Search

The possibility that polymyalgia rheumatica (PMR) can be diagnosed when both ESR and CRP are normal at the time of diagnosis and before therapy with glucocorticoids, has been often discussed in the literature. We present a case report of a 100-year-old Caucasian man referred to our outpatient clinic, complaining of chronic pain in the shoulder and hip girdle associated with normal values of both ESR (21 mm/1st hour) and CRP (4 mg/dL). In the previous four months, several anti-inflammatory drugs and painkillers associated with physiotherapy treatments gave no significant improvement in pain and self-care. After an ultrasound (US) and an 18-fluorodeoxyglucose positron emission tomography associated with total body computed tomography (18-FDG PET/CT) examination, PMR was diagnosed and he started therapy with 17.5 mg prednisone, obtaining a fast improvement in pain and self-care. After 10 months of tapering, he stopped prednisone without relapse. During a 3-year follow-up, no alternative diagnosis was done. When a patient complains of chronic bilateral shoulder and hip girdle pain associated with normal inflammatory indices, it is reasonable to think in the first instance that this person is not suffering from PMR. Moreover, the possibility that PMR may onset in a centenarian person, is exceptional. In our patient, when we piece the puzzle together, the diagnosis of PMR was the most possible one.

Capillary hemangiomas are benign tumors found in the skin and soft tissues in younger people. They occur in the central nervous system only rarely, and intradural occurrence is extremely rare. We report here a 60-year-old man presenting with thoracic girdle pain and progressive gait disturbance. Magnetic resonance images of the thoracic spine showed a12×8×20 mm, well-defined intradural mass at the T2 level, compressing the spinal cord laterally. Relative to the spinal cord, the mass was hypo- to isointense on T1-weighted images and relatively hyperintense on T2-weighted images, with strong enhancement on contrast-enhanced T1-weighted images. The patient underwent T1-2 hemilaminectomy with resection of the intradural extramedullary tumor, which showed characteristics of a capillary hemangioma on histologic examination. The patient’s symptoms improved following the surgery and no clinical or radiological evidence of recurrence was noted at the 2-year follow-up. We present this case with a review of the literature, highlighting features for differential diagnosis.

Data on the severity of signs and symptoms of lumbopelvic pain (LPP) during pregnancy are scarce. Therefore, this cross-sectional study examines the severity of LPP and pain-related signs and symptoms. Women with an uncomplicated pregnancy of 20-30 weeks were invited to participate. They rated their pain and fatigue on a numerical rating scale, and pain location was indicated on a drawing. Disability was scored on the Quebec Back Pain Disability Scale (QBPDS) and urine incontinence on a Likert scale. Physical examination consisted of the Active Straight Leg Raise (ASLR) test, the Posterior Pelvic Pain Provocation (PPPP) test and pain score, and force during isometric bilateral hip adduction. Of all 182 participants, 60.4% reported LPP. Mean pain level was 3.6 (SD 2.2); in 20.0% of the women the score was >5. The mean score on the QBPDS was 27 (SD 16); in 20.9% the score was >40. Compared to women without LPP, women with LPP more frequently suffered back pain in the past (p

Women with pregnancy-related pelvic girdle pain (PPP), or athletes with groin pain, may have trouble with the active straight leg raise (ASLR), for which a pelvic belt can be beneficial. How the problems emerge, or how the belt works, remains insufficiently understood. We assessed muscle activity during ASLR, and how it changes with a pelvic belt. Healthy nulligravidae (N=17) performed the ASLR, and walked on a treadmill at increasing speeds, without and with a belt. Fine-wire electromyography (EMG) was used to record activity of the mm. psoas, iliacus and transversus abdominis, while other hip and trunk muscles were recorded with surface EMG. In ASLR, all muscles were active. In both tasks, transverse and oblique abdominal muscles were less active with the belt. In ASLR, there was more activity of the contralateral m. biceps femoris, and in treadmill walking of the m. gluteus maximus in conditions with a belt. For our interpretation, we take our starting point in the fact that hip flexors exert a forward rotating torque on the ilium. Apparently, the abdominal wall was active to prevent such forward rotation. If transverse and oblique abdominal muscles press the ilia against the sacrum (Snijders' "force closure"), the pelvis may move as one unit in the sagittal plane, and also contralateral hip extensor activity will stabilize the ipsilateral ilium. The fact that transverse and oblique abdominal muscles were less active in conditions with a pelvic belt suggests that the belt provides such "force closure", thus confirming Snijders' theory. © 2009 Elsevier Ltd. All rights reserved.

Evaluation of an athlete's report of "hip pain" is challenging. Many conditions involving the pelvic girdle can present with overlapping pain distributions, and athletes often may have coexisting disorders. Appropriate evaluation requires thorough, systematic consideration of intra-articular hip disease, extra-articular local causes of hip pain, and referred pain from other musculoskeletal or even visceral sources. Although our understanding of intra-articular hip disorders has been greatly enhanced in recent decades through advances in hip arthroscopy, gaps still exist in our understanding of appropriate treatment, including effective nonsurgical protocols and when to consider surgical intervention. For instance, we have a better understanding of hip dysfunction related to structural changes that occur prior to the onset of arthritis, but we are also learning that correction of the structural changes does not always guarantee a correction of dysfunction and pain. Furthermore, athletes need instruction and guidance in retraining appropriate movement patterns after a surgical intervention. Risk stratification regarding which athletes need surgical intervention and what their needs are after specific surgical procedures remain undefined. In this review we will describe the differential diagnosis of hip and pelvic girdle pain in the athlete and then discuss how to use a history, physical examination, and appropriate imaging and diagnostic injections to arrive at a proper diagnosis. Lastly, a brief discussion is included of key concepts and controversies involved in treating some of the most common hip disorders experienced by athletes.

