Hip and Thigh Pain Arthur Jason De Luigi, DO Program Director, Sports Medicine Fellowship Director, Sports Medicine Director, Interventional Pain MedStar National Rehabilitation Hospital MedStar Georgetown University Hospital Medical Director and Head Team Physician US Paralympic Alpine Ski Team
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Hip and Thigh Pain Arthur Jason De Luigi, DO Program Director, Sports Medicine Fellowship Director, Sports Medicine Director, Interventional Pain MedStar.
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Hip and Thigh Pain
Arthur Jason De Luigi, DO
Program Director, Sports Medicine FellowshipDirector, Sports Medicine
Director, Interventional PainMedStar National Rehabilitation HospitalMedStar Georgetown University Hospital
Medical Director and Head Team PhysicianUS Paralympic Alpine Ski Team
Disclosures
• Nothing to Disclose
Overview
• Epidemiology• Hip and Thigh Anatomy• Physical Examination• Diagnostic Imaging• Pathology• Treatment
Incidence
• Hip and Thigh pain are very commonly the chief complaint of office visits– Account for 0.61% of all visits– About 1 in every 164 encounters
• Runners report an average yearly hip or pelvic injury rate of 2% to 11%.
Incidence
• NHANES III– 14.3% of patients aged 60 years and older
reported significant hip pain on most days over the previous 6 weeks.
– 18.4% of those who had not participated in leisure time physical activity during the previous month reported severe hip pain
– Opposed to 12.6% of those who did engage in physical activity
Common Hip Problems by Age• Newborn
– Congenital dislocation of hip• Age 2-8
– AVN of hip (Legg-Calve-Perthes), synovitis• Age10-14
• Negative power color Doppler does not exclude infection*
• Guided aspiration
– AJR 1998; 206: 731
Transient Hip Synovitis
• Anterior • Longitudinal
Acute Transient (“Toxic”) Synovitis• inflammatory process of hip w/ chronic irritation
and excess secretion of synovial fluid within the capsule; ? cause
• Most common dx in limping child <10, but it’s a Dx of exclusion; – r/o septic arthritis, SCFE, stress fx, etc.– Xrays normal; MRI helpful ruling out other causes– Labs: normal CBC, CRP
greater troch– S/Sx: sudden pain +/- pop, poor ROM, local pain and TTP
+/- muscle bulging away from the attachment
• Xrays needed to eval size/displacement• Tx: PRICEMM, progressive rehab
– Ortho referral if displacement >2 cm
Slipped Capital Femoral Epiphysis (SCFE)
• Slippage of femoral epiphysis laterally off femoral head– Most prevalent ages 9-15, esp overweight– Bilateral up to 50%
• S/Sx: insidious poorly localized hip/groin pain +/- radiation to knee, worse w/ activ– May have limited IR
• Xrays usually diagnostic; MRI early if neg but dz suspected
• Tx: immed NWB, Ortho referral, surgery
Kline’s Line: tangent to superior femoral neck on AP view
Normal transsection of physis
Abnormal: Less or no transsection of physis
Legg-Calve-Perthes
• Avascular necrosis of proximal femoral epiphysis– Most prevalent ages 4-9, males 4:1– Develops slowly
• S/Sx: intermittent deep hip pain worse w/ activity, +/- radiating to groin, ant/med thigh, knee; – limping, decreased ROM, and hip flexor tightness may be
noted• Xrays usually diagnostic: MRI or BS early if xray neg
but AVN suspected• Tx: Ortho referral; crutches, pain meds
• Contusion to the iliac crest• S/Sx: pain, swelling, and
ecchymosis– severe limit to motion– +/- palpable hematoma
• Xrays to r/o fractures• TX: rest, ice, compression, ?
benefit from steroid/lido inj after acute phase, progressive ROM, strength rehab
• RTP: padding over area
Trochanteric Bursitis
• Located in posterolateral aspect of greater trochanter– Located over the posterior and lateral facets of GT– Deep to the gluteus maximus and Iliotibial tract
• Abnormal bursal distention of trochanteric bursa in lateral hip
Trochanteric bursitis• Causes:
– friction between IT band, glut medius/minimus/max and greater trochanter; common in running w/ improper biomechanics and overtraining
– direct blows• S/Sx:
– local pain, tenderness over the greater trochanter
– Eval for leg length discrep, adductor/abductor muscle imbalance, hyperpronation
References• Birrer R. and O’Connor F. Sports Medicine for the Primary Care
Physician. Boca Raton: CRC Press, 2004.• Greene W. Essentials of Musculoskeletal Care. Rosemont:
American Academy of Orthopaedic Surgeons, 2001.• Hoppenfeld S. Physical Examination of the Spine and
Extremities. East Norwalk: Appleton-Century-Crofts, 1976;59-74.
• Lillegard W. Evaluation of Knee Injuries. In W Lillegard (ed), Handbook of Sports Medicine. Boston: Butterworth-Heinemann, 1999: 233-249.
• Netter F. Atlas of Human Anatomy. West Caldwell: CIBA-Geigy, 1989.
• Tandeter H. et al. Acute Knee Injuries: Use of Decision Rules for Selective Radiograph Ordering. American Family Physician. Dec 1999; 60: 2599-608. (For Radiograph Images)
References
• ACR practice guidelines for the performance of the musculoskeletal ultrasound examination– Nazarian et al.