The Common Vein Copyright 2009
Author
Definition
Hip pain is a common complaint. It encompasses many etiologies resulting in pain from the waist to the thigh.
Principles
This module will include pain secondary to the many structures that pass near the hip joint as well derangements of the femoral/acetabular joint.
Structural Considerations
The hip joint serves as the connection between the axial skeleton and the weight bearing lower extremity. As such, it transmits a tremendous amount of force with everyday activities. A common source of hip pain is from arthritis due to wearing of the articular cartilage. This mechanical type pain is often referred to the groin.
Functional Considerations
The primary function of the hip is to support the weight of the body in both static (standing) and dynamic (walking or running) postures. Hip pain can limit the ability to perform these functions resulting in alterations in gait. (e.g. trandelenberg gait)
Causes and predisposing factors
As mentioned previously, there are many etioloigies for hip pain. ( see differential diagnosis) The most common type of pain is due to osteoarthritis. The development of this condition is multifactoral. Structural anatomy related to the coverage of the femoral head by the acetabulum plays a role. Lifestyle and activity choices also influence the development and progression of this condition.
Differential Diagnosis
ankylosing spondylitis
avascular necrosis
congenital hip dysplasia
fracture
dysplasia
iliopsoas bursitis
iliotibial band syndrome
labral tear
meralgia paresthetica
muscle strain
osteoarthritis
osteoid osteoma
Perthe’s disease
piriformis syndrome
psoriasis
referred pain
rheumatoid artritis
septic arthritis
snapping hip syndrome
slipped femoral epiphysis
stress fracture
synovial chondromatosis
tendonitis
trochanteric bursitis
Labs
Laboratory tests are usually not indicated for most patients with acute or chronic hip pain. Patients with constitutional symptoms such as prolonged fever, night sweats, or weight loss should have a complete blood cell count (CBC), complete metabolic panel, erythrocyte sedimentation rate (ESR), and possibly a rheumatologic panel performed.
Imaging
Plain radiographs are useful in the work up of hip pain. These x-rays help the clinician to determine if a fracture or avulsion fracture is the cause of the disability. Hip joint osteoarthritis, avascular necrosis, and femoral neck stress fractures can also be diagnosed.
A 2-view radiograph, anteroposterior (AP) and lateral view of the hip, will adequately depict most clinically significant avulsion fractures. The frog-leg view is most useful for determining the presence of a stress fracture to the femoral neck or physeal fracture in the younger patient.
Magnetic resonance imaging (MRI) studies are increasingly used to help aid in the diagnosis of acute and chronic hip pain. MRIs show good definition for large muscle and tendon tears and aid in providing prognostic information based on the presence of edema, blood, or large fluid collections. In addition, the presence of large areas of tendon inflammation and degeneration can often be noted. MRI also determines whether collections of fluid are present in a bursa, although greater trochanteric bursitis is often not seen on MRI. Iliopsoas bursal collections can be visualized because they tend to be larger. Stress injuries of the apophysis and stress fractures of the pelvis, femoral neck or shaft, and pelvic bones are easily visualized on MRI. Degenerative changes within the hip joint and avascular necrosis are also evident on noncontrast MRIs. Of course, neoplastic processes are best evaluated with contrast-enhanced MRI.Intra-articular labral tears can only be diagnosed with a magnetic resonance arthrogram of the hip joint. The contrast must be injected into the joint under direct fluoroscopic or ultrasound guidance, which makes this imaging test more difficult to perform. Limitations of MRI include excessive cost, increased time to obtain images, and the static nature of the test.
Radionuclide triple-phase bone scans are indicated for the diagnosis of stress fractures anywhere in the body. These studies will typically show increased bone activity within 3 days of the commencement of the athlete’s symptoms and are rarely falsely negative.
Diagnostic ultrasound is increasingly used in the sports medicine office. Ultrasound machines may be mounted on carts or are portable, and they usually contain a 6?12 mm probe, which provides for adequate visualization for most musculoskeletal complaints. Ultrasound is useful in visualizing the fluid collections that are present with iliopsoas or greater trochanteric bursitis, as well as for demonstrating hematomas from acute quadriceps strains. Tendons can easily be seen, and partial or complete tendon ruptures and avulsions can be determined.
Tendinopathy is also easily visualized with ultrasound. The ultrasound criteria for tendinopathy include enlargement of the tendon, hypoechoic and hyperechoic changes that demonstrate collagen disorganization, microcalcifications, minute tendon tears, and decreased flow within the tendon. The iliopsoas, gluteus medius, proximal hamstring, and rectus femoris tendons are all easily visualized. Dynamic ultrasound is extremely useful for the evaluation of a snapping hip to determine the exact tendon involved, such as the iliopsoas snapping over the pelvic ring, or the tensor fasciae latae snapping over the greater trochanter. Ultrasound can also be used to guide injections into fluid collections, bursae, and the hip joint, and for guiding needle-based interventions for chronic tendinopathy
Management or Treatment
The treatment of hip pain is dependent on the underlying cause. Some basic principles of non operative management include:
Rest: The first treatment for most conditions that cause hip pain is to rest the joint, and allow the acute inflammation to subside. Often this is the only step needed to relieve hip pain. If the symptoms are severe, crutches or a cane may be helpful as well.
Ice and Heat Application: Ice packs and heat pads are among the most commonly used treatments for inflammation. Ice is useful in the acute period to decrease inflammation. Heat can be used later to relax the muscles as well.
Stretching: Stretching the muscles and tendons that surround the joint can help with some causes of hip pain. A good routine should be established.
Physical Therapy: Physical therapy is an important aspect of treatment of almost all orthopedic conditions. Physical therapists use different modalities to increase strength, regain mobility, and help return patients to their pre-injury level of activity.
Anti-Inflammatory Medication: Nonsteroidal anti-inflammatory medications, commonly referred to as NSAIDs, are some of the most frequently prescribed medications, especially for patients with hip pain caused by problems such as arthritis, bursitis, and tendonitis.