SUBJECTIVE: This is a (XX)-year-old female who comes in today complaining of right side pain on the outside of her hip. She says it goes down the outside of her leg. She was seen by the neurosurgeons for some low back pain and hip pain. Her back pain has disappeared.
She had an MRI in the past that showed some sort of synovial cyst that was diagnosed back in December. She states that her pain in her hip has been related to activities. She has pain going up and down stairs but it is just on the outside.
She denies any groin pain. She has a job that requires her to be up on her feet. The pain is worse at night. The patient saw her primary care physician. She was recommended to have an injection for her spine for synovial cyst, but she decided to not pursue this due to the lack of pain in her low back. She points to the outside of her hip, which she says is tender as well.
OBJECTIVE: The patient has point tenderness over the greater trochanter in the right hip. She has pain laterally with flexion of her hip and adduction of the hip. Range of motion of the right hip is about 10 to 20 internal rotation and 30 or 40 degrees external rotation but is symmetric bilaterally. She has 5/5 iliopsoas, quadriceps, hamstrings, gastrocnemius soleus, EHL and AT bilaterally. Sensation is intact to light touch grossly. She has negative Trendelenburg sign. The patient can stand on 1 leg for 5 seconds bilaterally without any weakness. Abduction strength is 5/5, but she does complain of pain on the right hip, on the outside of her hip. She has negative bicycle sign and Trendelenburg sign bilaterally.
IMAGING: Radiographs from December showed good joint space bilaterally, maybe some posterior inferior signs of some early osteoarthritis on the lateral, otherwise unremarkable.
ASSESSMENT: The patient has some trochanteric bursitis of the right hip.
PLAN: Today, we gave an injection with 80 Kenalog with 4 mL of 1% lidocaine. She was explained the risks and benefits. She has had this in the past and understood. We will have her follow up in 3 months. If she is still complaining of symptoms, we have instructed her to do some exercises to strengthen her abductors as well as stretching for iliotibial band.
