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ORTHOPEDICS 2007; 30:600
August 2007

A 44-year-old man reported mild low-back pain and right-sided leg pain for the
past two months. He also had weakness in his right leg. He reported no
concomitant numbness or tingling. Previous magnetic resonance imaging (MRI) was
consistent with T12-L1 central disk protrusion with thecal compression. After
physical therapy, the patient’s symptoms progressively worsened and he could not
walk. Medical history was unremarkable for trauma, drug use, or hereditary
illnesses.

Physical examination revealed no tenderness, trigger points, or paravertebral
muscle spasm in the the lumbosacral region. Straight-leg-raise tests were
negative bilaterally. However, external and internal rotations of the right hip
joint were painful and accompanied by minimal loss of hip muscle strength (4/5).
Left hip joint examination was normal. A right hip pathology rather than a
low-back problem was suspected, and MRI revealed avascular necrosis of the right
femoral head. Interestingly, before the patient presented to the orthopedics
department, he started to have concomitant left hip pain and another MRI showed
early avascular necrosis on the left side.

Any type of pain during physical examination may not always herald a pathology
pertaining to that exact region. Other likely causes should be suspected; and
the rest of the examination should be tailored accordingly.1 Likewise, in our
patient, although the initial problem was back pain and the MRI had been
somewhat consistent, prompt physical and radiological assessment showed that the
hip pathology was causing the symptoms. Treatment also might vary according to
the diagnoses. Moreover, one treatment method may be contraindicated in the
other. In our case, physical therapy that would otherwise help a patient with
low-back pathology was noncontributory, even unfavorable. Therefore, noteworthy
in the management of relevant patients would definitely be to reconsider the
diagnosis in case the initial treatment proved to be inconclusive. This is
especially true in idiopathic cases of avascular necrosis of the femoral head;
the chance of bilateral involvement during the disease course should be kept in
mind.

Reference
Özçakar L, Korkmaz N. When you hear hooves, don’t forget zebras along with the
horses. Rheumatol Int. 2003; 23:326.