Hip Pain Flashcards
Anatomy
Hip joint comprises femoral head articulated w/ acetabulum; blood supply to head and neck of femur from the medial femoral circumflex artery, total of 18 bursae; innervated by obturator nerve, femoral nerve, & sciatic nerve.
Osteoarthritis
Symptoms
Pain in goin w/ movement, better with rest, decrease ROM
Common in the elderly
Osteoarthritis
dx criteria
Hip pain with 2 or more of the following:
ESR<20
Osteophytes
Joint space narrowing
Trochanteric Bursitis
Lateral hip pain w/ point tenderness over trochanteric bursa, exacerbated by gait impairment/walking and direct pressure (lying on side), + Ober test, with or without IT band tightness.
Middle aged women, younger pts, runners
Meralgia paresthetica (lateral femoral cutaneous nerve entrapment)
Paresthesias, occasionally burning, over uppe router thigh (due to lateral femoral cutaneous nerve entrapment by inguinal ligament near the ASIS)
Obese or pregnant pts; DM patients; tight clothing.
Occult hip fracture
Severe pain w/partial wt bearing , pain w/ passive rotation
Elderly, osteoporosis, steroid use
Osteonecrosis
Groin or nospecific hip area pain often followed by thigh & buttock pain; rest & night pain common
Steroid users, EtOH, hx hip injury, sickle cell, SLE, trauma
Leriche syndrome
Claudication, buttock & hip pain, decrease pulses (2/2 iliofemoral atherosclerosis)
severe PAD
Referred pain and spinal stenosis
Back, hip & buttock pain secondary to lumbosacral disc and facet joint disease.
Middle-aged and elderly
Septic arthritis
Fever, hypotension, anterior hip pain
Immunocompromised; IVDU; systemic infection
Gluteus medius tendinopathy
Pain w/hip abduction and rotation, pain above the greater trochanter, positive trendelenburg sign
More common in women (wider pelvis)
Piriformis syndrome
Sciatic pain at SI joint or sciatic notch -> foot, w/o numbness/weakness; worse sitting on hard surface, decreases w/ walking (secondary to compression of sciatic nerve by the piriformis muscle)
Anatomic variation in sciatic nerve or piriformis muscle (ie fibrosis after trauma)
Labral tear
Anterior hip or groin pain, clicking/locking of the hip
Pt’s w/OA, athletes
Femoroacteabular impingement
Chronic groin antero/lateral pain worse with turning, decrease ROM, early onset OA (form of DJD of the hip joint)
Athletes (hockey, golf, dance, football, soccer)
Malignancy
Decrease weight, blood in stool, or constant pain
Personal of FHx of CA
Hernia
Groin pain radiating to hip
Wt lifters, elderly
Muscle strain
New onset pain after increase activity
Athletes, elderly
Evaluation
History
Location and character of pain (68% of pts w/intra-articular pathology c/o groin pain), provocative/palliative factors, timing (constant pain suggests infectious, inflammatory, or neoplastic etiology), back pain, claudication, paresthesias, ortho hx, impact on function.
Walking exam
Natural gait and heel-to-toe; look for antalgic/Trendelenburg gait and short leg limp
Squatting exam
Will be limited by mod-to-severe OA, bursitis, or muscle weakness.
FABER
his is flexed, abducted, and externally rotated; + in 88% of pts w/hip pathology.
Internal and External Rotation
decrease rotation in pts w/severe OA or septic arthritis
Palpation of trochanteric bursa
Hip must be flexed to 90, assess for tenderness
Sensory exam
Anterolateral exam w/ decreased or increased sensation in meralgia paresthetica
Straight leg raise
+ test elicits pain at 60 degrees elevation -> S1/L5 nerve root irritation
Lasegue sign
Thigh is flexed and internally rotated; resisted abduction or adduction reproduces sx (stretches sciatic nerve)
Vascular
LE pulses decrease in leriche syndrome
Ober Test
Pt lies laterally on unaffected side w/ hip extended, affected knee flexed to 90 degrees and abducted (w/hand on iliac crest for stability; examiner lowers affected knee; if unable to adduct to neutral position, + test.
XRay
Radiograph to assess for fracture in pt w/acute hip pain (typically wt-bearing AP pelvis and hip and axial cross-table film of the proximal femur)
MRI
When radiographs inconclusive, for suspected fx, osteonecrosis, infection, and tumor; radiolnuclide bone scan if MRI contraindicated
Ultrasound
Useful to guide aspirations; hip aspiration indicated if infection is suspected (should be image-guided)
Treatment
Bursitis
Avoid pressure over hip, bending and stairs; stretching, heat, APAP, NSAIDs, PT (for orthotic and gait evaluation); consider steroid injections if conservative management fails.
Treatment
Femoroacetabular impingement
Rest,/ PT, NSAIDS/APAP, ortho referral for arthroscopy in refractory cases
Treatment
Labral tear
PT; may require arthroscopic surgery
Treatment
Meralgia Paresthetica
Self-limited, benign condition w/spontaneous remission; reassurance, avoid tight garments, wt loss; if persistent consider gabapentin, carbamazepine, or phenytoin
Treatment
Osteoarthritis
Limit high impact acitvities, rest, heat, stretching; hip arthroplasty if failure of conservative Rx or significant disability
Treatment
Osteonecrosis
Rest, weight-bearing as tolerated, pain control; referral to ortho for surgical management of progressive disease, failure of conservative management.
Treatment
Piriformis syndrome
PT, stretching, NSAIDs, gabapentin, nortriptyline; steroid/botulinum toxin injection if conservative management fails.