The Painful Hip. Jennifer R Marks, MD

Transcription

1 The Painful Hip Jennifer R Marks, MD

2 The Painful Hip A 64 yo F presents to clinic complaining of a sore hip What further questions do you have for this patient? What is on your differential diagnosis? 2

3 Hip Anatomy EDSsQ_AUICigB&biw=1920&bih=963#imgdii=e85AbOJ2CkXSkM:&imgrc=8uNVEo6UmMiwrM: 3

4 Hip Physical Exam Inspect, anterior & posterior views Palpate Range of motion Strength and sensation (neuro) testing Gait FABER test (flexion-abduction-external rotation) tests for hip and sacroiliac pathology 4

5 The Painful Hip Anterior Lateral Posterior 5

6 The Painful Hip (anterior) Osteoarthritis Presentation Age related Symptoms include pain after activity, stiffness Pain sometimes referred toward the knee Progressive 6

7 The Painful Hip (anterior) Osteoarthritis Exam findings Pain with flexion Pain with external and internal rotation as well as abduction Antalgic gait 7

8 The Painful Hip (anterior) Osteoarthritis AP & lateral films of affected side (above is pelvis view for demonstration purposes) Worn articular cartilage imgrc=n6ddcguxq3_lgm: 8

9 The Painful Hip (anterior) Osteoarthritis Treatment NSAIDs, etc Cane (hold on good side!) ROM exercises, ideally non-weight-bearing including aqua therapy THR 9

10 The Painful Hip (anterior) Avascular Necrosis Presentation Gradual onset Usually a co-morbid condition SCD, gout, CKD, chronic steroids, ETOH Post-traumatic 10

11 The Painful Hip (anterior) Avascular Necrosis Exam findings Antalgic gait Pain on ROM Diagnosis Joint space preserved, but femoral head may become collapsed at end-stage Requires MRI to fully assess Treatment Pain management & THR 11

12 The Painful Hip (anterior) Pelvic fracture Presentation Pain in pelvis, groin, ilium, or buttock Exam Findings Point tenderness, bruising, possibly non-weightbearing Diagnosis X-ray, although occult fractures may require MRI Treatment Depends on degree of instability; NSAIDs, protected weight-bearing vs surgical intervention 12

13 The Painful Hip (lateral) Trochanteric bursitis Presentation Pain with pressure over area Pain often radiates toward knee Exam Findings Point tenderness Treatment Avoid pressure to area, NSAIDs, heat, steroid injection 13

14 The Painful Hip (lateral) mgrc=_mqy1wuy0btqem: 14

15 The Painful Hip (lateral) Lateral Cutaneous Femoral Nerve Syndrome (aka meralgia paresthetica) Presentation Anterolateral thigh hyperesthesia, burning/tingling Symptoms often relieved by rest, hip flexion Patient may be obese or wears tight clothing 15

16 The Painful Hip (lateral) Lateral Cutaneous Femoral Nerve Syndrome (aka meralgia paresthetica) Exam Findings Slight decrease in sensation may be elicited Consider abdominal and pelvic exam to evaluate for mass lesion that may be causing compression Treatment May resolve spontaneously Weight loss, loose clothing, injection of nerve distal to inguinal ligament 16

17 The Painful Hip (posterior) Gluteal hip pain is the least common pain pattern; ie, probably not the hip joint itself Differential diagnosis includes sacroiliac joint pathology, lumbar radiculopathy, herpes zoster, piriformis syndrome Likely requires imaging to determine underlying cause 17

18 References Essentials of Musculoskeletal Care, WB Greene, Ed, 2 nd edition Practical Orthopedics, LR Mercier, 5 th edition Uptodate.com 18