Meredith A. Goodwin and Elise M. Coletta
The evaluation of hip pathology is challenging for several reasons. Compared with other joints, the hip is relatively inaccessible to palpation and evaluation. Hip pathology can cause referred pain to the groin, buttock, thigh, or knee. Pain located in the hip area can have a lower back source (Chapter 12.5). In addition, hip pain can be referred from pelvic, intraabdominal, or retroperitoneal pathology (Table 12.3).
A. Pain characteristics. What is the exact location of the pain? Pain arising from the lumbar spine is perceived in the buttock and, less commonly, in the groin and anterior thigh. This must be differentiated from radicular pain arising from the spine. True hip pain more often localizes to the anterior midgroin or midthigh area. Lateral hip or thigh pain most likely represents trochanteric bursitis (1). How is the pain described? A “snapping” type discomfort is most commonly caused by iliotibial band syndrome. Constant pain can indicate infection or cancer.
B. Involved joints. Hip osteoarthritis (OA) can have a monarticular onset, or other joints may be involved. Of hip OA patients, 20% will develop bilateral involvement.
C. Precipitating factors. Has there been a recent fall or other trauma? In an elderly or an osteoporotic patient, hip fracture can occur after a very minor incident. A contusion over the greater trochanter can lead to persistent bursitis; a contusion over the iliac crest, to a tear of the muscle aponeurosis. Has there been any preceding athletic or overuse activity that could cause muscle strain? Ischial bursitis usually develops after prolonged sitting.
D. Other symptoms. Bacterial involvement of the hip joint can be accompanied by fever and shaking chills (2). Other symptoms may be present in cancer, pelvic, intraabdominal, or retroperitoneal pathology. Sciatica commonly accompanies trochanteric bursitis.
E. Past medical history. Any prior hip problems or hip surgery? A patient with a hip replacement may develop loosening of prosthetic components, which can be a source of pain, or can seed the joint during a recent infection or invasive procedure. Aseptic necrosis of the femoral head is more likely in patients with sickle cell disease. Previous occult hip fracture or delayed treatment, can also lead to aseptic necrosis. Patients receiving long-term steroids may manifest constant hip pain. Congenital or developmental defects are found in 80% of patients with hip OA.
A. General. If referred pain is suspected, evaluate the appropriate organ system. Palpate the groin and thigh for hernias, lymph nodes, and vascular cords. Assess gait. An unwillingness to bear weight suggests fracture, even with a negative preliminary x-ray finding. Check the neurovascular status of the distal extremity after any traumatic episode.
B. Musculoskeletal. Observe the involved extremity. In femoral neck fractures, the involved leg may appear slightly shortened and externally rotated. Intertrochanteric fractures can cause the involved leg to be internally rotated and shortened. Evaluate the spine, including the straight leg raise test, if spinal pathology is being considered. Compression of the patient’s pelvis with the patient side lying may localize pain to the sacroiliac joint. Check for leg length discrepancy by measuring each extremity from the anterior superior iliac spine (ASIS) to the medial malleolus; for hip joint shortening, measure from the ASIS to the greater trochanter.
Palpate the greater trochanter, ischial tuberosity, and surrounding muscle groups for tenderness. The hip joint is not easily palpated; palpable warmth is produced only when intensely inflamed. Document joint range of motion. Nondisplaced or impacted fractures may not be painful, except at extremes of motion. Pain in all directions suggests intraarticular disease. Pain arising from the hip is typically elicited at the extreme ranges of motion, as well as with motion against resistance. With the patient supine, bend the uninvolved leg at the knee and hip and bring it toward the chest. Watch the opposite hip for flexion (Thomas test), indicating a flexion contracture of that hip. Loss of internal rotation occurs early in OA, followed by the loss of extension, adduction, and flexion. Pain and an inability to fully abduct or extend the hip can also be seen in rheumatoid arthritis (RA). Trochanteric bursitis may present with pain on external rotation only. Muscle strain (e.g., a “groin pull”) will produce pain on passive stretch or resisted contraction of the involved muscles only. In iliotibial band syndrome, the “snapping” of the band may be audible and palpable as the hip is flexed and extended. Document any muscle weakness or muscle atrophy.
A. Radiographs. A suspected hip fracture requires anteroposterior and lateral or “frog leg” hip films. A fracture of the femoral neck can be difficult to visualize. In trauma cases, lateral oblique films are needed to evaluate the acetabulum. Radiologic changes of OA are ubiquitous in older patients and do not rule out other causes of hip pain. Radiographs of a septic hip joint often reveal a “moth-eaten” appearance of the subchondral bone on both sides of the joint (2).
B. Clinical laboratory. The sedimentation rate and white blood cell count are normal in synovitis; leukocytosis and an elevated erythrocyte sedimentation rate may be seen with a septic joint. If a septic joint is suspected, synovial fluid aspiration must be done promptly, as a delay of a few hours increases the chance of substantial joint damage. Joint fluid should be examined for glucose, protein, crystals, Gram’s stain, culture, cell count, and differential. Fluoroscopic guidance is needed to confidently localize the joint space.
A. Intraarticular disease. A deep, aching discomfort that is increased with weightbearing is characteristic of OA. In the later stages, hip OA can lead to rest or night pain. Femoral neck fractures occur most commonly in patients aged more than 50 years; intratrochanteric fractures occur at even older ages. Dislocation of the hip is rarely seen; it is most often associated with severe trauma.
Joint fluid analysis will assist in distinguishing a septic joint from a transient synovitis or crystal-induced arthropathy. Septic arthritis can lead to severe joint destruction within 2 to 3 weeks. Involvement of the hip joint in gout or pseudogout is rare. The femoral neck is a common site for metastatic cancer, which may lead to a pathologic fracture.
B. Referred pain. Lumbosacral disease is the most common cause of hip pain in a postadolescent, nonelderly individual (3).
References
1. Shbeeb MI, Matteson EL. Trochanteric bursitis. Mayo Clin Proc 1996;71:565–569.
2. Medsger TA, Jr. Diagnosis and treatment of arthritis. Emerg Med 1999;31:13–28.
3. Birnbaum JS. The musculoskeletal manual. Philadelphia: WB Saunders, 1986.
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
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More About This Book:
Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X 
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