A 56-Year-Old Teacher With Worsening Hip Pain

Avan Armaghani, MD


April 06, 2020

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 56-year-old woman with no significant past medical history presents with left hip pain. She began experiencing this pain about 4 months ago. She says that she initially noticed the pain when she was walking and that it would resolve with rest.

She saw a chiropractor and physical therapist but experienced only minimal relief. The pain then became progressively worse, and she began experiencing it at rest. She rates the pain as "8 out of 10" on a pain scale. She describes it as achy and localized in the left hip. The pain does not radiate down her leg. She denies any stiffness feeling in her hips.

The patient has taken over-the-counter pain relievers, which temporarily reduce the pain to "5 out of 10" on a pain scale. She has never experienced a similar sensation. She does not report any weakness, numbness, or tingling sensation in her legs. She has not had any recent trauma. She does not have fever, chills, blurry vision, double vision, cough, chest pain, shortness of breath, nausea, vomiting, or abdominal pain.

The patient is otherwise healthy and does not take any other medications beyond the aforementioned pain relievers. She works as a third-grade teacher. She denies smoking and or drinking alcohol. She is postmenopausal. She has a family history significant for a maternal aunt who was diagnosed with breast cancer at age 45 years and underwent surgery, chemotherapy, and radiation treatment. The patient does not have any other family history of breast cancer, ovarian cancer, or other cancer.

Physical Examination and Workup

Upon physical examination, the patient's vital signs include blood pressure of 140/90 mm Hg, pulse of 85 beats/min, temperature of 98.3°F (36.8°C), respiration rate of 15 breaths/min, and weight of 189 lb (85.7 kg).

Her mental status appears normal. She is alert and oriented and is sitting comfortably, with no acute distress. Her pupils are symmetric and reactive to light. Her extraocular movements are intact. Her conjunctivae are normal. Her cardiac, pulmonary, abdominal, and musculoskeletal examination findings are otherwise unremarkable.

She has normal muscle bulk and tone and normal upper- and lower-extremity strength. She has no swelling or no deformities. She has no pain with compression of the left or right hip. Her sensation is intact bilaterally. She has 5/5 strength in hip flexion and extension, knee flexion and extension, and ankle dorsiflexion and plantar flexion bilaterally. Results of a straight leg test are negative bilaterally. Her gait is normal.

The results of her complete blood cell count with differential and comprehensive metabolic panel are within normal limits.


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