Last week, a patient in her early fifties presented with a 5-month history of progressive left mid-anterior thigh pain after performing lunges and squats in January. She saw a therapist, who gave her some exercises and started Pilates classes, and initially she noticed an improvement.
However, over the next 3 months (and during the Covid-19 lockdown), she noticed increasing left thigh pain on weight-bearing and when mobilising. She consulted her therapist remotely, who advised different exercises, but she was also told to seek a medical review if she didn’t improve.
She eventually saw a GP, who referred the patient to me for an assessment. During our consultation, she volunteered to me her history of breast cancer 5 years ago, treated with surgery, chemotherapy and radiotherapy, and she stated that she had been having regular mammograms.
Examination revealed her to have an antalgic gait and she did not want to put any weight through her left leg. She had reduced left L2 power due to pain, and there was some quadriceps wasting. Her neurology was otherwise normal. Due to her previous history of breast cancer, an MRI was performed on the same day, and is shown below (T1 TIRM MRI):
a. coronal
b. axial
This imaging shows an infratrochanteric soft tissue mass expanding the left femoral shaft, with aggressive features, likely to represent a metastatic deposit.
The patient was advised to remain non-weight bearing through her left leg and she was referred for an urgent orthopaedic assessment for consideration of urgent intramedullary nailing, plus she also consulted her oncologist.
It is possible that the impact of the lockdown and the lack of access to face-to-face consultations may have led to a delay in this patient seeking help, but also, the relatively innocuous precipitating event may have induced a false sense of security. The latest figures from NHS England suggest that the number of urgent cancer referrals made from primary care this April fell 60% compared to last year.
Take home message:
Lockdown has put many different pressures on us all. Patients often delay seeking help, and when they do, the use of a telephone or newer technologies with video consultations means that getting patients to open up in the same way they would in a face-to-face consultation isn’t as easy.
Patients remain patients, red flags remain red flags, but in these unprecedented times of COVID-19 and lockdown restrictions, how do we ensure that we don’t miss things? Listening more carefully; probing harder and acting more quickly to get a second opinion if you have a sixth sense that something isn’t quite right or doesn’t stack up, is vital.
If you’re a GP or therapist and need to get a second opinion quickly, simply phone our appointment hotline 020 7496 3597 to directly access our multidisciplinary team of rheumatological, orthopaedic and pain medicine specialists.
Dr Simon Paul, Consultant Rheumatologist and Sports Physician
For more information visit:
https://sportsortho.co.uk/specialist/dr-simon-paul/
https://sportsortho.co.uk/specialists/