HIP PAIN

RACGP Words of wisdom

• When assessing a patient who presents with joint symptoms, history and examination are very important.
• Having a good understanding of anatomy and biomechanics will often help you identify the issue on history alone.
• Also, deciding if the condition is inflammatory or non-inflammatory, mono, pauci or polyarticular, symmetrical or asymmetrical will help you narrow down the differential diagnosis.
• A limping child with fever is an emergency: septic arthritis must be ruled out.
• Groin and thigh pain is usually referred from the hip, and gluteal pain from the lumbar spine.
• The majority of sports medicine presentations are chronic overuse-type injuries, often relating to biomechanics or load rather than a specific injury, and often present with non-specific symptoms.
  • These can occur with any amount of exercise and not only in athletes.
  • It is important to address these issues, often with a multidisciplinary approach, as they often discourage people from exercising.
• Think of compartment syndrome when a patient is in a cast and complains about pain, despite being on pain killers.
• Early intervention of inflammatory joint conditions with disease-modifying anti-rheumatic drugs will prevent and limit permanent joint damage

Critical Causes of Hip Pain (not to miss)

1. Septic Arthritis of the Hip: Sudden onset of severe hip pain, fever, inability to bear weight, redness, and swelling around the joint.
2. Hip Fracture: Severe pain in the hip or groin, inability to move the leg, bruising and swelling in and around the hip area.
3. Hip Avascular Necrosis: Gradual onset of hip pain, stiffness, limited range of motion, pain increases with standing or walking.
4. Peripheral Arterial Disease: Claudication (pain in the limbs while walking), changes in skin color, decreased pulse in the legs, sores or ulcers that won’t heal.
5. Peritonitis: Severe abdominal pain, tenderness in the abdomen, fever, nausea, and vomiting.
6. Slipped Capital Femoral Epiphysis (SCFE): Hip pain, knee pain, limping, restricted hip movement.
7. Malignancy involving hip or Pelvis: Persistent hip pain, weight loss, night sweats, fatigue.

Causes: Timing in the Elderly (acute versus insidious)

• Spontaneous onset without Trauma in elderly: Can indicate septic arthritis, hip fracture, or hip avascular necrosis. Symptoms include acute pain, difficulty in movement, systemic symptoms like fever.
• Insidious onset in elderly: May suggest osteoarthritis, malignancy, or hip fracture with less obvious symptoms like gradual increase in pain, stiffness, and limited mobility.

Causes: Anterior or Anterolateral Hip Pain or Groin Pain

• Anterolateral Hip Pain is most associated with intrinsic hip pathology
• May present with patient cupping the anterolateral hip between their thumb and index finger (C Sign)
• Referred Pain Considerations:
  • Inguinal Hernia
  • Lumbar Radiculopathy
  • Pelvic Pathology: Consider if there’s no pain on Hip Range of Motion or direct pressure.
• Hip Pain on Weight Bearing with Mechanical Symptoms
  • Snapping Hip
  • Hip Labral Tear
  • Iliopsoas Bursitis (Internal Snapping Hip)
  • Hip Loose Body or Chondral Lesions
• Hip Pain on Weight Bearing Without Mechanical Symptoms
  • Femoral Neck Fracture or Femoral Stress Fracture: Suggest Hip MRI, non-weight bearing if suspected despite negative Hip XRay.
  • Hip Impingement or Femoroacetabular Impingement: Pain especially on standing after prolonged sitting (e.g., from a car seat).
  • Hip Osteoarthritis
  • Hip Avascular Necrosis (Hip Osteonecrosis)
  • Septic Arthritis
• Anterior or Anterolateral Thigh Neuropathic Pain
  • Meralgia Paresthetica: Typically anterior thigh pain.
  • Lumbar Radiculopathy
• Children with Deep Referred Hip Pain (Especially with Weight Bearing)
  • Legg-Calve-Perthes Disease: Children 2 to 12 years old, especially males.
  • Slipped Capital Femoral Epiphysis: Overweight children aged 11 to 14 years old.
  • Transient Synovitis: Children ages 3 to 8 years old who refuse to bear weight. Must be distinguished from Septic Arthritis.
• Overuse or Sports-Related Anterior Hip Pain
  • Sports Hernia or Athletica Pubalgia: Anterior groin pain.
  • Clicking or Snapping Hip: Identified by Thomas Test or Snapping Hip maneuver.
  • Hip Stress Fracture
  • Resisted Muscle Testing and Local Tenderness: Hip flexor Muscle Strain, Adductor Strain (Groin Pull).
• C Sign: Patients may cup the anterolateral hip between thumb and index finger.

Causes: Lateral Hip Pain

• Iliotibial Band Syndrome: Pain and tenderness on the outer side of the hip, knee pain, worsened by activity.
• Greater Trochanteric Bursitis: Pain and tenderness over the outer hip, difficulty lying on the affected side, pain with walking or climbing stairs.

Causes: Posterolateral or Posterior Hip Pain

• Piriformis Syndrome: Pain in the buttock area, can radiate down the leg,

worsened by sitting for long periods or climbing stairs.

• Gluteus Medius Tendinopathy: Pain on the outer part of the hip, difficulty with walking or climbing stairs, tenderness over the hip.
• Hamstring Muscle Strain: Sudden, sharp pain in the back of the thigh, swelling, bruising, weakness in the leg.

