Hip and Knee Pain Flashcards
How do people often present with hip problems
Pain and discomfort Referred pain Night pain - insomnia Stiffness Pain when exercising
Where does true hip joint pain present
Mid groin
Pain on the outside of the hip is more likely to be?
Trochanteric bursitis
Referred pain from back
What would you look for in a patient presenting with hip pain
Deformity
Asymmetry
Scars - previous trauma or surgery
What would you feel for in a patient presenting with hip pain
Swelling - may be over trochanter in bursitis
Bony landmarks
Tenderness
Heat
What investigations may be done for hip pain
X-ray - though finding may be incidental so must compare to symptoms
ESR/viscosity if suspect inflammatory
FBC is infection suspected
What are the x-ray signs of osteoarthritis
Loss of joint space
Osteophytes
Sclerosis
Subarticular cysts
How do you manage hip pain
education weight reduction walking stick analgesia or NSAIDs Physio Mobility aid - car badge, home adaption etc
List some common causes of hip pain
OA RA and other arthritides Fracture Referred pain from back malignancy
List some rarer causes of hip pain
Soft tissue issues - bursitis
Paget’s
Infection
Avascular necrosis
Why are knee and hip problems increasing in the population
Age - more wear and tear etc
Obesity - more weight being put through joints
What are some common presentations of knee problems
Pain - often localised Stiffness Swelling or lump Giving way - unstable Deformity Loss of sleep Loss of function - can't kneel or trouble walking
What would you look for in a patient presenting with knee pain
Deformity
Gait
Swelling
Scars
What would you feel for in a patient presenting with knee pain
Bony landmarks
Tenderness
Effusion
Stability
What investigations may be done for knee pain
Usually none
X-ray
MRI
Urate - suspect gout?
How do you manage knee pain
Explanation Keep leg mobile Leg supports if knee unstable NSAID - short term Analgesia Physio Referral if severe
What are some common problems that affect the knee
Ligament strain - MC
Bursitis - common if on knees a lot
Osteoarthritis
Osgood-Schlatter’s - inflammation of tibial tuberosity and cartilage
What are some rarer problems that affect the knee
Chondromalacia patellae Meniscus injury Cruciate damage Gout RA Dislocation
What makes the hip an effective joint
Ball and socket
Wide range of movement
Stable - can take a lot of weight
List the layers of bone
Hyaline (articular) cartilage
Subchondral bone
Cancellous bone
What is FAI
Femoroacetabular impingement syndrome
Morphology of the femoral neck and/or acetabulum is altered
Causes issues with flexion, adduction and internal rotation
Name two types of impingement caused by FAI
CAM type
Pincer type
Describe a CAM type deformity
Caused by deformity in the femur - asymmetrical head
Usually occurs in young athletic men
Can be related to previous SUFE
Describe a pincer type deformity
Caused by deformity in the acetabulum
Acetabulum overhangs
Usually seen in females
Why are young athletic men likely to get FAI
May be due to increased weight bearing and stress in adolescent years
What damage does FAI do to the joint
Damages the labrum and causes tears
Damages cartilage
Leads to OA in later life
How do patients present with FAI
Groin pain relating to activity - particularly when flexing and rotating
Difficulty sitting
C-sign positive
FADIR provocation test positive
What is the FADIR provocation test
Tests flexion, adduction and internal rotation of the hip
How do you diagnose FAI
Imaging
Radiograph, CT and/or MRI
MRI best for looking at damage to labrum and oedema
How do you manage FAI
Just observe in asymptomatic patients
Arthroscopic/open surgery to remove CAM or debride tears
Osteotomy and debride labral tears for pincer impingement
Replacement in people with secondary OA
What is avascular necrosis
Failure of blood supply to the femoral head
What are the causes of AVN
Can be idiopathic or associated with trauma (e.g. damages to the blood supply)
How does idiopathic AVN develop
Coagulation of the microcirculation in the bone
Leads to venous thrombosis which causes retrograde arterial occlusion
Leads to hypertension in the bone
Decreases blood flow to the femoral head, leading to necrosis
Who is affected by AVN
Men
Typically age 35-50
Usually bilateral
What are the risk factors for AVN
Irradiation Trauma Hematologic diseases - leukaemia Decompression sickness - divers Alcoholism Steroid use
How do patient’s present with AVN
Insidious onset of groin
Exacerbated by stairs or impact
Examination usually normal
How do you diagnose AVN
Radiographs - normal unless late disease
MRI scan - most sensitive/specific
AVN is irreversible - true or false
BOTH
There are reversible and irreversible stages
How do you treat AVN
Bisphosphonates Core decompression Curettage & bone grafts Vascularised bone graft Rotational osteotomy Total hip replacement
What is ITOH
Idiopathic Transient Osteonecrosis of the Hip
Local hyperaemia and impaired venous return with marrow oedema and increased intramedullary pressure
How do patients present with Idiopathic Transient Osteoporosis of the Hip
Progressive groin pain
Difficulty weight bearing
Usually unilateral
Who is affected by Idiopathic Transient Osteoporosis of the Hip
Men more than women
Middle aged
Does affect pregnant women in 3rd trimester
How do you diagnose Idiopathic Transient Osteoporosis of the Hip
ESR - will be elevated
Radiographs
MRI - gold standard
Bone scan
What are the radiograph signs of Idiopathic Transient Osteoporosis of the Hip
Osteopenia of head and neck of femur
Thinning of cortices
Preserved joint space
How do you manage Idiopathic Transient Osteoporosis of the Hip
Self-limiting and should resolve in 6-9 months
Treat symptoms with analgesia
Protective weight bearing to avoid fracture - bone is weaker
What is trochanteric bursitis
Inflammation of the trochanteric bursa
Common condition caused by IT band tracking across the bursa and causing repetitive trauma
Who commonly gets trochanteric bursitis
Females - wider pelvis rubs on IT band more
Young, active patients
Older people
How does trochanteric bursitis present
Pain on lateral aspect of hip
Pain on palpation of greater trochanter
How do you diagnose trochanteric bursitis
Clinical diagnosis usually
X-ray usually normal
Visible on MRI but not normally needed
How do you treat trochanteric bursitis
Analgesia
NSAIDs
Physio
Steroid injection
Do you ever operate on trochanteric bursitis
No
No proven benefit
What is the common presentation for simple backache
20-55
Systemically well
Back, buttock and/or thigh pain
Pain changes with movement
What is the common presentation for nerve root pain
unilateral leg pain Parathesia in the same distribution Abnormal neurology Weakness Reflex and sensory changes Nerve stretch pain
Which risk factors suggest a more serious spinal pathology
Past history of Cancer, TB, HIV, IVDA Unexplained weight loss Constant unremitting pain Unable to lie supine or to sleep Age under 20 or over 55 Recent trauma
What are some key signs of cauda equina syndrome
Saddle Anaesthesia
Altered Bladder Control
Bowel Incontinence
Gait disturbance
What is the prognosis and treatment for simple backache
Prognosis good
90% better in 6 weeks
Advice and simple painkillers
What is the prognosis and treatment for nerve root pain
Good prognosis
50% better in 8 weeks
Give advice and pain management as per NICE guidelines
If not better after 2 months with 4 weeks of physio then refer for imaging
What is the next step if you suspect serious spinal pathology
Consider cancer, infection, fracture or inflammatory disease
Needs further investigations so refer urgently
What is the next step if you suspect cauda equina syndrome
Emergency surgical referral
