Unveiling Vascular Masquerades

A Case of Iliac Internal Stenosis Mimicking GTPS.

Magnus Håmsø, physiotherapist and manual therapist, Movon, Sandnes, and Bevegelsesklinikken, Vikeså. Magnus@fysioterapien.no

This case report describes a case where peripheral arterial disease was masked as GTPS (Greater Trochanteric Pain Syndrome). The experience is based on a patient case report. The patient has consented to publication.

Anamnesis

The patient is a woman between 55 and 60 years old with a 14-month history of lateral right hip pain. She is referred to a manual therapist via her general practitioner after being refused a cortisone injection of the trochanteric bursa at the hospital.

The patient underwent breast cancer treatment in 2015. She had undergone surgery, anti-estrogen therapy, and chemotherapy, which had led to gastrointestinal complications requiring multiple surgeries. She had cardiovascular disease in the form of hypercholesterolemia and hypertension. The patient was experiencing mild polyneuropathic symptoms with dysesthesia and paresthesia in hands and feet, likely due to cancer treatment side effects.

Fourteen months ago, the patient could walk 4km without pain. Now she can only walk 100-200 meters before hip pain forces her to stop. She is able to perform her job as a healthcare worker, as the department she works in does not require walking over such large distances that the pain directly hinders her work. She is otherwise engaged in very little recreational activity due to the pain. The patient lives with her husband, who is supportive and helps in everyday life. Since 2015, the patient has experienced some tough years. She also perceives the social and work situations as good and copes well with everyday life. She is slightly depressed due to the loss of function caused by the current symptoms and is frustrated that she can no longer go for walks.

Examination:

Pain localized to the right lateral hip, primarily over the greater trochanter. Aggravated by activity (standing/walking) or direct pressure of the lateral hip area such as lying on the side. Relieved by offloading in, for example, a sitting position. She reports no pronounced morning stiffness or pain at the beginning of movement. The patient does not regularly experience pain radiating or referring distally, but reports having felt pain spreading down the lateral thigh to the knee during periods of severe pain. A recent MRI of the hip shows tendinosis of the gluteus minimus and a small trochanteric bursitis. Clinical findings at the first consultation Inspection without remark. Brief gait analysis without remark (Only approx 100m tested) Adequate and symmetrical passive range of motion in the lumbar spine, hips, knees, and ankles. Lumbar spine screening does not reproduce known pain. Neurological screening tests are unremarkable except for known dysesthesia and paresthesia in the feet and fingers. Marked tenderness on palpation over the greater trochanter and in the gluteal muscles. Single-leg standing reproduces known pain within 15-30 seconds. Isometric tests of the abductors from a neutral position reproduce known pain. Isometric tests of the abductors from an adducted position reproduce known pain to an even greater degree. Passive adduction reproduces known pain FADER+R test is positive and reproduces known pain. FADDIR test evokes a pain in the lateral hip, but to a lesser extent than FADER+R and is described as different from her known pain. FABER test does not reproduce known pain. Reduced strength in abduction, uncertain whether it is primarily pain-related or a genuine weakness. No suspicion of a neurological cause of the strength deficit.

Conclusion after the first consultation:

Probable GTPS based on symptoms, gender, age, and clinical examination. After the first consultation, she received advice and guidance, activity modification, and exercises for lateral hip structures. Due to holiday leave, the follow-up consultation is conducted approximately 6 weeks after the first consultation.

Follow-up After about 6 weeks:

The patient reports that she has been able to perform the exercises within the restrictions she was given. She feels increased strength and power, and slightly less pronounced tenderness in the hip. However, there is no change in walking function, where she still needs to take breaks after about 100-200 meters. During this consultation, it becomes clearer that only 1-2 minutes of rest is required before she can repeat 100-200m of walking, with approximately the same symptoms as before. This can be repeated several times without significant increase in pain or reduction in walking distance. This new information warrants a vascular screening in the clinic with the following findings: No palpable groin pulse or distal pulses (dorsalis pedis artery and posterior tibial artery) in the right lower extremity. Weakly palpable groin pulse and noe palpable distal pulses in the left lower extremity. Bicycle and treadmill tests with approximately the same pulse loading yield identical symptom patterns with a sudden increase in pain after 1-2 minutes, becoming so severe that the patient has to stop the activity for 1-2 minutes before she can repeat the exertion.

