Evaluation of the adult with hip pain
- Bruce C Anderson, MD
Bruce C Anderson, MD
- Associate Professor of Medicine
- Oregon Health Sciences University
Hip pain is a common symptom with a number of possible causes . In a survey of 6596 adults ages 60 years and older, 14.3 percent reported significant hip pain on most days over the past six weeks .
Trochanteric and gluteus medius bursitis, osteoarthritis, and fractures of the femur are the most common conditions affecting the hip. The character and location of the pain, the movement and positions that reproduce the pain, and the affect on ambulation can be used to distinguish the conditions affecting soft tissues from disorders affecting the hip joint and adjacent bones.
This review will provide a general approach to the evaluation of patients with hip pain. More in-depth discussions of the diagnosis and treatment of specific disorders of the hip are found separately. The diagnostic approach to hip pain in children is discussed elsewhere. (See "Overview of hip pain in childhood".)
The hip joint is formed by the rounded head of the femur and its articulation with the acetabulum. The latter is formed by the union of the ilium, ischium, and pubis. The hip joint is a ball-and-socket joint that is relatively fixed to the body by the pelvic girdle. Because of this relative immobility, a primary abnormality of the hip or pelvis can cause symptoms in the lumbar spine or knee, and a primary abnormality in the lumbar spine or knee may cause a secondary abnormality in the hip .
The femoral neck is approximately 8 to 10 cm in length. Two bony prominences project from the femoral neck: the greater trochanter laterally and the lesser trochanter medially. The greater trochanter is the site of attachment for the abductor muscles (gluteus medius and gluteus minimus) and the external rotators of the hip. The main hip extensors are gluteus maximus and the hamstrings; the former attaches to the proximal femur, just distal to the greater trochanter. The lesser trochanter is the attachment site for the major hip flexor, the iliopsoas muscle.
- Anderson BC. Office Orthopedics for Primary Care: Diagnosis and Treatment, 2nd, WB Saunders, Philadelphia 1999.
- Christmas C, Crespo CJ, Franckowiak SC, et al. How common is hip pain among older adults? Results from the Third National Health and Nutrition Examination Survey. J Fam Pract 2002; 51:345.
- Steinberg GG, Seybold EA. Hip and pelvis. In: Orthopaedics in Primary Care, 3rd, Steinberg GG, Akins CM, Baran DT. (Eds), Lippincott Williams and Wilkins, Baltimore 1999.
- Swezey RL, Spiegel TM. Evaluation and treatment of local musculoskeletal disorders in elderly patients. Geriatrics 1979; 34:56.
- Altman R, Alarcón G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 1991; 34:505.
- Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am 1995; 77:459.
- Zizic TM, Marcoux C, Hungerford DS, Stevens MB. The early diagnosis of ischemic necrosis of bone. Arthritis Rheum 1986; 29:1177.
- LaPorte DM, Mont MA, Mohan V, et al. Multifocal osteonecrosis. J Rheumatol 1998; 25:1968.
- Moder KG, Hunder GG. Examination. In: Textbook of Rheumatology, 5th, Kelly WN, Harris ED, Ruddy S, et al. (Eds), WB Saunders, Philadelphia 1997. p.364.
- Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992; 268:760.
- Cardinal E, Chhem RK, Beauregard CG. Ultrasound-guided interventional procedures in the musculoskeletal system. Radiol Clin North Am 1998; 36:597.
- ETIOLOGY AND PRESENTATION
- Pain patterns
- - Lateral hip pain aggravated by direct pressure
- - Lateral hip pain associated with paresthesias and hypesthesias
- - Anterior hip or groin pain
- - Posterior hip pain
- - Lower anterior thigh pain
- Differential diagnosis
- - Trochanteric bursitis
- - Hip osteoarthritis
- - Meralgia paresthetica
- - Osteonecrosis
- - Occult hip fracture
- - Aortoiliac vascular occlusive disease
- - Referred pain from the lumbosacral spine or sacroiliac joint
- Overall hip function
- - Gait
- - Position change
- - Inspection for pelvic obliquity
- Maneuvers assessing specific conditions
- - Internal and external rotation
- - Patrick (Fabere) test
- - Palpation of the trochanteric bursa
- - Sensation of the anterolateral thigh
- - Straight leg raise
- - Lower extremity neurologic examination
- - Palpation of the sacroiliac joint
- - Palpation of lower extremity pulses
- CONFIRMATORY MANEUVERS AND PROCEDURES
- - Weight bearing AP pelvis x-ray
- - Magnetic resonance imaging
- - Radionuclide bone scan
- - Ultrasonography
- Local anesthetic block
- Hip aspiration
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS