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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 ar- thritis, 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 dis- ease is involved in such a paradoxical patient.

ANDRG LUSSIER RINALDO DE MBDICIS Department of Medicine Centre hospitalier universitaire Sherbrooke, Quebec, Canada

REFERENCES

1. Wallace DJ, Klinenberg JR, Morhaim D, Berlanstein B, Biren PC, Callis G: Coexistent gout and rheumatoid ar- thritis: case report and literature review. Arthritis Rheum

2. Brodel PT, Hollingsworth JW: Comparative morphology, respiration, and phagocytic function of leukocytes from blood and joint fluid in rheumatoid arthritis. J Clin Invest

3. Mowat AG, Baum J: Chemotaxis of polymorphonuclear leukocytes from patients with rheumatoid arthritis. J Clin Invest 502541-2549, 1971

4. Turner RA, Schumacher HR, Myers AR: Phagocytic function of polymorphonuclear leukocytes in rheumatic diseases. J Clin Invest 52:1632-1635, 1973

5 . 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

6. Baraf HSB, Caldwell DS, Reynolds P, Holmes Jr EW: Gouty arthritis: prevalence of chronic synovitis, poly- articular attacks, and positive serological tests for rheu- matoid factor (abstract). Arthritis Rheum 21:544, 1978

7. Kozin F, McCarty DJ: Rheumatoid factors in the serum of gouty patients. Arthritis Rheum 20: 1559-1560, 1977

8. Talbott JH, Altman RD, Ts’ai-Fan Yu: Gouty arthritis masquerading as rheumatoid arthritis or vice versa. Semin Arthritis Rheum 8:77-114, 1978

9. Lussier A, de MCdicis R, Marquis L, MCnard H: Inhibi-

22~81-86, 1979

451580-589, 1966

tion of adjuvant-induced arthritis in the hyperuricemic rat. Agents Actions 8536-542, 1978

10. Lussier A, de Mkdicis R: Manuscript in preparation 11. Trentham DE, Masi AT: Chronic synovitis in gout simu-

lating rheumatoid arthritis: demonstration of bilateral popliteal cysts and wrist synovial corrugation. JAMA 235:1358-1360, 1976

12. Owen DS, Toone E, Irby I: Coexistent rheumatoid arthri- tis and chronic tophaceous gout. JAMA 197:123-126, 1966

13. Owen DS: Personal communication

Manure shoveler’s hip: A previously unrecognized syndrome To the Editor:

We wish to report a novel occupational rheu- matic 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 pa- tient 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 se- vere 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 tro- chanteric area, and some questionable tenderness over her left lower lumbosacral spine. The pain was in- creased on abduction of her hip. Radiographic exami- nation of her lumbosacral spine showed no bony abnor- malities except for a minimal Schmorl’s node on the inferior surface of L2. A diagnosis of trochanteric bur- sitis was made and the patient was advised to discon- tinue shoveling horse manure, but this produced only partial relief. Injection with local anesthetic plus corti- costeroids 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 rec- ognized ( 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 immedi- ately superior to the greater trochanter. This patient’s

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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 bur- sae surrounding the greater trochanter (arrow).

clinical signs and symptoms are completely compatible with that diagnosis, and the relief of pain by local anes- thetic plus corticosteroids appears to confirm the diag- nosis.

Although predisposing factors such as trauma have been commented on (1) in the etiology of trochan- teric 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 hyper- extended 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 quan- tities of manure. Individuals at risk might include stable boys, horse owners, and journal editors.

MARK GINSBERG, MD RALPH GREEN, MD Research Institute of Scripps Clinic La Jolla, California MICHAEL WEISMAN, 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