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 most commonly felt in the groin and 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 greater trochanter is typically trochanteric bursitis

Hip Pain
Inflammatory disorders of the hip joint: 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

Rheumatoid arthritis Juvenile chronic arthritis (JCA) Rheumatic fever (a flitting polyarthritis) Spondyloarthropathy

Comparison of important causes of hip pain in children

DDH

.
Age (yrs) Limp Pain Limited movemnt 0-4 + Abduction

Transient synovitis
4-8 + + All, esp abduction and IR Normal

Perthes'

SCFE

Septic arthritis
Any Wont walk +++ All

4-8 + + Abduction and IR

Subchondral fracture Dense head Pebble stone epiphysis

10-15 + + All esp IR

Plain X-ray

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

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

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

the most lateral bony aspect of

the upper thigh.

Hip Range of Movement 1

FLEXION Have 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

ABDUCTION Make 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

ADDUCTION

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

Hip Range of Movement

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

EXTERNAL ROTATION

Again with the hip and knee flexed move the patients leg medially. (Normal range of movement ~ 60 degrees)

Hip Range of Movement

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
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

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 3

Test 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 patients 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 patients 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 groinmay 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
Examination of the sacroiliac joints

Patrick or Fabere test.

inflammatory (the spondyloarthropathies) infections, e.g. TB, Staphylococcus aureus (rare) osteitis condensans ilii degenerative changes mechanical disorders post-traumatic, after sacroiliac disruption or fracture

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 trochanter 2. 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