Anterior Hip Pain

1. Anterior Hip Pain Hilary Suzawa, MD Med/Peds August 2005

2. Hip Pain • Pt with hip pathology c/o pain may point to lateral aspect of proximal thigh, buttock, or groin • Pt with lumbar spine pathology c/o pain may also point to thigh, buttock, lower leg BUT do NOT have groin pain

3. Physical Exam • Observation • Can affected leg bear weight? • Posture? Gait? Ability to transfer from lying down to sitting to standing? • Height symmetry of iliac crests? • Check for leg length discrepancy— • Measure from ASIS to medial malleolus. • Difference >2 cm should be tx with heel lifts • Palpation

4. Physical Exam • Range of motion • Passive and active • Strength Internal rotation Abduction Flexion Adduction External rotation

5. Imaging • AP and frog leg views • Indications for X-ray • Painful gait • Inability to bear weight • Point tenderness at a site of muscular insertion • Marked reduced ROM

6. Pediatric Hip Pain • Transient synovitis • Most common cause of hip pain in children • Acute onset limp and refusal to bear weight or use affected leg • Improves over 2-3 days • Legg-Calve-Perthes • Males age 4-8 years • Septic arthritis • JIA (formerly JRA)

7. Adolescent Hip Pain • Slipped capital femoral epiphysis (SCFE) • Apophyseal Injury • Osteoid Osteoma

8. Slipped capital femoral epiphysis • Males > females • 11-14 years • Rapid growth • Obesity • Present with hip pain, medial knee pain, limp • Pain with passive internal rotation of a flexed hip • If dx is missed, increased risk of AVN of femoral head and early degenerative arthritis • 30-40% of cases are bilateral so must evaluate contralateral leg • No weight-bearing and referral to orthopedics

9. SCFE X-ray www.learningradiology.com

10. Apophyseal Injury • Acute muscle contraction can lead to avulsion of an apophysis (ossification center at the attachment of tendon to bone) • Overuse in adults leads to tendonitis but in adolescents leads to apophysitis • Localized pain and swelling, weakness, decreased ROM • X-ray to check if there is fracture and displacement

11. Apophyseal Injury Treatment • Rest, ice • Crutches for up to 3 weeks • For pain may benefit from heat, electrical stimulation, U/S • Rehabilitation—progressive resistance training • Limited sports participation 4-8 weeks after injury • Competitive sports 8-10 weeks after injury as long as X-ray improved, good strength and ROM, no pain

12. Osteoid osteoma • Benign bone tumor • May be dx incidentally on x-ray • Bone pain that is characteristically relieved by aspirin • Surgical excision for severe refractory cases

13. Adult Anterior Hip Pain • Disease of the hip • Stress Fracture • Strains and Tendonitis • Osteoarthritis and Inflammatory Arthritis • Bursitis • Nerve compression • Osteitis pubis • Acetabular tear • Disease of the back that radiates to the hip • Male or female GU disease • GI disease • Vascular structures

14. Stress Fracture • From chronic repetitive forces • Absorption of bone > metabolic repair during bone remodeling • Stress fractures of the pubic ramus, femoral neck, or proximal femur can cause anterior hip pain • Most common in distance runners, jumpers, ballet and aerobic dancers, triathletes

15. Femoral Stress Fracture • Possibility of progression to displacement and osteonecrosis of femoral head • Progression of hip pain: occurs late in activity  limits activity  occurs with any weight-bearing or at rest • Limited internal rotation of the hip and pain when the pt hops on the affected leg • X-ray may show fracture line, or area of lucency, or increased sclerosis • Compared with bone scan, MRI has similar sensitivity and improved specificity for stress fractures

16. Femoral Stress Fracture • Treatment • If there is displacement  urgent ORIF • If no displacement tx depends on the side of the femoral neck with the fracture • Percutaneous fixation is recommended if • Fracture line involves >50% of femoral neck OR • Fracture involves superior or lateral side of the femoral neck

17. Strains and Tendonitis • Strain=acute injury to a muscle or tendon • Violent muscle contraction or stretch leads to pain, swelling, ecchymosis • Tendonitis=acute inflammatory tendon changes secondary to overuse • Insidious onset of increasing activity intolerance • Iliopsoas tendonitis (“internal snapping hip”)—snap or clunk heard as hip moves from flexion to extension b/c of iliopsoas tendon moving medially to laterally across the femoral head

18. Strains and Tendonitis • Treatment • Rest • Ice • Compression • Avoid painful activity • Surgery is NOT recommended because muscle tissue not amenable to repair

