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Musculoskeletal clinical topic of the month – An unusual case of hip pain

Sarcoidosis and musculoskeletal disease

Sarcoidosis is a disease characterised by the growth of tiny collections of inflammatory cells (granulomas) in any body tissue — most commonly the lungs and lymph nodes. But it can also affect the eyes, skin, heart and other organs.

The cause of sarcoidosis is unknown, but it is most likely an autoimmune response to an external antigen such infectious agents, chemicals, and dust. There is a genetic predisposition to sarcoidosis. 

Muscular involvement is a common feature of sarcoidosis but is usually asymptomatic. The four clinical subtypes of muscular sarcoidosis have been characterised as:

  • Acute myositis
  • Chronic myopathic
  • Palpable nodular
  • Asymptomatic

In general, acute myositis is accompanied by fevers, muscle pain and elevated muscle enzymes. Chronic myopathic types tend to be associated with muscle atrophy and weakness. The palpable nodular type presents as non-tender masses within muscles.  

This case report highlights an unusual presentation of calcific tendinitis secondary to sarcoidosis, in an even more unusual place, the piriformis tendon.

Clinical Presentation

Clinical history;

  • 42-year-old man presented with a 7-day history of left hip pain.
  • Started after he went for a 30-minute evening run.
  • He developed non-specific pain around his left hip later that evening and over the following days.
  • Pain got progressively worse to the point he was bed bound and unable to walk.
  • Seen at LBSM on day 7, he was unable to fully weight bear and was mobilising with a crutch.
  • He denied systemic symptoms such as fatigue, myalgia, anorexia and weight loss.  
  • He had a similar episode to this 8 years ago at which time he was diagnosed with a gluteal abscess which was self-limiting. Blood tests at the time revealed normal white cell count and inflammatory markers.  

Past Medical history;

  • Sarcoidosis affecting his lungs, skin and eyes. No previous joint involvement. He had not had flare for 10 years and was not taking any medication.
  • Serum corrected calcium levels were consistently elevated over many years at 2.55 mmol/L. 

Exercise history;

  • He is fit and active, running three or four times a week.

Social history;

He works as an accountant and had been working for home through the COVID-19 pandemic.

Clinical examination;

  • On initial examination he was unable to fully weight bear on his left leg and was walking with a limp.
  • Unable to walk up or down stairs and could not maintain a single leg balance.
  • Reduced range in all movements of the left hip
  • Pain could not be directly reproduced through palpation.

Next steps;

  • Urgent left hip and pelvis MRI was ordered and the patient was advised to offload until the results were back.


Left Image – MRI (STIR 1 sequencing) imaging demonstrating a coronal view of calcific changes within the left piriformis muscle and tendon.

Right image – MRI imaging with axial view of calcific changes within the left piriformis muscle and tendon.

hip pain Musculoskeletal clinical topic of the month - An unusual case of hip pain


  • Patient asked to partially weight bear through left hip for one week, with the use 2 crutches.
  • Transitioned onto a gentle isometric loading programme with body weight and bands by end of first week.
  • Returned to full weight bearing gradually over a period of 2 weeks.
  • Restricted step count to 3000/day until completely pain free and then progressively increased to 10000/day (over period of 2 weeks).
  • Heavier loading programme for deep gluteal muscles and piriformis specific stretches started at 4 weeks.


  • Ultrasound guided corticosteroid and local anaesthetic injection into calcific portion of piriformis tendon insertion in first week which produced immediate positive response to pain.
  • Patient then prescribed 1 month course of anti-inflammatories and PPI cover.

