Hip Pain

Question 1

Anatomy

Answer 1

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.

Question 2

Osteoarthritis

Symptoms

Answer 2

Pain in goin w/ movement, better with rest, decrease ROM

Common in the elderly

Question 3

Osteoarthritis

dx criteria

Answer 3

Hip pain with 2 or more of the following:

ESR<20
Osteophytes
Joint space narrowing

Question 4

Trochanteric Bursitis

Answer 4

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

Question 5

Meralgia paresthetica (lateral femoral cutaneous nerve entrapment)

Answer 5

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.

Question 6

Occult hip fracture

Answer 6

Severe pain w/partial wt bearing , pain w/ passive rotation

Elderly, osteoporosis, steroid use

Question 7

Osteonecrosis

Answer 7

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

Question 8

Leriche syndrome

Answer 8

Claudication, buttock & hip pain, decrease pulses (2/2 iliofemoral atherosclerosis)

severe PAD

Question 9

Referred pain and spinal stenosis

Answer 9

Back, hip & buttock pain secondary to lumbosacral disc and facet joint disease.

Middle-aged and elderly

Question 10

Septic arthritis

Answer 10

Fever, hypotension, anterior hip pain

Immunocompromised; IVDU; systemic infection

Question 11

Gluteus medius tendinopathy

Answer 11

Pain w/hip abduction and rotation, pain above the greater trochanter, positive trendelenburg sign

More common in women (wider pelvis)

Question 12

Piriformis syndrome

Answer 12

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)

Question 13

Labral tear

Answer 13

Anterior hip or groin pain, clicking/locking of the hip

Pt’s w/OA, athletes

Question 14

Femoroacteabular impingement

Answer 14

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)

Question 15

Malignancy

Answer 15

Decrease weight, blood in stool, or constant pain

Personal of FHx of CA

Question 16

Hernia

Answer 16

Groin pain radiating to hip

Wt lifters, elderly

Question 17

Muscle strain

Answer 17

New onset pain after increase activity

Athletes, elderly

Question 18

Evaluation

History

Answer 18

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.

Question 19

Walking exam

Answer 19

Natural gait and heel-to-toe; look for antalgic/Trendelenburg gait and short leg limp

Question 20

Squatting exam

Answer 20

Will be limited by mod-to-severe OA, bursitis, or muscle weakness.

Question 21

FABER

Answer 21

his is flexed, abducted, and externally rotated; + in 88% of pts w/hip pathology.

Question 22

Internal and External Rotation

Answer 22

decrease rotation in pts w/severe OA or septic arthritis

Question 23

Palpation of trochanteric bursa

Answer 23

Hip must be flexed to 90, assess for tenderness

Question 24

Sensory exam

Answer 24

Anterolateral exam w/ decreased or increased sensation in meralgia paresthetica

Question 25

Straight leg raise

Answer 25

+ test elicits pain at 60 degrees elevation -> S1/L5 nerve root irritation

Question 26

Lasegue sign

Answer 26

Thigh is flexed and internally rotated; resisted abduction or adduction reproduces sx (stretches sciatic nerve)

Question 27

Vascular

Answer 27

LE pulses decrease in leriche syndrome

Question 28

Ober Test

Answer 28

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.

Question 29

XRay

Answer 29

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)

Question 30

MRI

Answer 30

When radiographs inconclusive, for suspected fx, osteonecrosis, infection, and tumor; radiolnuclide bone scan if MRI contraindicated

Question 31

Ultrasound

Answer 31

Useful to guide aspirations; hip aspiration indicated if infection is suspected (should be image-guided)

Question 32

Treatment

Bursitis

Answer 32

Avoid pressure over hip, bending and stairs; stretching, heat, APAP, NSAIDs, PT (for orthotic and gait evaluation); consider steroid injections if conservative management fails.

Question 33

Treatment

Femoroacetabular impingement

Answer 33

Rest,/ PT, NSAIDS/APAP, ortho referral for arthroscopy in refractory cases

Question 34

Treatment

Labral tear

Answer 34

PT; may require arthroscopic surgery

Question 35

Treatment

Meralgia Paresthetica

Answer 35

Self-limited, benign condition w/spontaneous remission; reassurance, avoid tight garments, wt loss; if persistent consider gabapentin, carbamazepine, or phenytoin

Question 36

Treatment

Osteoarthritis

Answer 36

Limit high impact acitvities, rest, heat, stretching; hip arthroplasty if failure of conservative Rx or significant disability

Question 37

Treatment

Osteonecrosis

Answer 37

Rest, weight-bearing as tolerated, pain control; referral to ortho for surgical management of progressive disease, failure of conservative management.

Question 38

Treatment

Piriformis syndrome

Answer 38

PT, stretching, NSAIDs, gabapentin, nortriptyline; steroid/botulinum toxin injection if conservative management fails.