Author: by Katarzyna Brachowska MCSP (Senior Specialist MSK Physiotherapist)
Low back and hip pain are common problems, especially in older adults, and are often linked to conditions such as arthritis, bursitis, or muscle tightness. However, on rare occasions, symptoms may be caused by less common conditions that are difficult to diagnose.
This case study highlights a 68-year-old female whose ongoing hip and buttock pain was eventually linked to a Tarlov cyst, a rare spinal condition that is frequently misdiagnosed. The case demonstrates the importance of careful assessment, monitoring of treatment response, and appropriate imaging when symptoms do not follow a typical pattern.
Patient Profile
- Age: 68 years
- Gender: Female
- Occupation: Retired
- Hobbies: Pilates (generally pain-free or pain-relieving), holidays
- Past Medical History: Previous episodes of lower back pain and stiffness; Underactive thyroid; History of left-sided bursitis (treated with three injections)
Her pain is most troublesome at night, frequently disturbing her sleep, and is aggravated by prolonged sedentary positions, particularly when sitting with her legs crossed. Mornings are notably difficult: she experiences increased pain and stiffness lasting more than 30 minutes, which gradually eases as she becomes more mobile throughout the day. Despite this, she continues to experience a persistent ache in the lower lumbar region and hip that fluctuates with activity levels.
During the objective assessment, hip range of motion reproduced her familiar symptoms. Both abduction and adduction provoked discomfort, while external rotation elicited clear pain. Strength testing highlighted irritability in the lateral hip muscles, with resisted external rotation and resisted abduction both reproducing her pain. Knee flexion and extension were full and symptom-free. Special testing revealed a sore response on FABER, whereas FADDIR was negative. The Ober test also provoked pain, suggesting involvement of the lateral hip structures and soft‑tissue tension contributing to her presentation.
We agreed on a combination of treatments for the best possible outcomes; the treatment plan is as follows:
- Heat Therapy (Lumbar) 10mins in sitting**
- Traction
- Lumbar Spinal Mobilisations
- Soft Tissue Massage
- Interferential Therapy
- Acupuncture
- Home exercises program (Sit to stand + feed forward + short lever + resisted band; bridge + hip adduction + Pilates small ball + balance exercises)
Although a range of treatments were trialled to help ease her symptoms, the improvements were short-lived. This pattern suggested that while these treatments were helping to calm the symptoms temporarily, they were not addressing the underlying cause of her ongoing back and hip pain.
During the course of her physiotherapy treatment, she also sought advice from her GP, who diagnosed her with bursitis and prescribed amitriptyline to help manage her symptoms. She was then referred to NHS physiotherapy, where she was given an exercise programme to follow. Despite her efforts, her pain continued without any meaningful improvement. As her symptoms persisted, she returned to the First Contact Practitioner for further assessment. Given the lack of progress and the ongoing nature of her discomfort, she was referred for an MRI scan, which ultimately revealed the presence of a Tarlov cyst, providing a clearer explanation for her ongoing back and hip pain. She is now awaiting an appointment with a neurologist to discuss the findings and plan the next steps in her management.
Tarlov cysts are relatively rare findings, and many people who have them never experience symptoms. Because they can sit quietly for years without causing problems, they’re often only discovered when someone undergoes imaging for persistent or unexplained pain. This is why careful differential diagnosis is so important. In this case, what initially appeared to be a straightforward bursitis turned out to be something entirely different once further assessment and imaging were carried out. It’s a strong reminder that if pain isn’t improving, or if something doesn’t feel quite right, seeking help early and being assessed by a physiotherapist can make a real difference. A thorough assessment can help identify when symptoms don’t fit the usual pattern and ensure that the right investigations are arranged, leading to the correct diagnosis and appropriate management.
American Association of Neurological Surgeons (AANS). (2021). Tarlov Cysts.
Feigenbaum, F., & Henderson, F. (2015). Tarlov cysts: A commonly misdiagnosed cause of chronic pain. Journal of Neurosurgery: Spine, 23(3), 1–9.
Paulsen, R. D., Call, G. A., & Murtagh, F. R. (1994). Prevalence and clinical significance of Tarlov cysts. American Journal of Neuroradiology, 15(2), 293–297.
Lucantoni, C., Than, K. D., Wang, A. C., & Park, P. (2011). Tarlov cysts: A controversial lesion of the sacral spine. Neurosurgical Focus, 31(6), E14.
Kaiser, R., & Holland, C. (2020). Differential diagnosis in low back pain: The importance of recognising atypical presentations. Physiotherapy Practice and Research, 41(2), 85–92.
