Background
The patient is 58 years old. Works as a teacher. Married, with two adult children. Previously healthy. At around 12 years of age, the patient had right-sided hip pain due to Calvé-Legg-Perthes disease (CLP). After about six months, the hip improved, and the patient had no complaints until their 50s.
After this, the patient has experienced exertional pain when walking, slight limping, and a feeling of stiffness. The pain is located in the right hip joint and towards the groin. The patient has some pain at rest and moderate night pain. Ibuprofen and Paracetamol as needed have had poor effect in the past few months. The patient has not been to a physiotherapist and has not had an X-ray. The pain is at worst VAS 5. It is worst at the start and improves when walking, but in the past six months, walking distance has been reduced to one kilometer.
Consultation video
Medical history
- Doctor
What can I help you with?
- Patient
I have developed more and more pain in the right hip. It has come gradually over several years.
- Doctor
Where do you feel the pain the most?
- Patient
Most in the front of the hip, towards the groin.
- Doctor
Have you had problems with your hip previously?
- Patient
Yes, when I was around 12 years old I was told that I had Calvé-Legg-Perthes. But after about half a year it got better, and I really had no complaints again until I was around 50.
- Doctor
How have the complaints developed since then?
- Patient
At first it was mostly load-related pain when I walked, and some limping and stiffness. Now it is more pronounced.
- Doctor
How is the pain at rest?
- Patient
A little pain at rest as well. And I have moderate pain at night.
- Doctor
What is worst?
- Patient
It is worst when I start walking. It gets a little better once I get going, but I have noticed in the past six months that I can no longer manage to walk as far.
- Doctor
How far can you walk now?
- Patient
About one kilometer.
- Doctor
Have you tried treatment?
- Patient
I have used Ibux and Paracet as needed. It helped a little at first, but has had poor effect in the past few months. I have not been to a physiotherapist and have not had an X-ray.
- Doctor
How painful is it at its worst?
- Patient
Around five out of ten.
Standard examination
Perform standard examination:
- 1 Inspection
- 2 Active movements
- 3 Passive movements
- 4 Isometric movements
- 5 Palpation
Tentative diagnosis
based on medical history and standard examination- Secondary osteoarthritis following Calvé-Legg-Perthes disease.
Examination
Special tests to strengthen or weaken the likelihood of the tentative diagnosis.
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1. Gait observation
Doctor
I want to first see how you walk.
Patient
Walks with a slight limp. The limp is clear enough to be detected during clinical observation.
That's usually how it is when I leave.
Findings
- Slightly limping gait.
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2. Trendelenburg's test
Doctor
Now I want you to stand on your right leg.
Patient
The test is positive on the right side. The pelvis does not remain stable when the patient stands on the right leg.
It feels unsteady on that side.
Findings
- Positive Trendelenburg's test for the right hip.
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3. Leg length assessment
Doctor
I will compare your leg length.
Patient
Recognizes that the right leg is shorter than the left and has tried an insole.
Findings
- The right leg is three centimeters shorter than the left.
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4. Hip flexion
Doctor
I want to examine the mobility of the hip. First, we bend it up.
Patient
The movement is clearly reduced, with pain at the end point and a hard stopping feeling.
It stops there.
It hurts at the very end.
Findings
- Approximately 50 percent reduced flexion with a hard end-feel and pain at the end point.
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5. Internal rotation
Doctor
Now I rotate the hip inward.
Patient
Clearly reduced and painful at the very end.
Yes, it is tight and painful there.
Findings
- Approximately 50 percent reduced internal rotation with a hard end-feel and pain at the end point.
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6. Abduction
Doctor
Then we test movement out to the side.
Patient
Clearly reduced range with recognizable stiffness and pain, not acute sharp pain.
It moves, but not very far.
It hurts when you reach all the way out.
Findings
- Approximately 50 percent reduced abduction with a hard end-feel and pain at the end point.
Learning points
- 1 Classic load-related hip pain localized towards the groin.
- 2 The difference between starting difficulties, some improvement with activity, and eventually reduced walking distance.
- 3 Structural hip pathology can cause limping, Trendelenburg sign, and leg length difference.
- 4 Flexion, internal rotation, and abduction must be tested systematically.