Medical mystery: The hip pain that seemed to signal cancer

If she hadn’t tripped over her neighbor’s dog, causing her to miss the step down into a sunken living room where she landed squarely on her left hip, Lynda Holland still might not know what was wrong.

Holland scrambled to her feet, shaken and grateful she hadn’t been injured: Her puffy down coat had cushioned her fall onto the hardwood floor. Then she realized the pain that had dominated her life for the previous six years had suddenly diminished.

“I thought, ‘This is weird,’” said Holland, 71, a retired administrative assistant who lives in suburban Maryland.

For years, Holland’s doctors had disagreed about what was wrong with her hip. She had undergone a slew of scans, plus painful biopsies of her hip bones. Her doctors had prescribed cortisone injections and months of physical therapy to treat what most concluded was osteoarthritis.

But when she sought an explanation for the reason that her March 2017 fall had relieved pain so severe it disrupted her sleep, an X-ray suggested an alarming possibility: a cancer recurrence.

In 2009, Holland, then 61, was diagnosed with early-stage breast cancer. She underwent a lumpectomy followed by radiation, which appeared successful in eradicating the cancer.

The pain in her upper left leg and hip joint started two years later. Both her oncologist and internist worried it might mean that her cancer had returned and spread to her bones. After a variety of tests found nothing significant, Holland began months of physical therapy for a condition her internist decided was trochanteric bursitis, inflammation of the fluid-filled sac near the hip joint. Neither rest, physical therapy, anti-inflammatory drugs, nor cortisone shots offered lasting relief.

In November 2013, she underwent an MRI scan of her hip. The report noted the presence of “calcified/ossified bodies” in her left hip, which had been detected on an earlier CT scan. The radiologist also noted fluid surrounding her left hip joint.

The radiologist concluded that the most likely cause of Holland’s hip pain was not bursitis but rather degenerative osteoarthritis.

A month before the MRI, Holland had undergone a long-planned partial replacement of her right knee to repair an injury she had suffered years earlier.

“My knee felt great,” she recalled. “But the hip did not change. That was a real disappointment.”

By 2015, she had developed pain in a second location: her lower back. As with her hip pain, none of the doctors she consulted could come up with a solution.

A week after she fell, Holland returned to the first orthopedist, who had performed her knee operation, and told him about her inexplicable improvement.

The doctor ordered X-rays and told her she appeared to have a large “loose body near her sciatic nerve.” He sent her to a third orthopedist who refused to operate for fear that if it were a malignant tumor, surgery could cause it to spread.

Instead, he sent her to a fourth specialist, orthopedic oncologist Felasfa Wodajo of Virginia Cancer Specialists.

To Wodajo, Holland’s symptoms and test results did not suggest osteoarthritis. Her joints showed no sign of the degeneration commonly seen in arthritis and she seemed much too active.

Most telling was Holland’s recent X-ray, which showed several dozen small white flecks that resembled pieces of popcorn scattered around her hip joint, along with the large nodule in her left buttock. Wodajo said he immediately knew what was wrong.

“If you’ve never seen it before, I’m not sure it would jump out at you,” he said. But as an orthopedic oncologist, he sees the uncommon condition three or four times a year. Wodajo told Holland her hip pain was caused by primary synovial chondromatosis.

Most commonly seen in men in their 50s, it is not inherited. It occurs when the synovium grows abnormally, generating small nodules composed of cartilage, some no larger than a grain of rice. These pellet-like bodies can become loose inside joints, where they can roll around, damaging the cartilage that covers the joint. In Holland’s case, her fall had dislodged a large calcified body that was pressing on her sciatic nerve.

Those “calcified/ossified bodies” the radiologist flagged in Holland’s 2013 MRI were hallmarks of the condition.

“On that MRI it’s glaringly obvious,” Wodajo said. Because the radiologist did not specialize in orthopedic cases, he noted, it appears their significance was missed.

Holland’s history of cancer may have complicated her diagnosis, Wodajo said, because doctors were focused on determining whether her cancer had returned.

Holland underwent surgery in July 2017 at Inova Fairfax Hospital. She spent one night in the hospital, less time than initially expected, and then recuperated at home. A week later, she was largely pain-free.

So far, the disorder has not recurred.

Holland hopes her experience will dissuade doctors from resorting to the catchall arthritis diagnosis “if they don’t know what’s wrong.”