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Hip Pain

Hip pain is a common cause of pain and disability among older adults prevalence of hip pain in the general population is 10 % and this increases with age hip OA is one of the most common diagnosis in primary care adult patients Most common locations of patients with hip OA presenting in primary care are
○ the greater trochanter
○ groin
○ thigh
○buttock areas 450 patients per 100 000 populations present to the primary care annually with hip pain – of them
○ 25 % resolve in 3 months
○ 35 % at 12 months according to to CDC lifetime risk for symptomatic hip OA is 18.5 % and 28.6 % for women there is 25 % risk of developing hip OA for people who live to the age of 85 hip joint is the second most commonly affected large joints in the body after knee joint

Hip is a ball and socket joint- formed by femoral head and acetabulum The joint consists of
○ articular cartilage
○ subchondral bone
○ synovium
○ joint capsule the articular surfaces are spherical with a marked congruity which limits the ROM but contributes to the considerable stability of the joint the joint surface comprises articular cartilage- which is avascular
articular cartilage is mainly composed of chondrocytes which is surrounded by a matrix that includes proteoglycans, glycosaminoglycans and collagen in a normal healthy hip joint the articular cartilage is sustained by conditions which are a balance of synthesis and degradation the hip represents a link between the upper body and lower body

heredity old age over weight heavy physical stress at work traumatic injuries certain occupations as farming

MSK related pain has a major impact on the individuals and the society – it is 2nd most common reason for GP visits and accounts for about 25 % of all GP consultations in the UK Reduced functional status from OA significantly increases morbidity from CAD , lung disease , diabetes , obesity , falls , frailty and various ailments In older woman radiographic evidence of hip OA has been found to be associated with an increases risk of mortality from all cause and CV disease among older white woman Hip OA is the commonest reason for total hip replacement and

Duration of symptoms Location of pain – lateral , buttock , anterior , knee Radiation How did the pain start Clicking / snapping / popping ( intra or extra-articular cause ) Instability Aggravating factors Trauma Walking aids ( which hand ) H/O previous surgery Night pain Related symptoms of spine , abdomen and lower extremity weakness , numbness or paraesthesia in lower extremity Effect on ADLs Occupation sports and recreational injuries

A full examination of the hip examines to assess the 4 distinct layers which are osteochondral , capsulolabral ,musculotendinous and neurovascular – this is a 21 step physical examination A full evaluation may involve a seated , supine , lateral tests and ends with prone test A focused test based on clinical suspicion may be undertaken in primary care A general approach to examination may involve
○ inspection of skin – look for discoloration , wounds or gross deformity
○ bony – length comparison 
○ gait – observe stride length , foot rotation , pelvic rotation , stance phase
 antalgic gait , Trendelenberg test
○ palpation – around greater trochanter / bursae , anterior superior iliac spine , ischial tuberosity , iliac crest , iliotibial band
○ neurovascular – motor -hip adduction , thigh abduction , hip flexion , hip extension
○ sensory
○range of movement- flexion ,extension , abduction , internal rotation and external rotation
○ special tests based on clinical suspicion as Faber , Thomas etc


suspected hip fracture h/o trauma fever associated systemic features signs of infection for e.g
○ cellulitis over the joint
○ large effusion and erythema
○ inflamed scar / wound over a previously replaced joint known primary malignancy ( for e.g prostate or any reproductive cancer or breast cancer ) severe muscle spasm sudden inability to weight bear or walk avascular necrosis / osteonecrosis evidence of new inflammatory arthropathy unexplained weight loss h/o prolonged corticosteroid use

Anterior hip pain –Anterior Osteoarthritis Pain Femoroacetabular impingement Hip flexor muscle strain / tendonitis Iliopsoas bursitis Hip fracture ( proximal femur ) Stress fracture Inflammatory arthritis Acetabulo-labral tear Avascular necrosis of femoral head ( AVN )

Most common- indicates pathology of the hip joint

Lateral hip pain-Greater trochanteric bursitis Gluteus medius muscle dysfunction Iliotibial band syndrome Meralgia paresthetica

