Hip pain differential diagnosis synovitis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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The many causes of hip pain are documented in other pages on this web site.

Of these many causes of hip pain, only a few are associated with synovitis or inflammation of the joint capsule of the hip joint.

Transient synovitis is the most common cause of hip pain in children. Transient synovitis usually occurs in children between the ages of 2 to 10 years of age, favoring boys, usually affecting one hip. It is characterized by pain in the hip, groin and inner thigh, limping, difficulty with walking or standing, decreased range of motion of hip joint, and low-grade fever. Although the cause is unknown, it is believed that viral infections or minor injuries cause inflammation of the synovial membrane.

Transient synovitis is important because it is similar to early stages of other conditions such as tuberculous arthritis and Legg-Calve-Perthes disease.

A high fever is suggestive of other diseases.

X-rays are usually normal in transient hip synovitis. In blood tests, an ESR can be slightly elevated. X-Rays and blood tests help to rule out other diseases. If other diseases are suspected, further tests are required.

The pain usually goes away within a few weeks.

Septic arthritis is a medical emergency. In this situation, a patient will have severe pain in the groin and will be unable to move the hip. Fever and chills will also be common. Joint fluid will reveal evidence of infection. In most cases, surgery to drain the hip is required.

The hip is the second most common location for pigmented villonodular synovitis. It starts with deep monoarticular pain lasting several months. The pain is alleviated by rest. Patients feel pain in the anterior groin or the lateral hip. The pain is frequently intermittent.

X-rays show bony erosions in the head and neck of the femur and acetabulum in 95 percent of patients.

MRI is highly sensitive and specific for the diagnosis of pigmented villonodular synovitis of the hip.

Pigmented villonodular synovitis should be considered in the differential diagnosis of patients from 20 to 45 years of age who have one-sided hip pain. Most patients with this disease have a long history of pain and disability. The presence of nontraumatic effusions of the hip or knee are suspicious.

The diagnosis of pigmented villonodular synovitis is confirmed by biopsy of the synovium. The treatment of choice is synovectomy.

Diffuse pigmented villonodular synovitis has a high rate of local recurrence.

Rheumatoid arthritis can also affect the hip. This disease affects joints in a symmetric fashion. On exam, the patient has pain in the groin with limited range of motion because of pain. Patients will often hold the hip in slight flexion. MRI scanning may help establish the presence of synovitis. As with any painful inflamed joint it is mandatory to rule out an infection so arthrocentesis of the hip should be performed prior to injecting steroids.

Juvenile forms of rheumatoid arthritis, unlike the adult form, favor the hip. Pediatric rheumatology evaluation is recommended.

Spondyloarthropathies (inflammatory forms of arthritis that may affect the spine) such as psoriatic arthritis and Reiter’s disease may also affect the hip and cause hip pain with synovitis. This group of diseases tends to affect the hip often. The key here is differentiating hip disease which usually presents with pain in the groin as opposed to sacroiliac disease or lumbar spine disease which may cause symptoms in the buttock region.

Crystal-induced forms of arthritis such as gout and pseudogout may also affect the hip and cause synovitis and effusion (excess synovial fluid). Aspiration of fluid from the hip will help establish the diagnosis. Anti-inflammatory medication, steroid injection, and uric acid lowering therapy in the case of gout will benefit as well.

Osteoarthritis of the hip presents in middle-aged or older people. When severe, it will cause pain that is due to a combination of mechanical factors as well as synovitis. Groin pain and limited internal rotation will be the major clues to diagnosis. Patients will often have difficulty getting their shoes and sox on and off. The diagnosis is made clinically and confirmed by x-ray. Treatment may consist of anti-inflammatory medication as well as physical therapy and stretching exercises. End stage disease- defined as disease that causes intractable pain or marked limitation of activities of daily living- will require hip joint replacement.

Loose bodies- pieces of cartilage or bone that break off and migrate around in the joint- may cause hip pain and synovitis. Symptoms include pain, particularly with weight-bearing. Diagnosis can be confirmed by MRI. Arthroscopic treatment may be helpful.

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