The Painful HipJennifer R Marks, MD

• A 64 yo F presents to clinic complaining of a “sore hip”

• What further questions do you have for this patient?

• What is on your differential diagnosis?

The Painful Hip

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https://www.google.com/search?q=hip&source=lnms&tbm=isch&sa=X&ved=0ahUKEwj5p7_2-arVAhXjy4MKHd-EDSsQ_AUICigB&biw=1920&bih=963#imgdii=e85AbOJ2CkXSkM:&imgrc=8uNVEo6UmMiwrM:

Hip Anatomy

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• Inspect, anterior & posterior views • Palpate• Range of motion• Strength and sensation (neuro) testing• Gait• FABER test (flexion-abduction-external

rotation)…tests for hip and sacroiliacpathology

Hip Physical Exam

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• Anterior

• Lateral

• Posterior

The Painful Hip

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• Osteoarthritis

• PresentationAge relatedSymptoms include pain after activity, stiffnessPain sometimes referred toward the kneeProgressive

The Painful Hip (anterior)

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• Osteoarthritis

• Exam findingsPain with flexionPain with external and internal rotation as well as abductionAntalgic gait

The Painful Hip (anterior)

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• Osteoarthritis

• AP & lateral films of affected side (above is pelvis view for demonstration purposes)

• Worn articular cartilagehttps://www.google.com/search?q=hip+x+ray+osteoarthritis&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjT05C02LfVAhWCxFQKHextD_QQ_AUICigB&biw=1920&bih=963#

imgrc=N6ddcguxq3_LGM:

The Painful Hip (anterior)

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• Osteoarthritis

• TreatmentNSAIDs, etcCane (hold on “good” side!)ROM exercises, ideally non-weight-bearing including aqua therapyTHR

The Painful Hip (anterior)

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• Avascular Necrosis

• Presentation• Gradual onset• Usually a co-morbid condition

• SCD, gout, CKD, chronic steroids, ETOH• Post-traumatic

The Painful Hip (anterior)

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• Avascular Necrosis• Exam findings

• Antalgic gait• Pain on ROM

• Diagnosis• Joint space preserved, but femoral head may

become collapsed at end-stage• Requires MRI to fully assess

• Treatment• Pain management & THR

The Painful Hip (anterior)

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• Pelvic fracture• Presentation

• Pain in pelvis, groin, ilium, or buttock• Exam Findings

• Point tenderness, bruising, possibly non-weight-bearing

• Diagnosis• X-ray, although occult fractures may require MRI

• Treatment• Depends on degree of instability; NSAIDs,

protected weight-bearing vs surgical intervention

The Painful Hip (anterior)

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• Trochanteric bursitis• Presentation

• Pain with pressure over area• Pain often radiates toward knee

• Exam Findings• Point tenderness

• Treatment• Avoid pressure to area, NSAIDs, heat, steroid

injection

The Painful Hip (lateral)

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https://www.google.com/search?q=meralgia+paresthetica&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiW_qvV3bfVAhXk7YMKHXhNDCQQ_AUICigB&biw=1920&bih=963#imgrc=_MqY1WUY0BTQEM:

The Painful Hip (lateral)

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• Lateral Cutaneous Femoral Nerve Syndrome (aka meralgia paresthetica)

• Presentation• Anterolateral thigh hyperesthesia,

burning/tingling• Symptoms often relieved by rest, hip flexion• Patient may be obese or wears tight clothing

The Painful Hip (lateral)

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• Lateral Cutaneous Femoral Nerve Syndrome (aka meralgia paresthetica)• Exam Findings

• Slight decrease in sensation may be elicited• Consider abdominal and pelvic exam to evaluate

for mass lesion that may be causing compression• Treatment

• May resolve spontaneously• Weight loss, loose clothing, injection of nerve distal

to inguinal ligament

The Painful Hip (lateral)

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• Gluteal hip pain is the least common pain pattern; ie, probably not the hip joint itself

• Differential diagnosis includes sacroiliac joint pathology, lumbar radiculopathy, herpes zoster, piriformis syndrome

• Likely requires imaging to determine underlying cause

The Painful Hip (posterior)

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• Essentials of Musculoskeletal Care, WB Greene, Ed, 2nd edition

• Practical Orthopedics, LR Mercier, 5th edition• Uptodate.com

References

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