Posterior hip pain-Referred pain from lumbar spine Degenerative disc disease Facet arthropathy Spinal stenosis Sacroiliac joint dysfunction Hip extensor or rotator cuff muscle strain Aorto-iliac valve dis ( rare )

Least common , suggests a source outside the hip joint

the joint –Osteoarthritis Rheumatoid arthritis Septic joint Tumour ( Primary and metastatic ) Trauma Avascular necrosis

Soft tissue- Contusion Myositis ossificans Iliotibial band syndrome Trochanteric bursitis Iliopsoas bursitis

Neuromuscular –Sciatica Lateral Femoral Cutaneous N Irritation Intrinsic disorders ( muscle imbalance ) 
▬ Spasticity – Cerebral palsy , CVAs and Spinal cord injuries 
▬ Flacid paralysis – Poliomyelitis , Myelomeningeocele , Charcot-Marie-Tooth disease
 Extrinsic disorders- contractures
▬ Charcot neuropathic jt
▬ Parkinson’s disease
▬ Multiple sclerosis
▬ Upper motor neuron injury
▬ Head / Spinal cord injury

Intra-articular –Labral tears Loose bodies Femoroacetabular impingement Capsular laxity Synovitis Ligament teres rupture Chondral damage


Intra-articular causes are usually addressed arthroscopically

extra-articular –Muscles
▬ Abductor muscle injuries
▬ Gluteus muscle tear Nerves
▬ Sciatica
▬ Obturator nerve irritation
▬ Lateral femoral cutaneous nerve irritation ( LFCN )
▬ Piriformis syndrome Tendons
▬ Snapping hip syndrome ( ITB or Iliopsas )
▬ Bursa
▬ Trochanteric bursitis
Greater Trochanteric Pain Syndrome- encompasses several diagnosis that include trochanteric bursitis and tendinosis ( or even a degenerative tear ) of the gluteus medius or minimus muscle Ligaments
▬ Inguinal ligament strain
▬ Joint capsule Sacroiliac joint pathology

Referred –Lumbar spine , discs or nerve roots Urogenital problems Knee Non-musculoskeletal pathology

XR –Initial imaging test for hip and pelvic abnormalities Radiographs show a sensitivity of 15.6 % and specificity og 90.9 % for radiographic hip OA , the +ve PPV was 20.7 % and NPV 97.6 % Routine views are AP of the pelvis , AP of the hip It is important to note that hip pain is discordant with radiographic hip OA – this means that many older people with hip OA might be missed if diagnosticians relied on hip radiographs It has been noted that hip pain was not present in many hips with radiographic evidence of OA and many people with painful hips did not have radiographic evidence of hip OA

CT scan –Following trauma ( Pelvic CT- part of whole body CT protocol ) To assess Osseous structures in the area around the hip Visualise fractures of acetabulum or sacrum If MRI cannot be done for any reason MPR- multiplanal reconstruction ( spiral / helical CT ) 3D reconstruction CT Arthrography → CT scan of hip after intra-articular injection of contrast under fluoroscopic guidance
○ evaluation of joint cartilage and acetabular labrum
○ if MR arthrography contraindicated or unavailable

Ultra sound-Not widely used as an imaging tool for adults Neonatal hip or congenital dislocation Assessment of soft tissue , fluid structures and non-mineralized structures Soft tissue assessment for muscle tears , fluid collections and bursitis Aid in joint injection ( dynamic real time visualization )

MRI –Extremely sensitive in injuries to cartilage , muscle , ligaments and tendons Has broadened the differential diagnosis of pain around the hip jt and improved treatment of these problems MR Arthrogram can identify intra-articular abnormalities as cartilage defects , loose bodies and labral tears Radiation free

