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A 72-year-old woman presents to your clinic complaining of left hip pain. She denies antecedent trauma and localizes the pain to the lateral hip. It radiates down her left lateral thigh but not to her groin. The pain is exacerbated when she lays on it at night. The pain has progressed, prompting her visit today.

  • What additional questions would you ask to learn more about her lower extremity pain?
  • How does localizing the pain help in generating a differential diagnosis?
  • How can you use the patient history to identify serious diagnoses?

Pain in the proximal lower extremities may result from diseases of blood vessels or peripheral nerves or local infection, or it may be referred from local structures, such as hip pain referred to the ipsilateral knee. Disorders of use and abuse, particularly sports-related disorders, predominate in this area.

Deep pain arising from vessels, fascia, joints, tendons, periosteum, and supporting structures is often poorly localized and dull; it may be accompanied by joint stiffness and deep tenderness. The close proximity of structures and complicated functional anatomy of the region make localization of the pain and identification of the affected structure even more difficult. Pain that arises from adjacent or supporting structures may be attributed to the joints in the absence of any true joint pathology.

Pain arising from disorders of the tendons, muscles, and bursae of the buttock and thigh commonly results from inflammation due to athletic injuries. Hip pain is often a consequence of degenerative or inflammatory conditions. Pain caused by diseases of the peripheral nerves or by entrapment neuropathies, such as meralgia paresthetica, can be difficult to sort out by history. Neuropathic pain may result from reflex sympathetic dystrophy/chronic regional pain syndrome (RSD/CRPS), a poorly understood condition that occasionally follows local trauma, stroke, or spinal cord injury. Irritation of the lumbar nerve roots (herniated nucleus pulposus, osteoarthritis) can cause lower extremity pain and may complicate the diagnosis of more localized disorders such as trochanteric bursitis and peripheral sciatic nerve inflammation.

Complex functional relationships may obscure primary and secondary etiologies of pain. Gait abnormalities are a common consequence and occasional cause of disorders in this region. Degenerative hip joint disease may result in a gait disturbance that causes piriformis syndrome or trochanteric bursitis. Atherosclerotic complications usually occur in the setting of extensive or systemic vascular disease. Deep venous thrombosis (DVT) requires immediate identification and action.

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BursitisPain and inflammation of the structure containing the fluid that lubricates a joint or tendon sheath.
Degenerative joint diseaseCharacteristic painful, noninflammatory changes in a joint that result from "wear and tear" of chronic use and abuse.
Entrapment neuropathyPain and loss of function resulting from a nerve passing through a physiologic space that is narrowed secondary to acute or chronic trauma or inflammation.
Neuropathic painPain in a region as a result ...

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