200 Section - When the Hip Masquerades as the Spine: Bilateral Femoral Head Avascular Necrosis Presenting as Chronic Lumbosciatalgia

Avascular necrosis of the femoral head with bilateral hip collapse presenting as chronic lumbosciatalgia in a 60-year-old man.

Case Description:

A 60-year-old-man with diabetes and chronic alcoholism developed right groin pain, radiating posteriorly to mid-leg, with claudication and functional limitation, progressing to the use of two crutches. Seven months later he was referred to Orthopaedics for chronic bilateral lumbosciatalgia. Lumbar imaging excluded compressive radiculopathy and he was sent to Physical and Rehabilitation Medicine(PRM) for conservative treatment. Examination showed an older-than-stated appearance, severe bilateral hip pain on internal and external rotation, antalgic gait with bilateral support, load-induced groin pain, and trigger points in the gluteus medius, without supine pain or neurological signs. He received opioids, NSAIDs, gabapentin, dry needling and trigger-point injections without sustained benefit. Given the poor response, hip-focused findings and risk factors, pelvic MRI was requested at the first PRM visit, physiotherapy was withheld, and MRI confirmed avascular necrosis of the femoral heads. Urgent Orthopaedics review led to uneventful bilateral total hip arthroplasty, followed by a PRM-supervised rehabilitation program.

Discussions:

Avascular necrosis of the femoral head is a progressive disease caused by disruption of subchondral blood supply, often related to alcohol, corticosteroids, diabetes or trauma. Early MRI-based diagnosis is essential to preserve function and prevent secondary osteoarthritis. This case shows how hip pathology may mimic lumbar radiculopathy, delaying appropriate imaging and treatment. The HOOS-12 (Hip disability and Osteoarthritis Outcome Score-12) improved from 16.7% pre-operatively to 85.4% 1 month post-operatively.

Conclusions:

Comprehensive history and focused musculoskeletal examination by the physiatrist before starting rehabilitation is essential to confirm the diagnosis of referral to PRM and to consider differential diagnosis. In this case report, they were crucial to suspect hip disease, identify risk factors and avoid ineffective therapy. PRM has a key role in early recognition, appropriate referral and optimization of post-arthroplasty functional outcomes.