Hip and Buttock Pain

dr. Meike Magnasofa

NDT 2008

Some bony anatomical areas worth noting:1) Anterior superior iliac spine 2) Anterior inferior iliac spine 3) Pubic tubercle

4) Pubic symphysis 5) Superior pubic ramus 6) Inferior pubic ramus 7) Greater trochanter 8) Lesser trochanter 9) Femur 10) Head of femur 11) Ischial spine

12) Ischial tuberosity 13) Sacroiliac joint 14) Posterior inferior iliac spine 15) Crest of ilium

Hip Pain

• Hip joint pain is mostcommonly felt in the groinand anteromedial aspect of the upper thigh, usually described as a deep aching pain, aggravated by movement

• Hip joint pain may radiate

to the knee (sometimes exclusively around the knee)

• Pain over the greatertrochanter is typicallytrochanteric bursitis

Hip Pain

Inflammatory disorders of the hip joint:

• Rheumatoid arthritis• Juvenile chronic arthritis (JCA)• Rheumatic fever (a flitting

polyarthritis)• Spondyloarthropathy

Childhood disorders:• Developmental dysplasia of the

hip (DDH) • Congenital subluxation of hip and

acetabular dysplasia• Perthes' disorder (pseudocoxalgia

or coxa plana)• Septic arthritis• Slipped capital femoral epiphysis

(adolescent; coxa vara))• Stress fractures of the femoral

neck• Transient synovitis

Comparison of important causes of hip pain in children

.DDH Transient

synovitis

Perthes' SCFE Septic arthritis

Age (yrs) 0-4 4-8 4-8 10-15 Any

Limp + + + + Won’t walk

Pain - + + + +++

Limited movemnt

Abduction All, esp abduction and IR

Abduction and IR

All esp IR All

Plain

X-ray

• Normal or dislocation• No diagnostic value on neonatal period (use USG)

Normal Subchondral

fracture

• Dense head

• Pebble stone

epiphysis

AP may be

normal

• Frog view

shows slip

Normal

Use Ultrasound

Hip Exam 1

• Exam of any joint: LOOK, FEEL, MOVE, MEASURE, TEST FUNCTION, LOOK ELSEWHERE & X-RAY

Inspection• Walking with a limp, the leg

adducted & foot externally rotated: osteoarthritis of hip joint

• Accident: shortened & externally rotated: neck femur fracture (a)

• Hip internally rotated: posterior dislocation (b)

• Hip externally rotated: anterior dislocation

Hip exam 2

Palpation

Feel one to two finger-breadths

below the midpoint of the inguinal

ligament for joint tenderness.

Check for trochanteric bursitis,

gluteus medius tendinitis and

other soft tissue problems over

the most lateral bony aspect of

the upper thigh.

Movement

• Range of Motion:– Flexion/ Extension– Internal/ External Rotation– Abduction/ Adduction• Check in several positions• Compare with the contralateral

side• Neurovascular exam

Passive movements (patient supine):• flexion (compare both sides) 140°• external rotation (knee and hip

extended in adults) 45-50°• internal rotation (knee and hip

extended in adults) 45°• abduction (stand on same side—

steady pelvis) 45°• adduction (should see the patella

of the opposite leg) 25°

Hip Range of Movement 1

FLEXIONHave the patient flex their knees & move their hip joint into the flexed position as fair as possible. (Normal range ~ 120 degree)

(If you keep the knee extended the range of movement in the hip joint is limited by tension in the hamstring muscles)

Hip Range of Movement 2

ABDUCTIONMake sure you stabilze the pelvis by placing a hand on the opposite anterior iliac crest and holding the ankle with the other hand. The hip is abducted until the pelvis tilts. (Normal range of movement ~ 45 degrees)

Hip Range of Motion 3

ADDUCTION

Cross one leg over the other until pelvis begins to tilt. (Normal range of movement ~ 30 degrees)

Hip Range of Movement 4

INTERNAL ROTATION

Flex the hip and knee to 90 degrees.

Now move the leg laterally.

(Normal range of movement ~ 45

degrees)

Hip Range of Movement 5

EXTERNAL ROTATION

Again with the hip and knee flexed move the patients leg medially.

(Normal range of movement ~ 60

degrees)

Hip Range of Movement 6

EXTENSION

Have the patient lie prone

on the couch. Immobilise the pelvis

with one hand while extending the hip

with the other hand

Hip Exam 3

Measurements

True Length of the legs

Measure the distance

between the anterior

iliac spine to the tip of the

medial mallous, with the

anterior spines lying at the

Same transverse level.

Compare to the other side.

Measurements

The apparent length

is measured from the

xiphisternum to the tip of the

medial mallous, with the legs in a

parallel position. Compare.

