Author: Jaynie Criscione, BS
Co Author #1: Cayla Kalani, BS Cooper University Health Care, Camden, NJ
Co Author #2: Cody Clinton, DO Cooper University Health Care, Camden, NJ
Co Author #3: Dug Su Yun, DO Cooper University Health Care, Camden, NJ
Senior Editor: Christian Fulmer, DO, FAMSSM
Editor: Maggie Stark, DO, MS

Patient Presentation:
A 38-year-old African American male presented to a primary care sports medicine clinic after a referral from orthopedic surgery for acute worsening of chronic bilateral hip pain, right greater than left. His symptoms were exacerbated six weeks prior after standing from sitting, prompting an emergency department (ED) visit. In the ED, he had sharp posterior right sided leg pain, worse with walking and causing functional limitations. He had no relief from over-the-counter analgesics and a methylprednisolone taper. Review of systems was negative for fevers, chills, shortness of breath, nausea, vomiting, saddle anesthesia, and bowel/bladder dysfunction.

History:
The patient reported over 10 years of bilateral hip pain. About 10 years prior, he had presented to the ED with concern for a straddle injury. Imaging incidentally found bilateral femoral neck fractures. No further work up from an orthopedic or metabolic standpoint was pursued at that time.

His daily medications included quetiapine and pantoprazole with ibuprofen and acetaminophen as needed for pain. His past medical history was significant for childhood rickets and legal blindness. He reported a half pack per day smoking history as well as housing instability. Family history was notable for rickets in his mother and maternal grandmother as well as maternal chronic kidney disease.

Physical Exam:
On physical exam, the patient was five feet tall with varus alignment of the knees. An antalgic gait was present. There was no tenderness to palpation over the cervical, thoracic, or lumbar spinous processes. His bilateral lower extremities were neurovascularly intact with soft compartments.

His bilateral hips were tender to palpation with limited internal and external rotation due to pain. He had 4+/5 strength with hip flexion bilaterally. Otherwise, his lower extremity strength was 5/5 throughout.

He had pain elicited with flexion, abduction, and external rotation (FABER), flexion, adduction, and internal rotation (FADIR), and log roll testing. His straight leg test was negative bilaterally.

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