A Real Pain in the Back

Tiffany Chan MD, Joel Abraham MD, Michael Medina MD

INTRO

FAI is thought to arise from bone deformity

 

Pain 2/2 friction b/t femoral head and acetabulum eroding into cartilaginous labrum

 

Risk factor for OA

 

Gait disturbance & hip/groin pain are common

 

Can rarely present with isolated LBP

 

METHODS

 

Informed consent was obtained from patient for case report. IRB approval not required

 

PATIENT PRESENTATION

 

29 yo M with 12+ years of back pain

 

Lower lumbar region, band-like distribution between the iliac crests and sacroiliac joints

 

Worse with activity, left side worse than right

 

No hip pain, radiculopathy, or weakness.

 

No inciting event.

 

PHYSICAL EXAM

 

Positive for lumbar paraspinal tenderness, reproducible with facet loading

 

FADIR test produced mild discomfort at left anterior hip, but very mild compared to pain reproduced during above lumbar exam.

 

FABER test was negative bilaterally.

 

INTERVENTIONS

 

Failed conservative treatment with medications and physical therapy

 

Autoimmune workup negative.

 

RFA of L3-S1 facets provided > 50% relief for 6 months in past.

 

Diagnostic hip injections provided moderate relief

 

Imaging of hips obtained

 

ORS reluctant to operate d/t subtle findings

BILATERAL HIP IMAGING

X-ray:

(L) Peripheral crossover sign

Tönnis grade 0 = no signs of osteoarthritis

No ischial spine sign nor significant cam lesion

MRI:

(R) Mild to mod. cartilage loss; no labral tear

(L) Articular cartilage was intact; increased signal in labrum but no definitive tear

DIAGNOSTIC ARTHROSCOPY

Left hip:

Significant labral tear from 11 o'clock to 3 o'clock

OUTCOME

>90% reduction in pain after left labral repair.

Patient plans to repeat surgery on right hip.

DISCUSSION

Hip pathology can contribute to LBP, despite subtle exam & imaging findings.

Incidence of primary hip disorder presenting as isolated LBP is reported to be as low as 2.5%.

Case highlights importance of aggressively seeking hip pathology even in patients presenting w/ isolated LBP.