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hip pain

Hip pain is the most common symptom of hip disease. Etiology: 1) groin, anterior thigh & medial thigh pain a) osteoarthritis of the hip (most common in adults) b) connective tissue diseases (next most common) - rheumatoid arthritis - polymyalgia rheumatica - ankylosing spondylitis c) transient synovitis d) osteomyelitis e) septic arthritis f) idiopathic avascular osteonecrosis g) hip fracture h) pigmented villonodular synovitis i) referred pain - testicular torsion - lumbar herniated disk - knee pain [3] j) adductor/quadriceps muscle strain k) iliopectineal or iliopsoas bursitis l) acetabular labrum tear 2) lateral hip & thigh pain a) trochanteric bursitis b) fascia lata syndrome c) abductor, gluteus muscle strain, gluteal tendinopathy [10] d) meralgia paresthetica [3,4] 3) posterior hip (buttocks) & thigh pain a) radiculopathy b) tumors c) discitis d) spondylolisthesis e) ischial bursitis f) sacroiliitis g) hamstring strain h) sciatic impingement (sciatica) i) osteoarthritis of the hip 4) children & adolescents a) slipped upper femoral epiphysis b) juvenile arthritis c) Perthes' disease d) sickle cell disease e) hemophilia f) acute leukemia 5) bone metastases [3] Clinical manifestations: 1) generally manifests as groin pain & less commonly - pain in the thigh or buttocks - pain in the pelvis - pain in the proximal femur - referred pain: knee pain 2) groin pain increased by weight bearing [3] 3) pain when first getting out of a chair or bed 4) difficulty ascending stairs 5) patient may walk with a limp 6) decreased hip range of motion 7) hip stiffness may improve with activity in connective tissue disease, but worsen with osteoarthritis 8) bilateral pain that occurs when walking & is relieved by rest suggests vascular or neurogenic claudication 9) fever may be associated with septic joint 10) gait abnormalities, i.e. Trendelenberg gait 11) muscle atrophy in quadriceps indicated severe disease in hip joint 12) positive Trendelenberg sign 13) presence of ecchymoses or abrasions suggests trauma 14) tenderness to palpation along lateral aspect of hip & greater trochanter suggests trochanteric bursitis 15) abnormalities in range of motion, mainly limitation of abduction & internal rotation are common with intra-articular hip disease (FADIR test) 16) The FABER test may cause posterior hip pain with sacroiliitis, groin pain with intra-articular joint disease & lateral hip pain with greater trochanteric pain syndrome 17) pain on hip extension suggests sacroiliac pain, lumbar spine disease, or articular hip pain 18) sensory & motor abnormalities are suggestive of radiculopathy Laboratory: 1) erythrocyte sedimentation rate (ESR) 2) C-reactive protein (CRP) 3) serologic tests for rheumatologic diseases 4) complete blood count (CBC) 5) serum uric acid 6) joint aspiration for Gram stain & culture if septic joint is suspected Radiology: 1) plain radiographs of both hips with weight-bearing films - suspected intra-articular pathology, bone fracture, hip dislocation - anteroposterior (AP) & frog-leg lateral views in child to rule out: - Legg-Calve-Perthes disease - slipped capital femoral epiphysis 2) pelvic films for comparison of symmetry 3) magnetic resonance imaging for suspected avascular necrosis Differential diagnosis: - bursitis a) pain located laterally (trochanteric bursitis) or posteriorly b) pain worsend by lying on affected bursa [3] - referred pain, from abdomen, groin, back, knee [3] Management: 1) pharmacologic agents a) non-steroidal anti-inflammatory drugs (NSAIDs) b) tricyclic antidepressants c) acetaminophen d) topical capsaicin e) short-term narcotics for acute pain f) glucocorticoid injection 2) physical modalities a) heat, ice, ultrasound b) physical therapy to maintain range of motion & strengthen target muscle groups when pain is adequately controlled c) weight loss d) exercise* [10] 3) surgery a) femoral osteotomy b) hip replacement 4) patient education* [10] * most effective modalities for gluteal tendinopathy [10] Note: - management of hip pain secondary to septic arthritis or osteomyelitis differs from that described above

Related

sacroiliitis Trendelenberg gait Trendelenberg sign/test trochanteric bursitis

General

pain [odyn-]

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 745
  2. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Plante M, Wallace R, Busconi BD. Clinical diagnosis of hip pain. Clin Sports Med. 2011 Apr;30(2):225-38. PMID: 21419954
  5. Byrd JW. Evaluation of the hip: history and physical examination. N Am J Sports Phys Ther. 2007 Nov;2(4):231-40. PMID: 21509142 Free PMC Article
  6. Brown MD, Gomez-Marin O, Brookfield KF, Li PS. Differential diagnosis of hip disease versus spine disease. Clin Orthop Relat Res. 2004 Feb;(419):280-4. PMID: 15021166
  7. Lesher JM, Dreyfuss P, Hager N, Kaplan M, Furman M. Hip joint pain referral patterns: a descriptive study. Pain Med. 2008 Jan-Feb;9(1):22-5. PMID: 18254763 Free Article
  8. NEJM Knowledge+ Question of the Week. Oct 25, 2016 http://knowledgeplus.nejm.org/question-of-week/4532
  9. Houghton KM. Review for the generalist: evaluation of pediatric hip pain. Pediatr Rheumatol Online J. 2009 May 18;7:10. PMID: 19450281 Free PMC Article
  10. Mellor R, Bennell K, Barry R Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ 2018;361:k1662 PMID: 29720374 https://www.bmj.com/content/361/bmj.k1662