When confronted with a case of hip pain in an adult, the clinician is most likely to think of fracture or joint inflammation such as osteoarthritis, realizing however that there are many other possibilities (Table 38). How can the clinician think of them on the spot? Anatomy is the key. The hip is composed of skin, muscle, bursa, ligament, joint, and bone. It is also supplied by nerves, arteries, and veins. Looking at each of these structures in terms of etiology, skin should prompt the recall of herpes zoster, and muscle should prompt the recall of contusion or sprain. The bursa should allow one to recall greater trochanter bursitis—a common and easily treated form of hip pain. Thinking of the ligaments, consider sprain. Visualizing the joint would prompt consideration of osteoarthritis, gout, and RA as well as congenital dislocation of the joint, slipped femoral epiphysis, Legg–Perthes disease, and rheumatic fever. Visualizing the bone should prompt recall of fracture and primary and metastatic tumors. Visualizing the nerves, one should think of the sciatic nerve and consider a herniated lumbar disc, cauda equina tumor, or sciatic neuritis (which is rare). Considering the arteries and veins may prompt one to think of avascular necrosis.
The history and physical examination will allow differentiation of many of the conditions listed above. For example, the history of trauma suggests sprain, fracture, or contusion. Remember that fractures of the hip can occur in elderly persons without a history of trauma. A positive straight-leg-raise (SLR) test suggests a herniated disc or other cauda equina pathology. X-ray of hip and lumbosacral spine will help rule out fracture or osteoarthritis, but CT scan, bone scan, or MRI may be necessary. If x-rays and laboratory examinations are negative, a trial of lidocaine injections into the greater trochanter bursa or other trigger points may be diagnostic.
HIP PAIN
M I N T Malformation Inflammation Neoplasm Trauma Skin Muscle Myositis Bursa Contusion Ligaments Sprain Joint Bone Osteomyelitis Nerves Neuritis
CASE PRESENTATION #46 A 56-year-old white woman complained of increasing left hip pain which began 3 months ago and had gradually gotten worse. There is no history of trauma, fever or chills, and no numbness or tingling of the extremities. She had a mastectomy for breast cancer 5 years previously.
Read excerpts from these other book chapters related to Stiff hip:
Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
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More About This Book:
Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8 
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