29 A 34-Year-Old Male With Chronic Bilateral Gluteal Pains


Case 29

A 34-Year-Old Male With Chronic Bilateral Gluteal Pains



R. Michelle Koolaee



A 34-year-old male presents for outpatient evaluation of 3 to 5 years of bilateral hip pains that have become progressively worse over the past few months. The pain is located in the gluteal areas bilaterally and is worse first thing in the morning, with several hours of associated morning stiffness. It gets better as the day goes on, although it never fully resolves. The pain is worse on the right side.



Why is it important to ask about joint stiffness in the morning?


It is important to ask about joint stiffness in the morning when evaluating for an inflammatory arthritis, such as rheumatoid arthritis or ankylosing spondylitis (AS). Furthermore, you should think about a possible inflammatory arthritis in the sacroiliac (SI) joints in anyone who presents with chronic gluteal pain. The hallmark of inflammatory arthritis is the presence of joint pain that is better with activity and worse with prolonged rest. Because the joints are at rest while one is asleep, it makes sense that the joints are more painful and stiff in the morning. Morning stiffness lasting less than 30 minutes is more indicative of osteoarthritis (a noninflammatory arthritis), whereas stiffness greater than 1 hour indicates more likely an inflammatory arthritis. This patient has several hours of morning stiffness in his SI joints, concerning for an inflammatory arthritis.



Step 2/3


Clinical Pearl


Another great clue to help figure out whether patients have an inflammatory arthritis is to ask them if the pain (particularly back pain) ever wakes them up from sleep at night.



The patient denies any other joint pains, recent infections, rashes, or blurry/painful vision. He has no nausea, vomiting, or abdominal pains. He also denies fevers, chills, weight loss, or night sweats. The remaining review of systems (ROS) is negative.



Step 1


Basic Science Pearl


When you present clinical cases to your attending, the history of present illness (HPI) should contain only the pertinent positive and negative symptoms (rather than listing every single symptom). These symptoms were chosen because they relate directly to the differential diagnosis (see below section on differential diagnosis). Your attending should have a sense of your differential diagnosis after the HPI. The ROS includes anything that does not relate directly to the HPI.




He has no previous past medical history and has had no surgeries. His family history is significant for a maternal aunt with rheumatoid arthritis (RA). He is originally from India and works as a physician. He is not married and denies any smoking or alcohol use. He has no allergies and does not take any medications.



Step 1/2/3


Basic Science/Clinical Pearl


In any patient for whom you are considering an autoimmune illness, it is critical to ask about family history of autoimmunity. Autoimmune diseases as a whole, particularly lupus and multiple sclerosis, frequently run in families. It is thought that a combination of genetic and environmental factors contribute to activating disease. However, people definitely can still develop autoimmune diseases without a family history of autoimmunity.



On physical exam, he is afebrile and has no rashes, nail pitting, or onychomycosis/onycholysis. His musculoskeletal exam is notable for an abnormal Schober’s test (with only 2 cm of lumbosacral flexion) and right SI joint pain with an abnormal Patrick test on the right. His left Achilles tendon is also moderately swollen compared to the right side, with no associated warmth, tenderness, or erythema. The rest of his physical exam is normal.



What are the Schober’s and Patrick tests?


The Schober’s test is used to measure the degree of lumbosacral flexion. The examiner makes a mark approximately at the level of L5 (the fifth lumbar vertebrae). He or she then makes a second mark 10 cm above the first mark. The patient is asked to touch his or her toes. By doing so, the distance between the two marks should increase by ~5 cm. If the distance increases by less than 5 cm, it indicates limited lumbosacral flexion. This is typically seen in patients with AS (or any seronegative inflammatory arthritis) but can also be seen in elderly patients with severe lumbar degenerative disc disease. This test should be done in any patients (particularly young men) who present with inflammatory back or SI joint pain.


The Patrick test is performed to evaluate for pathology of the SI joint or hip. The test is performed by having the tested leg flexed, abducted, and externally rotated (a mnemonic to remember this is that the leg will look like the letter “P” when performed on the left side). It is important to make sure you ask the patient if the pain elicited with the maneuver is the same pain they presented to you with.


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Jun 15, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on 29 A 34-Year-Old Male With Chronic Bilateral Gluteal Pains

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