How to outsmart hip pain
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.
Click here: Second Opinion Arthritis Treatment Kit
Hip pain is common ...and confusing when it comes to diagnosis.
The hip is a true 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 hardening of the arteries).
Pain felt on the lateral part of the hip (outside of the hip) is usually due to trochanteric bursitis or gluteal tendinopathy. It is aggravated by activity, lying down on the affected side, and crossing the leg of the affected side.
Bursitis in the bottom part of the hip (ischiogluteal bursitis) can cause pain in the lower buttocks that is aggravated by sitting.
There are many causes of pain in the hip. The most common degenerative mechanical cause is osteoarthritis. A typical patient will be older. 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.
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.
Disorders involving structures adjacent to the hip include various types of bursitis and tendonitis. Among the many types of bursitis and tendonitis that can develop include trochanteric bursitis, iliopsoas bursitis, pyriformis and obturator internus entheopathy, and gluteus medius insertional muscle insertional pain. The distinction should be made by an experienced clinician.
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 for fracture or for revealing end stage hip disease as a 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, disease modifying drugs. Thermal modalities (heat and cold), physical therapy, and glucocorticoid injections may be helpful. For gluteal tendinopathy, ultrasound-guided needle tenotomy with platelet-rich plasma is the treatment of choice.
Surgery is indicated for patients who have fracture or end stage arthritis.
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