Clinical History
A 28-year-old male, an avid wing foiling enthusiast, presented with a 5-month history of progressive left hip pain. The pain had been atraumatic and did not follow a change in training load. Initially described as a deep, aching discomfort localised to the buttock region, the pain was initially severe enough to disturb his sleep but had somewhat settled by the time he presented to the Sport & Exercise Medicine clinic.
Over time, the pain extended to the anterior and lateral hip, occasionally radiating to the left foot. These symptoms were exacerbated by prolonged sitting or exercising but did not significantly interfere with cycling or walking up to 10 km per day. Activities such as single-leg squats and lunges caused mild discomfort, but delayed pain was the most striking feature, often worsening hours after exertion.
Therefore, the patient had engaged in months of relative rest from aggravating activities such as those involving impact. He had also had several sessions of physiotherapy and managed with mainly hamstring strengthening and load management.
Along with the nighttime discomfort, the patient also reported having noticed his clothes becoming loser over the last few months however this had been attributed to being less active and therefore losing muscle. The patient had no gastrointestinal or chest symptoms, nor any night sweats.
Clinical Examination of the Hip
- Observation: No overt gait abnormalities or asymmetry.
- Hip Range of Motion: Symmetrical and pain-free internal and external rotation of both hips.
- Lower Limb Strength Testing: Bilateral hip strength was well-preserved with normal muscle bulk.
- Special Tests: FABER and FADIR tests were negative. No tenderness was noted upon palpation of pubic symphysis, ischial tuberosity, hip joints or surrounding structures.
- Functional Movements: Activities like squatting and lunging reproduced mild pain but were generally well-tolerated. Single leg hop was negative for reproduction of pain.
Diagnostic Investigations
- MRI Scan: Multifocal bone marrow oedema in the pelvis, sparing traditional weight-bearing areas such as the femoral head or acetabulum.
- Initial Bloodwork: Elevated C-reactive protein (CRP) at 106 mg/L, FBC revealed normocytic anaemia. Normal prostate-specific antigen (PSA). Vitamin D levels were normal.
- CT Scan: Widespread lymphadenopathy (swollen lymph nodes) above and below the diaphragm.
Lymphadenopathy above and below the diaphragm can be a sign of lymphoma, a type of cancer that affects the lymph nodes:
Follow-Up Findings
The findings were suggestive of neoplasia and the patient was referred to the haematology MDT (Multidisciplinary Team). After a lymph node biopsy and further PET scans, Hodgkin’s lymphoma was confirmed. This systemic malignancy explained the atypical MSK presentation, including the bone marrow changes and persistent inflammatory marker elevation.
Diagnosis
The final diagnosis was classical Hodgkin’s lymphoma, presenting atypically with focal pelvic bone marrow oedema and chronic hip pain.
Management
- Oncologic Referral: Immediate coordination with hematology-oncology specialists for staging and initiation of chemotherapy.
- Supportive Measures: Tailored physical therapy to maintain mobility and manage pain during cancer treatment.
- Monitoring: Serial imaging and inflammatory marker assessments to evaluate response to therapy.
Discussion: Lymphoma and Its Musculoskeletal Manifestations
Lymphomas, particularly Hodgkin’s lymphoma, are systemic malignancies of the lymphatic system. While they typically present with systemic symptoms such as fever, night sweats, and weight loss (the “B symptoms”), they can also manifest atypically with musculoskeletal complaints, including pain, weakness, or functional impairment. Musculoskeletal symptoms in lymphoma often arise due to:
- Bone Involvement:
- Lymphoma can infiltrate bone marrow, leading to localized bone pain or tenderness. Imaging may reveal lytic lesions or bone marrow oedema, which can mimic other conditions like infections or fractures.
- Soft Tissue Involvement:
- Lymphadenopathy adjacent to musculoskeletal structures can compress nerves or muscles, leading to referred pain or functional disturbances.
- Paraneoplastic Phenomena:
- Cytokine release in lymphoma can trigger systemic inflammation, resulting in arthralgia or myalgia.
MRI showing bilateral multifocal bone marrow oedema
The Importance of Red Flags in Musculoskeletal Pain
Identifying red flags in patients presenting with musculoskeletal pain is essential to detect serious underlying conditions like lymphoma. Key red flags include:
- Unexplained Weight Loss: Significant unintended weight loss may indicate malignancy.
- Night Sweats and Fever: These systemic symptoms are often associated with lymphoma and other serious conditions.
- Persistent Pain Unresponsive to Treatment: Pain that does not improve with standard management may suggest a more serious underlying pathology.
- Palpable Masses: The presence of unexplained soft tissue masses should raise suspicion for malignancy.
- Elevated Inflammatory Markers: Increased levels of markers like C-reactive protein (CRP) can indicate systemic inflammation or malignancy.
The Role of Red Flags in Early Diagnosis
- Prompt Recognition: Identifying red flags allows healthcare professionals to initiate timely investigations, such as imaging and laboratory studies, to narrow differential diagnoses.
- Appropriate Referrals: Systemic red flags should trigger referrals to oncology, infectious disease specialists, or rheumatologists, ensuring comprehensive evaluation.
- Avoiding Delays in Treatment: Early detection of malignancies like lymphoma significantly improves prognosis, as treatment is most effective at earlier stages.
Key Learning Points
- Persistent bony pain despite a significant period of relative offloading and rehabilitation warrants further systemic evaluation.
- Collaboration between sports medicine, radiology, and oncology can expedite diagnosis and treatment in complex cases.
- Hodgkin’s lymphoma, though uncommon, should be considered in cases with unexplained systemic features and musculoskeletal findings.
This case illustrates the critical role of holistic assessment and interdisciplinary care in uncovering a diagnosis beyond the musculoskeletal system.
References:
- Bone marrow involvement in Hodgkin lymphoma. (2021). British Journal of Radiology Case Reports. Retrieved from https://academic.oup.com/bjrcr/article/8/5/20210182
- Musculoskeletal manifestations of lymphoma. (2021). BMC Medical Imaging. Retrieved from https://bmcmedimaging.biomedcentral.com/articles/10.1186/s12880-021-00667-4
- Comprehensive lymphoma management strategies. (2003). Skeletal Radiology, 32(7), 397-404. Retrieved from https://link.springer.com/article/10.1007/s00256-003-0709-y
- Red flags in musculoskeletal pain. (2013). BMJ, 347, f7095. Retrieved from https://www.bmj.com/content/347/bmj.f7095
- Diagnostic considerations for atypical presentations. (2020). Journal of Orthopaedic & Sports Physical Therapy, 50(5), 262-270. Retrieved from https://www.jospt.org/doi/pdf/10.2519/jospt.2020.9971
- Role of MRI in detecting lymphoma-associated bone lesions. (n.d.). Consultant360. Retrieved from https://consultant360.com
