Hip Pain
Differential Overview
❑Hip osteoarthritis
❑Trochanteric bursitis
❑Ischial bursitis
❑Iliopectineal bursitis
❑Iliopsoas bursitis
❑Nerve root compression
❑Meralgia paresthetica
❑Obturator inflammation
❑Iliac apophysitis
❑Hip fracture
❑Aortoiliac insufficiency
❑Polymyalgia rheumatica
❑Ankylosing spondylitis
❑Septic arthritis
❑Osteonecrosis
❑Sacroiliitis
Diagnostic Approach
Pain arising from the hip joint is aggrevated with or after use, particularly weight-bearing, and improved with rest. In contrast, constant pain, particularly pain at night, should suggest an infectious, inflammatory, or neoplastic process.
In disease of the hip joint, the earliest limitation is internal rotation with the hip hyperextended. The hip joint is palpated just below the inguinal ligament lateral to the femoral artery. Tenderness and/or crepitance are usually felt there with movement. Manual internal and external rotation of the hip with the knee and hip in flexion usually reproduces pain as does concussion of the heel with the examiner’s palm.
Clinical Findings
Hip osteoarthritis The onset is gradual, beginning with minor aching or stiffness exacerbated by prolonged standing, walking, or stair-climbing. Stiffness present after prolonged inactivity loosens with use and then worsens with continued activity. The range of motion is limited, and there may be crepitance. With advanced disease, there may be a limp, antalgic gait, and positive Trendelenburg sign (buttock falls when standing on the opposite foot) indicative of abductor weakness. The hip is held in flexion, external rotation, and adduction.
Trochanteric bursitis Pain occurs in the lateral aspect of the hip, often radiating into the knee, and is exacerbated at night. Prominent tenderness over the greater trochanter is characteristic.
Ischial bursitis Usually induced by prolonged sitting on a hard surface, it is manifest as buttock pain, increased with direct pressure, such as sitting. Pain may also radiate posteriorly down the leg. There will be tenderness over the ischial spine.
Iliopectineal bursitis It causes pain on hip flexion and tenderness localized to the lateral border of the Scarpa triangle.
Iliopsoas bursitis The pain worsens with hyperextension of the hip. Flexion and external rotation reproduce the pain.
Nerve root compression L1 and L2 impingement may be referred to the hip. Reversed straight leg raising will increase the pain.
Meralgia paresthetica A characteristic burning dysesthesia over the anterolateral thigh is caused by entrapment of the lateral femoral cutaneous nerve at the anterior superior iliac spine.
Obturator inflammation This is recognized by a positive obturator sign, and pain increases with internal rotation of the hip.
Iliac apophysitis Pain and tenderness are located over the iliac crest at the insertion of the tensor fascia lata.
Hip fracture Fracture should be suspected after any fall in an elderly patient. The leg will be shortened and externally rotated. The pain is usually severe although ambulation may be possible.
Aortoiliac insufficiency Advanced atherosclerosis produces claudication (pain with walking, relieved by rest) that radiates to the hip and buttock (Leriche syndrome). There may be a diminished femoral pulse and a bruit.
Polymyalgia rheumatica There is bilateral aching of the proximal musculature (hips and shoulders) in an elderly patient, with prominent weakness on arising from a chair. Passive range of motion is preserved.
Ankylosing spondylitis Sacroiliac and lumbar spine involvement are concurrently present, with pain radiating to the hip.
Septic arthritis Suspect infection when there is fever, a source for hematogenous seeding, or hardware in the hip. The hip is held in flexion, and there may be a bulging, tender joint capsule.
Osteonecrosis Also known as avascular or aseptic necrosis. There is a gradual onset of groin pain and limitation of movement. Predisposing conditions include chronic steroid use, hemoglobinopathy, and alcoholism.
Sacroiliitis There is posterior hip pain with focal tenderness, and pain with the Patrick test (the affected leg is flexed, abducted, and externally rotated to place the ankle on the opposite knee, then the leg is lowered toward the exam table), but not with passive motion of the hip joint.
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Hip symptoms
Read excerpts from these other book chapters related to Hip symptoms:
Medical Books Excerpts
- HIP PAIN
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- Hip Pain
- "In A Page: Pediatric Signs and Symptoms" (2007)
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- HIP PAIN
- "Differential Diagnosis in Primary Care" (2007)
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- Hip Pain
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- HIP PAIN
- "Differential Diagnosis in Primary Care" (2007)
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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Hip symptoms
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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