Author: Dr Lorraine de Gray
A 37-year-old gentleman was referred by his GP for management of back pain. On taking a history from him, it became clear that he had suffered from lumbar back pain radiating into both hip joints since he was a teenager. He had a very physical job as a landscape gardener and reported that he woke up every morning feeling very stiff and in pain, but the stiffness did improve as he became more physically active during his work. Although he had sought advice regarding his back pain in the past, no investigations had been arranged. This was the first time he was being seen in a pain clinic.
Of note ten years previously he had undergone an arthroscopic procedure to his left hip joint after being diagnosed with a labral tear. Subsequently the left hip pain improved only to return four years ago, although he reported that the right hip was more painful and stiff then the left. He reported no other swollen or painful joints and had no family history of note.
The patient had tried Diclofenac in the past for the pain arising from the hip joints but this had been discontinued due to gastrointestinal side effects. He was currently taking Tramadol 100mg four times daily, Paracetamol 1gram four times daily as well as Amitriptyline 50mg nocte and Lansoprazole 15mg once daily.
On examination he had a very stiff posture with a thoracic kyphosis. He was very wiry and muscular. He had minimal spinal movement all the way from the neck down to the lumbo-sacral region. Both hip joints had a marked reduced range of movement and he struggled to flex or extend at the waist level.
Before continuing, consider the following questions:
- Is there any other information you would like to know?
- What are the potential differential diagnoses?
- Are there further investigations that would be helpful?
- Would this patient benefit from evaluation by another speciality?