Some of the diagnoses you should consider is hip degeneration, sacroiliac joint sprain, upper lumbar neuropathy, iliopsoas strain, quadratus femoris strain, pectineus strain, adductor strain, late effects of scar tissue from lumbar surgery with or without neurological sequela causing a lumbar spine neuropathy.

Physical Exam Findings:

Weight: 110, Height: 5’2”

Examination of the right groin and anterior thigh demonstrated a severely shortened, inflamed and contracted iliopsoas. Her pectineus was inflamed, her adductor group, gracilis and sartorius were shortened and contracted. She had multiple trigger points in the iliotibial band and quadratus femoris.

Examination of this patient’s low back demonstrated full and complete function of the bilateral sacroiliac joints with no sign of inflammation or fixations. There was a scar from her fusion of L4 and L5 but no swelling or spasms evident. There was some tenderness bilaterally at the gluteus maximus but it was minimal. However, the right gluteus maximus was slightly atrophied. Hip flexion, extension and external rotation were painful and stiff.

Question: What is your working diagnosis at this point?