A 46-year-old female was admitted complaining of progressive, severe girdle pain consistent with the left Th3 dermatome. Neurological examination on admission revealed dysesthesia and radiating pain in the left Th3 territory. Plain X-rays and tomograms of the thoracic spine revealed a beak-like bony excrescence arising from the lamina and projecting moderately to the Th3/4 intervertebral foramen, suggesting ossification of the thoracic ligamentum flavum (OYL). Myelography showed the dural sac compressed from laterally just below the left Th3 pedicle, which suggested that the Th3 nerve root was compressed by the OYL. After Th3 nerve root decompression through hemilaminectomy and foraminotomy, the girdle pain disappeared. OYL is known to cause thoracic radiculomyelopathy, but presentation with intercostal neuralgia only is very rare. The authors review the literature and stress the importance of myelography for diagnosis.

Background Polymyalgia rheumatica (PMR) is an inflammatory disease of the elderly characterized by girdle pain and systemic symptoms. Imaging techniques, such as 18F-fluorodesoxyglucose (FDG)-PET/CT, have demonstrated that inflammation is localized mainly in the joint capsule and in bursae, with occasional large vessel vasculitis. However, the correspondence between FDG uptake and subjective symptoms is unclear. We have recently demonstrated that interspinous bursitis is typical of PMR, although it does not associate with pain. Objectives To test if FDG uptake, which is frequently seen in the girdles of PMR patients, is associated with the clinical experience of pain in the individual patients. Methods Eighty-four patients affected by PMR according to the ACR/EULAR criteria were studied. A standardized clinical examination, including pain at pressure of the long head of the biceps (LHB), the subacromial area (SA), the ischiatic (IB) and trochanteric (TB) bursae, and at mobilization of the shoulder and hip girdles, was performed immediately before PET/CT. After a minimum of six hours fasting, a dose of 4.8-5.2 MBq of FDG per kilogram body weight was injected through a peripheral vein catheter. Data acquisition started between 60 and 90 minutes after tracer administration. Patients underwent simultaneous FDG-PET and CT imaging from the skull base to the knee using an integrated PET/CT scanner (Hirez; Siemens Medical Solutions, Knoxville TN, USA). PET raw data were reconstructed by means of ordered subset expectation maximization and attenuation correction was performed using the CT raw data. The entire CT dataset was fused with the 3-dimensional PET images using an integrated software interface (Syngo Image Fusion; Siemens Erlangen, Germany) to create superimposed anatomical images. Joint uptake was scored relative to liver uptake as 0=no uptake present, 1=lower than liver uptake, 2=similar to liver uptake, 3=higher than liver uptake. Results A history of shoulder pain was present in all patients, whereas that of the pelvic girdle was present in 42/84 (50%). The concordance between pain elicited in the different areas and FDG uptake is shown in the table for the right (R) and left (L) sides. At clinical examination, 11/84 (13.1%) patients reported spontaneous pain or pain on passive motion which was clearly more intense in one shoulder. In these cases, tracer uptake was more intense in the symptomatic side in only 2, whereas in the remaining ones it was symmetrically distributed (bilaterally absent in 1 and bilaterally present in 8). Pelvic pain side was discordant in only 1 patient. The TB and IB were involved more often at PET than clinically. Conclusions The concordance between pain and FDG uptake in the girdles of PMR patients is only modest, except for shoulder capsulitis/synovitis, suggesting that factors other than inflammation visible at PET could contribute to clinical presentation. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3011

A case of spinal cord compression from an intradural arachnoid cyst in the thoracic region is reported. The patient was a 59-year-old female. She had noted thoracic girdle pain and urinary trouble for 2 years. Neurologically, she showed muscle atrophy and weakness of the right leg, and loss of all sensory modalities below the 7th thoracic cord (Th7) level bilaterally. Metrizamide myelography showed no abnormal findings, but computed tomography (CT) following the metrizamide myelography demonstrated marked enlargement of the subarachnoid space and remarkable rightward and ventral displacement of the spinal cord. During surgery it was noted that the spinal cord was severely compressed by an arachnoid cyst from Th4 through Th6. After this operation, neurological deficits disappeared completely. Most spinal intradural arachnoid cysts arise in the region of the septum posticum in the thoracic portion. Various etiologies have been postulated. Although conventional myelogram has been the most important form of examination, intradural arachnoid cysts may be filled incompletely or not at all in the myelography performed in a prone position, because they mostly locate on the dorsal aspect of the spinal cord. There are some reported cases in which intradural arachnoid cysts were found a few hours after myelography. Therefore it is not so easy to diagnose intradural arachnoid cysts with conventional myelography. With metrizamide CT myelography, intradural arachnoid cysts can be visualized more easily.