References

  1. Martin, Hal David, and Ian James Palmer. “History and physical examination of the hip: the basics.” Current reviews in musculoskeletal medicine vol. 6,3 (2013): 219-25. doi:10.1007/s12178-013-9175-x
  2. Hip physical exam adults from https://www.orthobullets.com/recon/5037/hip-physical-exam–adult
  3. Reiman, Michael P, and Kristian Thorborg. “Clinical examination and physical assessment of hip joint-related pain in athletes.” International journal of sports physical therapy vol. 9,6 (2014): 737-55.
  4. Orthopedic hip examination by Pawl Thawley via https://www.elitephysicalmedicine.co.uk/wp-content/uploads/2012/02/Hip-examination-.pdf
  5. Adult Hip pain pathway from https://www.enhertsccg.nhs.uk/sites/default/files/pathways/Hip%20Pain%20in%20Adults%20V3.pdf
  6. R. Juhakoski, M. Heliövaara, O. Impivaara, H. Kröger, P. Knekt, H. Lauren, J. P. A. Arokoski, Risk factors for the development of hip osteoarthritis: a population-based prospective study, Rheumatology, Volume 48, Issue 1, January 2009, Pages 83–87, https://doi.org/10.1093/rheumatology/ken427
  7. Kolber, Morey J. PT, PhD, CSCS*D1; Hanney, William J. PT, DPT, PhD, ATC, CSCS2; Cheatham, Scott W. PT, DPT, PhD, ATC, CSCS3; Salamh, Paul A. PT, DPT, PhD4 Risk Factors for Hip Osteoarthritis, Strength & Conditioning Journal: June 2017 – Volume 39 – Issue 3 – p 35-41 doi: 10.1519/SSC.0000000000000222 https://journals.lww.com/nsca-scj/fulltext/2017/06000/risk_factors_for_hip_osteoarthritis__insight_for.6.aspx
  8. Juhakoski, R & Heliövaara, M & Impivaara, O & Kröger, Heikki & Knekt, P & Lauren, H & Arokoski, J. (2009). Risk factors for the development of hip osteoarthritis: A population-based prospective study. Rheumatology (Oxford, England). 48. 83-7. 10.1093/rheumatology/ken427.
  9. South & West Devon Formulary and Referral https://southwest.devonformularyguidance.nhs.uk/referral-guidance/south-devon-torbay/musculoskeletal-joint-disorders/chronic-hip-pain-and-management-in-adults
  10. Erik Poulsen, Søren Overgaard, Jacob T Vestergaard, Henrik W Christensen, Jan Hartvigsen, Pain distribution in primary care patients with hip osteoarthritis, Family Practice, Volume 33, Issue 6, 1 December 2016, Pages 601–606, https://doi.org/10.1093/fampra/cmw071
  11. The Joint Pain Advisor Approach for Knee and Hip Pain https://www.nice.org.uk/sharedlearning/the-joint-pain-advisor-approach-for-knee-and-hip-pain

  12. Kim ChanNevitt Michael CNiu JingboClancy Mary MLane Nancy ELink Thomas M et al. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study 
  13. Moss, A S et al. “Annual incidence rates of hip symptoms and three hip OA outcomes from a U.S. population-based cohort study: the Johnston County Osteoarthritis Project.” Osteoarthritis and cartilage vol. 24,9 (2016): 1518-27. doi:10.1016/j.joca.2016.04.012
  14. Differential diagnosis of Pain around the Hip Joint Lisa M Tibor MD and Jon K Sekiya MD
  15. Hip pain in young adults Australian Family Physician Vol 43 No4 April 2014 Pages 205-209
  16. Maguel Fernandez , Peter Wall , John O’Donnell , Damian Griffin Commissioning guide : Pain arising from the hip in adults accessed via https://www.rcseng.ac.uk/healthcare-bodies/docs/commissioning-guides-
boa/painful-hip-commissioning-guide
  17. Evaluation and management of hip pain : an algorithmic approach J Fam pract 2003 Aug ; 52 (8) : 607-17 Margo K , Drezner J , Motzkin D
  18. Fundamentals of Musculoskeletal Imaging Lynn McKinns
  19. An Algorithmic Approach to Mechanical Hip Pain Lazaros A et al HSS J ; 2012 Oct ; 8(3) : 213-224
  20. Surgery of Hip -Imaging of the Hip Kawan S Rakhra and Adnan M Sheikh 395-411

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