Forty-two-year-old Russell McCoy was energized and sweaty as he finished a three-mile run around his neighborhood. He headed straight for his refrigerator and cracked open a diet soda, downing it in a couple of swigs. Holding the empty can, he backed toward the garbage pail, pivoted, shot, and scored. Then pain, sudden and excruciating, lanced through his left hip. He bent over, aware that he had twisted something the wrong way. Breathing deeply, he felt a little better. A few hours later, though, he tried to run a few strides and almost yelped from the pain. For the next two weeks, he took it easy. But the hip didn’t get better.
I first saw Mr. McCoy in June, two months after the soda-can episode. He had already been to another doctor, who was convinced this was “referred pain”—in other words, pain in one body area that is actually the result of a problem in another. According to that doctor, Mr. McCoy had strained his lower back muscles and was experiencing it as hip pain. A week of an anti-inflammatory medicine and stretching exercises for the lower back had not helped, however. An X-ray of the hip a month later showed no sign of arthritis or fracture, and an MRI of the lower back hadn’t revealed much either, just a small disk bulge that seemed unrelated to the pain.
Over the two months since the injury, my patient told me, he had gained 10 pounds. He wasn’t exercising because it hurt too much. He wasn’t sleeping well, either; the hip ached when he lay on his left side. He sucked his breath in sharply when I pushed on the greater trochanter, the bony outer part of his upper left thigh.
His main symptom—the sore spot on his hip that hurt when pressed—was typical for trochanteric bursitis, inflammation of the greater trochanter’s bursa. A bursa is a fluid-filled sac that allows adjacent tissues to glide over each other. When injury or overuse irritates the bursa, any pressure or movement around it will cause pain. I recommended treating the inflammation with a cortisone injection.
My patient cringed at the thought of a needle poking into the painful area. Instead, he decided to seek yet another opinion, this time from an orthopedic surgeon. Like the first doctor, the surgeon believed the symptoms originated in the lower back. He had Mr. McCoy see a physical therapist, who thought the back had nothing to do with it and that he had strained a muscle in his hip. The next stop was a chiropractor, who worked on both hip and back with no improvement.
Finally, four months after our first visit, Mr. McCoy was back in my waiting room. His belly now bulged over his belt, and he grimaced each time his left foot hit the floor. “I’m ready for the injection,” he said. “Let’s go for it.”
I had him lie on his right side, located the most tender area on the top of his left thigh, and injected a mixture of anesthetic and cortisone. Injections like these are among the few procedures that can give almost instant relief. The anesthetic numbs the sore area immediately, and the steroid kicks in within two days. If the anesthetic helped, it would support my diagnosis, and we could be pretty sure that the steroid would work. If the anesthetic didn’t help, then it probably wasn’t trochanteric bursitis after all.
I held my breath as he took a few steps. He winced. The injection had not worked.
It had been six months since Mr. McCoy first hurt his hip, and now we were right back where we started. I had run out of ideas. The physical exam, the X-ray results, and the injection had ruled out the common causes of hip pain—arthritis, bursitis, fracture, referred pain from the lower back—but he still couldn’t run. In many situations, the search for a cause of pain ends without an answer, and we change our focus to pain control. But I was not ready to give up.
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