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Manure shoveler's hipA previously unrecognized syndrome.

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LETTERS
940
cancer might very well be the added phenomena to look
for in the mixed arthritis.
Further studies on the experimental model of
mutual exclusion of RA and gout have led us to raise
another hypothesis: potential mutual exclusion between
ankylosing spondylitis and gout (9). With regard to the
conditions associated with mixed rheumatoid-gouty arthritis, we have recently seen a patient with ankylosing
spondylitis and gout where the third factor was also a
cancer (hypernephroma).
Do too many cooks spoil the immunologic
broth? That could be the case in mixed arthritis. The
finding of RA or ankylosing spondylitis associated with
gout may well be a red marker that a third rascally disease is involved in such a paradoxical patient.
ANDRGLUSSIER
DE MBDICIS
RINALDO
Department of Medicine
Centre hospitalier universitaire
Sherbrooke, Quebec, Canada
REFERENCES
1. Wallace DJ, Klinenberg JR, Morhaim D, Berlanstein B,
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Biren PC, Callis G: Coexistent gout and rheumatoid arthritis: case report and literature review. Arthritis Rheum
22~81-86,1979
Brodel PT, Hollingsworth JW: Comparative morphology,
respiration, and phagocytic function of leukocytes from
blood and joint fluid in rheumatoid arthritis. J Clin Invest
451580-589, 1966
Mowat AG, Baum J: Chemotaxis of polymorphonuclear
leukocytes from patients with rheumatoid arthritis. J Clin
Invest 502541-2549, 1971
Turner RA, Schumacher HR, Myers AR: Phagocytic
function of polymorphonuclear leukocytes in rheumatic
diseases. J Clin Invest 52:1632-1635, 1973
Ripault J, Benoist M, Nguyen-Huy D, Bloch-Michel H:
Synovite prolifkrative aprks injections intra-articulaires de
micro-cristaux d’urate de sodium chez le lapin: note
-prCliminaire. Rev Rhum Ma1 Ostkoartic 36:435-440,
1969
Baraf HSB, Caldwell DS, Reynolds P, Holmes Jr EW:
Gouty arthritis: prevalence of chronic synovitis, polyarticular attacks, and positive serological tests for rheumatoid factor (abstract). Arthritis Rheum 21:544, 1978
Kozin F, McCarty DJ: Rheumatoid factors in the serum
of gouty patients. Arthritis Rheum 20: 1559-1560, 1977
Talbott JH, Altman RD, Ts’ai-Fan Yu: Gouty arthritis
masquerading as rheumatoid arthritis or vice versa.
Semin Arthritis Rheum 8:77-114, 1978
Lussier A, de MCdicis R, Marquis L, MCnard H: Inhibi-
10.
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tion of adjuvant-induced arthritis in the hyperuricemic
rat. Agents Actions 8536-542, 1978
Lussier A, de Mkdicis R: Manuscript in preparation
Trentham DE, Masi AT: Chronic synovitis in gout simulating rheumatoid arthritis: demonstration of bilateral
popliteal cysts and wrist synovial corrugation. JAMA
235:1358-1360, 1976
Owen DS, Toone E, Irby I: Coexistent rheumatoid arthritis and chronic tophaceous gout. JAMA 197:123-126,
1966
Owen DS: Personal communication
Manure shoveler’s hip: A previously
unrecognized syndrome
To the Editor:
We wish to report a novel occupational rheumatic syndrome that has recently come to our attention.
A 27-year-old white woman presented with pain of 8
months duration in the region of the left hip. The patient raised horses and was at this time caring for a mare
and a foal. The symptoms began shortly after her stable
boy quit and she began shoveling horse manure herself.
The hip pain waxed and waned until approximately a
month prior to presentation, at which time her mare,
who was pregnant, began to produce copious volumes
of stool. Associated with this increased load of manure
to be shoveled, the patient’s hip pain became quite severe and was markedly aggravated by weight-bearing,
leading her to seek medical attention.
On physical examination the patient had point
tenderness over her left gluteal region and the left trochanteric area, and some questionable tenderness over
her left lower lumbosacral spine. The pain was increased on abduction of her hip. Radiographic examination of her lumbosacral spine showed no bony abnormalities except for a minimal Schmorl’s node on the
inferior surface of L2. A diagnosis of trochanteric bursitis was made and the patient was advised to discontinue shoveling horse manure, but this produced only
partial relief. Injection with local anesthetic plus corticosteroids then produced approximately 80% relief.
Subsequently, the patient has no longer shoveled horse
manure and has had minimal pain on standing.
The syndrome of trochanteric bursitis is well recognized ( l ) , and refers to inflammation of the bursae of
the gluteus maximus muscle as it passes over the region
of the greater trochanter to insert on the lateral surface
of the femur. A second bursa that is often involved is
that of the gluteus medius muscle which lies immediately superior to the greater trochanter. This patient’s
LETTERS
94 1
d. 4L
Figure 1. Effect of shoveling on the hip. The individual on the left is shown in normal shoveling position. The person on the
right is shoveling manure. To avert the nose, the individual on the right hyperextends the left hip producing stress in the bursae surrounding the greater trochanter (arrow).
clinical signs and symptoms are completely compatible
with that diagnosis, and the relief of pain by local anesthetic plus corticosteroids appears to confirm the diagnosis.
Although predisposing factors such as trauma
have been commented on (1) in the etiology of trochanteric bursitis, a clear relationship to this type of activity
has not been previously noted. In this patient, there was
a striking association between increases in quantities of
manure shoveled and increases in pain. Figure 1 shows
that in the act of shoveling manure (shown in the right
panel), it is probable that the hip would be hyperextended to avert the nose. Since the gluteus maximus
extends the leg at the hip (2) chronic hip hyperextension
could well lead to imtation of the trochanteric bursae
which serve this muscle. Thus, manure-shoveling may
be pathogenetically, as well as circumstantially, related
to the patient’s trochanteric bursitis.
It is for this reason we feel justified in terming
this syndrome “Manure Shoveler’s Hip” and suggest
that the term apply to trochanteric bursitis occurring in
an individual with a history of shoveling large quantities of manure. Individuals at risk might include stable
boys, horse owners, and journal editors.
MARK GINSBERG, MD
RALPHGREEN, MD
Research Institute of Scripps Clinic
La Jolla, California
MICHAELWEISMAN, MD
University of California, San Diego
Department of Medicine
La Jolla, California
REFERENCES
1. Gordan GJ: Clin Orthop 20193, 1961
2. Goss CJ, editor: Gray’s Anatomy. Philadelphia, Lea &
Febiger, 1966 p 500
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hipa, syndrome, unrecognized, shoveler, manure, previously
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