Referral to diagnostics and treatment at the hospital:

Based on more accurate medical history information and new clinical examinations, suspicion of circulatory disease is now high. The new hypothesis warrants a consultation with the vascular surgery department at the hospital, who after a referral admits her for rapid assessment. At the hospital, no palpable pulse is found in the right groin, and weakly palpable pulse in the left groin. ABI (Ankle-brachial index) - 0.27 and 0.66 in the right and left lower extremities, respectively. CT angiography reveals atherosclerotic changes in the distal aorta and pelvic arteries.

Treatment provided by the vascular surgery department:

Bilateral iliacus communis stenting. After the operation they report satisfactory ABI, palpable pulses, and normal circulation. After the surgical intervention, the patient no longer has debilitating pain. The clinical tests that were initially positive (single-leg standing, isometric tests (from neutral and adducted positions), and FADER+R) no longer reproduce known pain. She can immediately walk 1500 meters without her known debilitating pain.

Current situation:

15 months have passed since the intervention (spring 2024). The patient has normal walking capacity with respect to her known pain. She has quit smoking and is undergoing further rehabilitation and training. The patient exercises two to three times a week and responds as expected with increasing cardiovascular and musculoskeletal load tolerance. She is no longer hindered by debilitating hip pain, but by a cardiovascular system that is not adequately rehabilitated - and a muscular-skeletal system that is still deconditioned.

Discussion:

Lateral hip pain can have many causes, with GTPS being a prevalent condition, especially in women over 50 years without signs of arthrogenic or neurological issues. In this case report, a classic medical history for GTPS together with a too narrow clinical examination led to an incorrect conclusion and diagnosis for the patient. With the medical history available, including cardiovascular disease, smoking, and a history of cancer and treatment, a vascular screening should have been performed early on. As the case shows, the medical history information regarding exertional pain relieved completely with relatively short rest, together with the bicycle and treadmill tests, ABI and pulse palpation, would have immediately increased suspicion of a vascular cause for the symptoms. This could have accelerated both the diagnosis and treatment of the condition.

Take home message:

Suspect vascular issues. Do simple clinical tests as pulse palpation, ABI and treadmill/bicycle tests to strengthen or weaken the hypothesis.

Read what I have read after this case

An uptdate on interal iliac artery stenosis from 2015

Mahé, G., Kaladji, A., Le Faucheur, A., & Jaquinandi, V. (2015). Internal Iliac Artery Stenosis: Diagnosis and How to Manage it in 2015. Frontiers in Cardiovascular Medicine, 2. https://www.frontiersin.org/articles/10.3389/fcvm.2015.00033

Epidemiology, natural history, diagnosis and treatment of Peripheral Arterial Disease

Dhaliwal, G., & Mukherjee, D. (2007). Peripheral arterial disease: Epidemiology, natural history, diagnosis and treatment. The International Journal of Angiology : Official Publication of the International College of Angiology, Inc, 16(2), 36–44. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2733014/

Diagnostic value of ankle-brachial index

Alagha, M., Aherne, T. M., Hassanin, A., Zafar, A. S., Joyce, D. P., Mahmood, W., Tubassam, M., & Walsh, S. R. (2021). Diagnostic Performance of Ankle-Brachial Pressure Index in Lower Extremity Arterial Disease. Surgery Journal (New York, N.Y.), 7(3), e132–e137. https://doi.org/10.1055/s-0041-1731444

Clinical tests to diagnose gluteal tendinopathy and GTPS

Grimaldi, A., Mellor, R., Nicolson, P., Hodges, P., Bennell, K., & Vicenzino, B. (2017). Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. British Journal of Sports Medicine, 51(6), 519–524. https://doi.org/10.1136/bjsports-2016-096175

A similar case report published in Journal of Manual & Manipulative therapy (2018)

Huml, E. L., Davies, R. A., Kearns, G. A., Petersen, S. M., & Brismée, J.-M. (2018). Common iliac artery occlusion presenting with back and leg pain: Case report and differential diagnosis considerations for neurogenic/vascular claudication. Journal of Manual & Manipulative Therapy, 26(5), 249–253. https://doi.org/10.1080/10669817.2018.1526465

Differentiation between neurogenic and vascular claduication

Nadeau, M., Rosas-Arellano, M. P., Gurr, K. R., Bailey, S. I., Taylor, D. C., Grewal, R., Lawlor, D. K., & Bailey, C. S. (2013). The reliability of differentiating neurogenic claudication from vascular claudication based on symptomatic presentation. Canadian Journal of Surgery, 56(6), 372–377. https://doi.org/10.1503/cjs.016512