Causes: Groin Pain or Hip Pain in Athletes

• Idiopathic in 30% of cases
• Adductor Strain or Adductor Tendinitis (Groin Pull) – Sharp pain in the groin or inner thigh, pain during movement, swelling
• Pubic Instability
• Osteitis Pubis
• Myositis Ossificans
• Sports Hernia (Athletic Pubalgia)
• Direct Inguinal Hernia (power lifters, middle aged patients)
• Femoral Hernia (women)
• Groin Disruption
• Iliopsoas Strain or Iliopsoas Bursitis – Pain in the front of the hip, difficulty with hip flexion, tenderness in the groin area.
• Snapping Hip syndrome
• Femoral Neck Stress Fracture – Dull, aching groin pain, worsened by activity, especially running or jumping.
• Pubic Ramus Stress Fracture
• Pubic Apophysitis (children and young adult athletes)
• Avulsion Fracture (Adolescent Athletes)
  1. Anterior Superior Iliac Spine Avulsion Fracture
     1. Rapid sartorius contraction in jumping sport
     2. Responds to non-operative conservative therapy
  2. Anterior Inferior Iliac Spine Avulsion Fracture
     1. Strong rectus femoris contraction in kicking sport
     2. Responds to non-operative conservative therapy
  3. Ischial Tuberosity Avulsion Fracture
     1. Rapid hamstring contraction in sprinting, hurdling
     2. Fragments >1-2 cm may require ORIF
• Nerve entrapment – Burning sensation, tingling, or numbness in the outer thigh.
  1. Genitofemoral nerve entrapment
     1. Upper anterior thigh and Groin Pain
     2. Follows abdominal surgery (also seen in cyclists)
  2. Lateral Femoral Cutaneous Nerve Entrapment (Meralgia Paresthetica)
     1. Lateral thigh pain
  3. Ilioinguinal Nerve Entrapment
     1. Upper medial thigh or genital pain
  4. Iliohypogastric nerve entrapment
     1. Lateral gluteal region and abdominal Muscle region pain
  5. Obturator Nerve Entrapment
     1. Medial thigh and adductor region pain

Causes: Hip Pain in Pregnancy

• Common, benign causes
  1. Lumbosacral strain
  2. Sciatica
  3. Pelvic structure compression
• Femoral Head Osteoporosis or Fracture: Pain in the hip or groin, difficulty walking, pain worsened with weight-bearing.
• Transient Osteoporosis of the Hip: Hip pain, typically in the second and third trimester, more pronounced discomfort with physical activity.
• Deep Vein Thrombosis: Swelling in the leg, pain in the calf, warmth over the affected area.

Causes: Hip Joint Disorders by Age

1. Pediatric Causes (under age 8-12 years)
   1. Legg-Calve-Perthes Disease
   2. Septic Joint
   3. Toxic Synovitis
   4. Monarticular Arthritis (e.g. Lyme Disease)
   5. Malignancy (Osteosarcoma, Ewing Sarcoma, Leukemia)
2. Adolescent causes
   1. Slipped Capital Femoral Epiphysis (SCFE)
   2. Hip Avulsion Fracture
3. Adult causes
   1. Osteoarthritis of femoral head (especially over age 50 years)
   2. Avascular Necrosis of the Femoral Head
   3. Acetabular labral tear

Causes: Musculoskeletal Causes of Groin or Hip Pain

• Bone Causes
  1. Hip Fracture
  2. Femoral head avascular necrosis
  3. Cancer (primary site or metastases)
• Joint Causes
  1. Hip Osteoarthritis
  2. Septic Arthritis
  3. Gouty Arthritis
  4. Osteoid Osteoma
  5. Osteitis Pubis
• Muscle or tendon Causes
  1. Iliotibial Band Syndrome
  2. Trochanteric Bursitis
  3. Iliopsoas Bursitis
  4. Piriformis Syndrome
  5. Myositis Ossificans
• Neurologic Causes
  1. Lumbar Disc Disease
  2. Lumbar Spinal Stenosis
  3. Coccygodynia
  4. Meralgia Paresthetica (see nerve entrapment above)

Causes: Non-Musculoskeletal Causes of Groin or Hip Pain

• General
  1. Inguinal Hernia
  2. Inguinal Lymphadenopathy or Lymphadenitis
  3. Lumbar Disc Disease with L1-2 or S2-3 radiculopathy
  4. Nephrolithiasis
  5. Abdominal Aortic Aneurysm
  6. Appendicitis
  7. Diverticulitis
  8. Inflammatory Bowel Disease
  9. Malignancy
  10. Herpes Zoster
• Women
  1. Ovarian Cyst
  2. Urinary Tract Infection
  3. Pelvic Inflammatory Disease
• Men
  1. Epididymitis
  2. Hydrocele
  3. Varicocele
  4. Prostatitis
  5. Testicular Cancer

Hip pain in young adults

Extra-articular	Intra-articular
Muscles Abductor muscle injuries Gluteus muscle tears          Nerves Sciatica Obturator nerve irritation LFCN- lateral femoral cutaneous nerve irritation      Piriformis syndrome Tendons Snapping hip (iliotibial band or iliopoas) Bursa Trochanteric bursitis Ligaments Inguinal ligament strain Joint capsule Referred pain Lumbar spine Knee Non-musculoskeletal pathology	Bones FAI – femoroacetabular impingement OA AVN – avascular necrosis DDH – developmental dysplasia of the hip. Fractures Perthe’s Septic arthritis Soft tissues Labral tear Chondral defect Ligamentum teres injury