Note:• Unequal true leg length =

hip disease on shorter side.• Unequal apparent leg length =

tilting of pelvis

Hip Exam 3Test function & special tests

Trendelenburg test:• Detects weakness of the

gluteus medius hip abductors.• This can be due to true

weakness as in neurological disease or wasting associated with hip arthritis or to painful reflex inhibition.

• In an adult the commonest cause of a positive test is osteoarthritis of the hip.

• Ask the patient to stand on each leg in turn. Observe the pelvis for any tilt. In normal individuals the pelvis will rise on the side of the leg that has been lifted. With instability, the pelvis may drop on the side of the leg that has been lifted. Repeat on the other side.

Thomas test:tests for fixed flexion deformity

• To detect occult hip flexion contracture: Have patient flex right knee and pull firmly against abdomen. This flattens the normal lumbar lordosis.

Note: Degree of flexion of left hip(negative test: If hip remains on table, positive test: if hip flexes and thigh is off the table) Repeat for left hip

Trendelenberg Test

• Negative Trendelenberg • Positive Trendelenberg

Thomas Test• Place your hand behind the

small of the patient’s back, between it and the couch. There is normally a small gap here due to normal lumbar lordosis. Abolish the lumbar lordosis by asking the patient to flex the hip and feel the lumbar spine flatten out onto your hand. When you are happy that the lumbar spine is flat, see if the patient’s other knee is flat on the couch. If not, measure the angle of (fixed) hip flexion. Then repeat the test asking the patient to clasp their other knee up against their chest and observe for fixed flexion deformity in the previously flexed hip

Hip Exam 4

Look elsewhere

Examine

lumbosacral spine, sacroiliac joints,

groin and knee.

Consider hernias and possibility of PID

 

Hip x-ray

Loss of joint space, subchondral bone cysts, subchondral sclerosis & osteophyte formation

A left total hip replacement

Buttock Pain• Common causes presenting in GP is a referred pain

from the lumbosacral spine and the sacroiliac joints.• Common causes of muscular and ligamentous strains:

Trauma and overuse injuries from sporting activities• The hip joint is a common target of osteoarthritis, usually

presents after 50 years.

‘Hip pocket nerve' syndrome

Patient presents with 'sciatica', especially confined to the buttock and upper posterior thigh (without local back pain), the possibility of pressure on the sciatic nerve from a wallet in the hip pocket. This problem is occasionally encountered in people sitting for long periods in cars (e.g. taxi drivers). It appears to be related to the increased presence of plastic credit cards in wallets

Osteoarthritis of the hip

Clinical features• equal sex incidence• after 50, increases with age• may be bilateral: starts in one• insidious onset• at first, pain worse with activity,

relieved by rest, then nocturnal pain and pain after resting

• stiffness, especially after rising• characteristic deformity• stiffness, deformity and limp may

dominate (pain mild)• pain usually in groin—may be

referred to medial aspect of thigh, buttock or knee

Physical examination• abnormal gait• gluteal and quadriceps wasting• first hip movements lost are IR

and extension• hip held in flexion and ER (at first)• eventually all movements affected• order of movement loss is IR,

extension, abduction, adduction, flexion, ER

Treatment• Conservative• Surgery :Total hip replacement (elderly)Femoral osteotomy (younger)

Sacroiliac pain• a dull ache in the buttock, can

be referred to the groin or posterior aspect of the thigh.

• unilateral or bilateral.• no neurological symptoms • severe cases cause a heavy

aching feeling in the upper thigh.

Causes of sacroiliac joint disorders

• inflammatory (the spondyloarthropathies)

• infections, e.g. TB, Staphylococcus aureus (rare)

• osteitis condensans ilii• degenerative changes• mechanical disorders• post-traumatic, after sacroiliac

disruption or fracture

Examination of the sacroiliac joints

• Patrick or Fabere test.

Gluteus medius tendinitis and trochanteric bursitis

• Pain around the lateral aspect of the hip radiating down to the thigh.

• Distinction between these two conditions is difficult: the pain of bursitis tends to occur at night, tendinitis occurs with such activity as long walks and gardening.

• Treatment is similar:1. Determine the points of maximal tenderness over the trochanteric region and mark them. (For tendinitis, this point is immediately above the superior aspect of the greater trochanter2. Inject aliquots of a mixture of 1 mL of long-acting corticosteroid with 5-7 mL of LA into the tender area, which usually occupies an area similar to that of a standard marble.

Snapping or clicking hip• Painless but annoying

Causes• a taut iliotibial band (tendon or

tensor fascia femoris) slipping backwards and forwards over the prominence of the greater trochanter or

• the iliopsoas tendon snapping across the iliopectineal eminence

• the gluteus maximus sliding across the greater trochanter

• joint laxity

• Treatment: Exercise 1-2 minutes twice daily to produce stretching sensation along the lateral aspect of the thigh