Patient Self-monitoring tools

Patient completed LBSM pain and symptom diary throughout treatment

Key Summary – Calcific tendinitis and Sarcoidosis

  • Calcific tendonitis refers to a build-up of calcium in the tendon complex.
  • This can cause a build up of pressure in the tendon, as well causing a chemical irritation.
  • Typically calcific tendinitis is acute or acute on chronic and extremely painful when “flares”.
  • In addition to the chemical irritation and pressure, the calcific deposit reduces the space between adjacent structures and inflammation (demonstrated by the high signal in the muscle).
  • It typically occurs in in the rotator cuff, patella tendon and gluteus medius tendon.
  • Conditions that elevation serum calcium, will naturally predispose to calcium deposits in the body.
  • No laboratory tests are diagnostic of sarcoidosis.
  • Elevated serum calcium is a recognised abnormality associated with sarcoidosis and is seen in 10% of all patients with sarcoidosis.
  • Hypercalcaemia in sarcoidosis is thought to be due to the overproduction of vitamin D by macrophages in the sarcoid granuloma due to disruption in feedback regulation.
  • Malignancy should always be considered as a differential diagnosis in patients with elevated hypercalcaemia.
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    Orla Mulligan
    Administration and Social Media Manager
    Administration, LBSM

    Orla Mulligan is the administration and social media manager for LBSM. She has a strong background in sport having herself played netball at an elite standard for the U21s Northern Ireland team in the European Championships as well as the U21s competition for Saracen Mavericks.

    She understands youth sport pathways having herself played and training in the netball Kent regional pathway. She has a keen interest in most sports and a good understanding of how injury and illness can impact on the mind and body, as well as rehabilitation pathways.

    She looks forward to speaking and assisting LBSM patients and gives her best support to them during their treatment pathway.

    A day in the life of Orla involves communicating with patients via phone and email, managing and organising clinics, operations and media management.

    Outside of work, Orla is a gym enthusiast, enjoys tennis and still finds the time for an occasional game of netball.

    Maddie Tait
    BSc, MSc
    Associate, LBSM
    Musculoskeletal and Sports Podiatrist

    Maddie treats and manages complex foot and ankle injuries in London and Surrey.

    She is particularly interested in helping her patients improve their quality of life and achieve their personal goals, working closely with Foot and Ankle Consultants, Sports Medicine Doctors and Physiotherapists.

    Maddie has a sporting background herself having previously represented England in Hockey. She understands the demands of elite sport and the importance of physical and mental health. In her spare time, Maddie continues to enjoy an active lifestyle by running, cycling and attending a Pilates class.

    Having graduated from University of Brighton with a MSc (hons) in Podiatry, Maddie focused her career in Podiatric Sports Injuries and Biomechanics. Previously she completed a BSc (hons) in Sport Science at Loughborough University.

    A day in the life of Maddie involves consulting patients in clinic, performing gait and biomechanical assessments, measuring and fitting orthotics and braces. She also regularly teaches and presents at sports medicine and podiatry conferences.

    Outside of work, Maddie still finds time to play hockey and enjoys running and skiing.

    Mr Prakash Saha
    Consultant Partner, LBSM
    Consultant in Vascular Surgery

    Mr Prakash Saha is a Consultant Vascular Surgeon at LBSM. He takes pride in providing the best possible results for his patients by using the most appropriate non-surgical and surgical methods based on clinical evidence, patient results and satisfaction.

    He treats fit and active people suffering with a range of cardiovascular issues, from painful leg swelling associated with exercise to venous insufficiency, post-thrombotic syndrome and leg ulcers. He also treats people with arterial system problems including poor circulation, compression syndromes and aneurysms. He carries out both endovascular and open aortic repair and has some of the best outcomes in the country.

    Mr Saha studied medicine at the United Medical & Dental Schools at Guy’s and St. Thomas’ Hospitals before completing his higher surgical training in London and the South East. During this time, he was awarded the prestigious NIHR Clinical Lectureship in Vascular Surgery at St. Thomas’ Hospital, giving him comprehensive training in open and endovascular techniques for treating arterial and venous disease. Prakash completed his aortic surgery training at the St. George’s Vascular Institute before carrying out a specialist fellowship at the Royal Prince Alfred Hospital, Sydney.

