Hip pain differential diagnosis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a 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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There are many causes for hip pain. When patients complain of hip pain, they are not always pointing towards their hip. And because this “hip pain” is so ill-defined, the diagnosis is not always easy to make. Let me explain...

The hip is a ball and socket joint. The “ball” is the head of the femur (lower leg bone) and the socket is the acetabulum- a part of the pelvis.

The hip is held in place with ligaments, tendons, and muscles. It is surrounded by a series of bursae which are fluid filled sacs designed to cushion the area.

Hip pain may arise from the joint itself, the femur, the pelvic bone, the pelvis, blood vessels and nerves near the hip joint, and even the abdomen.

It is important to differentiate true hip pain from other types of pain in the hip region. True hip pain is felt towards the front, in the groin region. It may radiate down the front of the thigh.

Pain felt in the buttock is usually referred from the low back. It may also come from the sacroiliac joint, bursitis, or arterial insufficiency (lack of normal blood flow due to atherosclerosis [hardening of the arteries]).

Disorders involving structures adjacent to the hip include various types of bursitis and tendonitis.

Pain felt on the lateral part of the hip (outside of the hip) is usually due to trochanteric bursitis. It is aggravated by activity, lying down on the affected side, and crossing the leg of the affected side.

Other forms of hip pain include pyriformis syndrome, enthesopathy of the obturator internus, and gluteus medius origin pain. All of these need to be evaluated under ultrasound guidance to make a correct diagnosis.

Bursitis in the bottom part of the hip (ischiogluteal bursitis) can cause pain in the lower buttocks that is aggravated by sitting. This is also known as “weaver’s bottom.”

The groin region of the hip has many other bursae and these can become inflamed, leading to severe pain. The pain is aggravated by flexion and extension of the hip.

The most common cause of hip pain in older individuals is osteoarthritis. They will complain of pain in the groin or front of the thigh and will have difficulty getting their shoes and sox on and off because of the reduced ability to externally rotate their hip. Internal rotation is also severely limited as well.

Sometimes the acetabulum (the cup part of the pelvis that articulates with the femur) may be damaged and torn. This will also cause significant pain.

Sometimes loose pieces of cartilage can break off and cause pain within the hip joint as well. These pieces are called “loose bodies.”

Patients with inflammatory forms of arthritis such as rheumatoid arthritis, psoriatic arthritis, reactive arthritis, ankylosing spondylitis, infection, and crystal induced disorders will also have severe pain in the groin. They will have significant pain with weight bearing. Limitation of internal and external rotation will be quite evident.

Avascular necrosis (AVN) refers to a condition where the head of the femur dies due to lack of blood flow. This may occur as a result of injury, high dose steroids, or blood disorders such as sickle-cell anemia. Patients who have AVN complain of severe pain, especially at night. The diagnosis is made by magnetic resonance imaging. Early treatment consists of core decompression. Later treatment involves surgery to replace the head of the femur.

Fractures of the hip and pelvis due to osteoporosis may also cause pain in the hip and groin. These are termed insufficiency fractures. Often they are missed by plain x-ray. Magnetic resonance imaging or bone scanning are often required for diagnosis.

Pelvic and abdominal problems that cause hip pain are aneurysm of the aorta, pelvic inflammatory disease, kidney stones, and swollen lymph nodes.

Pain radiating to the hip may arise from degenerative arthritis or degenerative disc disease in the spine, inflammation of the sacroiliac joints, and pinched nerves.

This latter problem can cause great confusion. Pinched nerves in the T12 to L1 level can cause pain in the buttock and outside part of the hip. Pinched nerves in the L2 to L4 level can cause pain in the groin or front of the thigh- mimicking hip disease.

Pain in the front of the hip and thigh can also be caused by bursitis, tendonitis, hernia, fracture, or kidney stone.

Physical examination can point to the correct diagnosis. The skilled physician will evaluate range of motion as well as those factors which reproduce the pain. Careful evaluation of the abdomen is indicated to rule out diseases and conditions that can cause hip pain such as aneurysm or hernia. Local tenderness may suggest bursitis. Examination of the low back may show that the origin of the pain is the low back rather than the hip.

Laboratory analysis may provide clues to an underlying inflammatory condition. For instance, an elevated erythrocyte sedimentation rate (ESR) could point towards an inflammatory cause. Patients with suspected infection of the hip joint will require aspiration of fluid from the hip joint for proper diagnosis.

X-rays seldom are helpful other than to detect fracture or for documentation in preparation for hip replacement surgery. Magnetic resonance imaging, on the other hand, may be very helpful for diagnosis.

Treatment is dependent on the diagnosis. Treatment for an arthritis condition will involve anti inflammatory medication and, in the case of inflammatory arthritis, and disease modifying drugs. Thermal modalities (heat and cold), physical therapy, and glucocorticoid injections may be helpful. Viscosupplement injections (lubricants such as Hyalgan, Synvisc, Supartz) have been used with varying degrees of success.

Recently, autologous (a patient's own) stem cells have been used with varying degrees of success as a treatment for osteoarthritis. Refinements of the technique look very promising. Further work is needed.

Surgery is indicated for patients who have fracture or end stage arthritis.

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