Hip Pain and a Fever: Expanding the Differential

Pranay Prabhakar, MD*1; Richard Paul Ramonell, MD1 and Dr. Rumman A. Langah, MD, FACP2, (1)Emory University, Atlanta, GA, (2)Emory University Hospital, Atlanta, GA

Meeting: Hospital Medicine 2016, March 6-9, San Diego, Calif.

Abstract number: 742

Categories: Adult, Clinical Vignettes Abstracts

Keywords: , , ,

Case Presentation: A 41 year old otherwise healthy male presented with three days of severe left hip pain.  He reported daily aerobic exercise, new weight training, and prolonged standing at work.  Pain was associated with fevers and intermittent numbness and tingling in his left lower extremity and progressed until he could not support weight on the leg.  Physical exam was significant for fever to 38.7 C, tenderness to palpation over the left trochanter, and severe pain with passive and active movement of the left hip worse with abduction; log roll test was positive.  Labs were significant for leukocytosis to 13,000 cells/microliter, CRP 90.4 mg/L, and ESR 53 mm/hr.  X-ray of the hip showed soft tissue calcifications adjacent to the left trochanter and MRI pelvis with and without gadolinium showed a chronic tear of the gluteus medius at the insertion of the greater trochanter with associated calcific trochanteric bursitis and edema in the gluteus medius muscle.  A diagnostic aspiration of the left subtrochanteric bursa showed clear fluid with negative gram stain and culture.  The patient was diagnosed with Greater Trochanteric Pain Syndrome and improved with physical therapy and NSAIDs.  At discharge, he was able to ambulate and was referred to outpatient physical therapy.

Discussion: Pain overlying the greater trochanter—a site where three bursae, the hip abductor, lateral thigh muscles, and the iliotibial band converge—is a common debilitating complaint.  However, recent imaging and histopathological studies in such patients have shown that in many patients labelled as having “trochanteric bursitis,” the bursa is without any inflammation (as evidenced by negative bursal fluid studies in this case).  Gluteus medius/minimus inflammation or tear is the core pathophysiological process resulting in pain at the greater trochanter, which is more accurately described with a contemporary term: greater trochanteric pain syndrome (GTPS).  Septic or another primary trochanteric bursitis is frequently high on the differential especially in patients with fever and elevated inflammatory markers; this condition must be ruled out with history, examination, fluid analysis, and imaging.  Management of GTPS is primarily conservative with avoidance of further muscle/tendon injury by limiting activity, NSAIDs, gait and posture focused physical therapy.  Local steroid injections may help relieve symptoms, while surgery is rarely indicated.

Conclusions: GTPS has replaced trochanteric bursitis as a more accurate descriptor of lateral hip pain to account for the more common involvement of lateral hip muscles and tendons and rarity of isolated bursal involvement.  Our patient’s initial presentation concerning for infection and eventual histological and imaging analysis confirming its etiology illustrates the value of placing GTPS—a condition that can respond well to conservative management—on the differential in patients with fever and acute hip pain.

To cite this abstract:

Prabhakar P, Ramonell RP, Langah RA. Hip Pain and a Fever: Expanding the Differential. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 742. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/hip-pain-and-a-fever-expanding-the-differential/. Accessed July 20, 2019.

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