    Mr Saha regularly lectures and runs workshops across the globe on the latest surgical techniques to treat vascular disease. He has also been awarded a number of research grants from the Royal College of Surgeons, the Circulation Foundation, the Wellcome Trust, the Academy of Medical Sciences, and the British Heart Foundation, which has led to over 80 publications and the development of innovative technologies to help treat patients. For this work, Prakash has received a number of prizes, including the Venous Forum prize from the Vascular Society of Great Britain and Ireland, an International Young Investigator Award, and an Early Career Investigator Award from the American Heart Association.

    A day in the life of Mr Saha involves seeing patients in clinic, operating in surgical theatre or lecturing at his university. He also regularly teaches and presents at vascular and sports medicine conferences.

    Mr Saha is an avid cyclist and tennis player (although yet to get a set of Dr Seth!). Outside of work, he spends time with his family who consists of 3 children and enjoys travelling.

    Dr Gajan Rajeswaran
    Consultant Partner, LBSM
    Consultant in Sports and Musculoskeletal Radiology

    Dr Gajan Rajeswaran is a Consultant Musculoskeletal Radiologist at LBSM, with an extensive background of working in elite sport. He is one of the most recognised radiologists in the sports medicine field. He provides top level imaging and medical diagnostic services for patients and athletes.

    Dr Gajan Rajeswaran completed his undergraduate medical training at Imperial College London and his radiology training at Chelsea & Westminster Hospital. He has obtained two post-CCT fellowships in musculoskeletal imaging. He was appointed as a consultant at Chelsea & Westminster Hospital in 2011.

    He has a passion for all sports having worked as a radiologist at the Glasgow Commonwealth Games and London World Athletic Championships and continues to support The Championships, Wimbledon. He also continues to work with a number of Premier League and Championship Football Clubs, Premier League Rugby Clubs, England Sevens Rugby, British Athletics and the Lawn Tennis Association.

    A day in the life of Dr Rajeswaran involves giving his expert opinion on investigations such as MRI and CT scans, x-rays and ultrasound. He also performs injection lists under ultrasound, CT and X-ray including spinal injections. He also regularly teaches and presents at sports medicine conferences.

    Dr Gajan Rajeswaran is an avid football fan and life-long fan of Tottenham Hotspur (for which he offers no apologies!). Outside of work, he spends time with his family and has a keen passion for photography.

    Dr Ajai Seth
    Medical Director, LBSM
    Consultant in Sport and Exercise Medicine

    Dr Ajai Seth is a Sport and Exercise Medicine Physician. He has dedicated his career to helping people with sport and exercise related injury and illness. He consults and treats everyone from the elite athlete to the weekend warrior.

    Dr Ajai Seth is part of the British Tennis Sports Physician team at the LTA and has also provided cover to elite athletes at Wimbledon Tennis, European Tour Golf, Premier League Football, British Athletics, and the Men’s England Football academies as part of the FA.

    He also prides himself for working in disability sport and is currently the Chief Medical Officer for Team GB Wheelchair Tennis which has taken him to the Olympics and Paralympics.

    Dr Ajai Seth is dedicated to education, training and research and is a Senior Lecturer in Sports Medicine at King’s College London where he lectures in all aspects of Sports Medicine and Science.

    He also has a passion for travel and Expedition Medicine, which has seen him accompany medical, scientific and charity expeditions all around the world. He also has vast experience in treating musculoskeletal injuries from children and adolescents to veteran exercisers, both male and female.

    Dr Seth also has positions in leading Sport Medicine organisations, including the non-executive board for the UK’s largest Sports Medicine charity, BASEM and Past President for the Royal Society of Medicine. 

    A day in the working life of Dr Seth involves consulting his patients in clinic, performing diagnostics and ultrasound guided injections. He also regularly lectures and tutors students and presents at sports medicine conferences internationally. He also spends part of the working week at the National Tennis Centre, LTA, supporting British Tennis players.

    Outside of work, Dr Seth enjoys playing club tennis, triathlon, golf, running and skiing (but will give any sport a go!). He enjoys keeping fit and active and good quality family time with his wife and three children.