19. Osteoarthritis • Osteoarthritis is the most common cause of anterior hip pain in patients >50 yrs • Fairly steady pain, progressively worse with activity • Painful, limping gait • Pain worse with full internal rotation and extension of the hip • X-ray shows joint space narrowing • Normal space is ~4 mm with less than 1 mm difference between sides

20. Osteoarthritis • Treatment • Analgesics • Exercise • Aerobic exercise • Flexibility • Resistance training • Joint ROM • Total joint arthroplasty

21. Inflammatory Arthritis • Seronegative spondyloarthropathies • Ankylosing spondylitis, Reiter’s Syndrome, Psoriatic arthropathy, enteropathic arthropathy • Crystalline arthropathies • Gout, pseudogout • Rheumatoid arthritis • Septic arthritis • Viral arthritis

22. Inflammatory Arthritis • Pain worse in the AM and improves with activity • Enthesopathy (pain and inflammation at site of muscle insertion) • Systemic symptoms (fever, weight loss) • Skin or eye symptoms • X-ray—absence of osteophytes • Elevated ESR or CRP • Joint fluid with WBC 2,500-5,000/mm3 • Tx NSAIDS, exercise, may need anti-rheumatic meds

23. Bursitis • Trochanteric Bursitis • Most commonly injured bursa in the hip • Caused by falls onto the lateral hip, overuse injuries esp in runners and dancers • Bursa over the ischial tuberosity • Caused by a fall on the buttock • Iliopsoas (iliopectineal bursa) • Anterior groin pain that is worse with resisted hip flexion

24. Nerve Compression • Sciatic nerve • L4-5, S1-S3 • Compression by the piriformis muscle • Dull ache in the buttock that may radiate down posterior thigh • Females >males • Spine X-rays to differentiate from nerve root compression in the lumbosacral spine

25. Nerve Compression • Lateral femoral cutaneous nerve • Compressed as it passes under the inguinal ligament, esp in obese patients • Meralgia paresthetica • Numbness or pain over the anterolateral thigh

26. Osteitis Pubis • Pain and bony erosion of the symphysis pubis • More common in soccer, rubgy, tennis and ice-hockey players • Males > females • Pain over the pubic area that radiates laterally across the anterior hip • Aggravated by striding, kicking, pivoting

27. Osteitis Pubis • X-rays may show symphysis widening, cystic changes, sclerosis; check “flamingo view” • Tx is hip adductor and rotator stretching exercises

28. Acetabular Labral Tears • Activity-related sharp groin and anterior thigh pain that is worse with extension • Deep clicking sensation • Feel that the hip is “giving way” • Sx for >6 months • May have clicking palpated on Thomas test • Imaging may not be helpful • Hip arthroscopy is gold standard

29. Clinical Case 1 • 37 yo WF w/ no PMH presents c/o pain over her left hip and left lateral thigh down to the knee • Pain is worse when she gets up from a seated position but then feels better after she takes a few steps • However, pain can recur after she has been walking for ~20 minutes • Pt likes to run and do yoga

30. Clinical Case 1 • On PE VS are normal • Pt’s hip exam shows tenderness over the left lateral greater trochanter • Pt also has discomfort with external rotation on the left

31. Clinical Case 1 • What is your leading dx? • What tests would you like to order? • +/-X-ray • What tx would you give? • NSAIDS • Iliotibial band stretching program • Corticosteroid injection into greater trochanteric bursa

32. Clinical Case 2 • 45 yo WF with h/o HTN and DM presents c/o gradual onset of pain in the right thigh and groin area over the past 6 mths. • Initially pain was only with walking but now pain occurs at rest. • Pt c/o 10 minutes of stiffness when she awakes

33. Clinical Case 2 • VS are normal except pt’s weight is 167 lbs and BMI is 32 • Pt has an antalgic gait • Pt has good strength and reflexes • Straight leg raise is negative B • ROM of right hip is intact except for loss of internal rotation compared to the left

34. Clinical Case 2 • What is your leading dx? • Osteoarthritis • What tests would you order?

35. Clinical Case 2 • What treatment would you give? • Physical Therapy for exercises and to evaluate need for walking device • Acetaminophen or NSAID • Total hip replacement

36. Bibliography • O’Kane, J. Anterior Hip Pain. American Family Physician 1999; 60 (6). • Adkins, S and Figler, R. Hip Pain in Athletes. American Family Physician 2000; 61 (7). • Snider, Robert. Essentials of Musculoskeletal Care 1997.