Author: Charles Bell, MD
Co Author #1: Alcott, Robert MD
Senior Editor: Marc Hilgers, MD, PhD, FAMSSM
Editor: Rock Vomer, DO, DPT

Patient Presentation:
Patient is a 51-year-old gentleman who was referred to our sports medicine clinic for evaluation of acute onset, atraumatic, neck pain, left hip pain, and right knee pain.

History:
On presentation to clinic, the patient endorsed 12-13 day history of progressive neck stiffness with inability to turn his head without severe pain. Approximately 5 days after onset of neck symptoms, patient noticed new onset significant left hip and groin pain that has caused him to limp while walking. Patient denied any known trauma, previous diagnosis of cervical or hip degenerative disease, rash, history of IV drug use, headache, limb weakness, or radiation of pain into upper or lower extremities. Patient was referred from the emergency department where he initially presented 5 days after neck symptom onset and was prescribed diclofenac for pain relief. He had also been seeing a physical therapist for several days prior to our evaluation. He denied any benefit from PT or Nsaid therapy.

Upon further questioning, approximately 3 weeks prior to the development of these new musculoskeletal symptoms, the patient reported a bout of severe gastroenteritis, with diarrhea, abdominal pain, mild body aches, and high fevers. He was seen in the ER and subsequently diagnosed with Salmonella gastroenteritis. He completed a course of trimethoprim/sulfamethaxazole with subsequent resolution in symptoms. At time of presentation to our clinic he had not had any further fevers, chills, or diarrhea.

The patient also offered a personal history of lumbar DDD, and multiple family members with "severe spinal arthritis."

Physical Exam:
On palpation multiple trigger points along both upper trapezius muscles were identified, there was no midline boney tenderness to palpation.
The patient demonstrated approximately 25% active cervical rotation bilaterally and limitation in cervical flexion and extension. Spurling's test did not provoke the patients neck pain.
The patient demonstrated equal and intact sensation to light touch for both upper and lower extremities, and grossly normal strength throughout. The left hip exam demonstrated pain with passive internal rotation and active hip flexion and tenderness to palpation on the hip abductor group. The right knee demonstrated a very small suprapetallar effusion, mild joint line tenderness to palpation, negative ligamentous and meniscus testing.

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