o Contrast No findings identified to explain pt's sx. No abnormal signal identified along expected course of R LFCN Limited US, abdomen, RLQ Well-defined lesion along LCFN at level of inguinal ligament. Lesion continuous w/ proximal & distal nerve segments, w/ localized nerve thickening, consistent w/ neuroma. Tenderness w/ transducer pressure, indicative of irritation at site. FINAL WORKING DIAGNOSIS: Neuroma of LFCN TREATMENT AND OUTCOMES: USG hydrodissection of LFCN, resulting in complete pain relief immediately following procedure, & at 2 week f/u. Pt returned to clinic 6mo later c/o return of sx. Repeat hydrodissection performed, w/ complete resolution of sx.