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

– Slipped Cap Fem Epiphysis• Age 14-25

– Stress Fracture• Age 20-40

– Labral Tear• Age >40

– Osteoarthritis

Anatomy

• Bones– Pelvis

• Ilium• Ischium• Pubis• Sacrum

– Femur

Anatomy

Anatomy

Anatomy

Anatomy

Anatomy• Anterior

– Iliopsoas– Quadriceps

• Vastus Medialis• Vastus Intermedius• Vastus Lateralis• Rectus Femoris

– Sartorius• Medial

– Adductor Magnus– Adductor Longus– Adductor Brevis– Gracilis

• Posterolateral– Piriformis– Gluteus Maximus– Gluteus Medius– Gluteus Minimus– Tensor Fascia Lata

• Iliotibial Band

Physical Examination

Anterior Hip Pain• Examination

– Inspection• Walking/Gait• Pelvic position/splinting• Atrophy/ecchymosis/bony deformity

– Palpation– ROM

• Flexion/extension/internal/external rotation• Strength

– Special Tests• FABER• FADIR

Thomas test• Snapping Hip Test• Hernia exam

Range of Motion

• Flexion: 110 to 120 degrees

• Extension: 10 to 15 degrees

Range of Motion

• Abduction: 30 to 50 degrees

• Adduction: 30 degrees

Range of Motion

• External rotation: 40 to 60 degrees

• Internal rotation: 30 to 40 degrees

Special Tests

• modified Thomas Test– hip flexor and quad flexibility

Special Tests

• Patrick’s Test(FABER)– hip joint – SI joint

Special Tests

• Labral Injury– FADIR: – Flexion, Adduction,

Internal Rotation• Axial Loading• pain +/- click

Lateral Hip Pain

• Examination– Special Tests

• Ober Test• Trendelenberg Test

Special Tests

• Ober Test– iliotibial band flexibility

Posterior Hip Pain

• Examination– ROM– Leg Length– Neurologic

• Reflex• Strength• Sensory

– Special Tests• Piriformis• FABER (Patrick)• Gaenslen’s• Gillet• Fortin• Facet Loading• Straight Leg Raise• Reverse SLR

Range of Motion

• Lumbar Range of Motion– Flexion – 80o

– Extension – 35o

– Lat Bend – 40o

– Rotation – 3-18o

Special Tests

• Leg length– true leg length discrepancy

congenital maldevelopmenttrauma

– functional leg length discrepancyscoliosis

Special Tests

• Leg length– Measured from ASIS to medial malleolus– Functionally measured

• knees & hips flexed with thumbs on medial malleolus then knees and hips extended

Neurologic Examination

Special Tests

• Patrick’s Test(FABER)– hip joint – SI joint

Special Tests

• Gaenslen’s Sign

Pain at ipsilateral SIJ is positive test

Special Tests• Piriformis Test

– Piriformis flexibility or pain– Sciatic Nerve Distribution

Special Tests

• Popliteal Angle– Hamstring flexibility

Diagnostic Imaging

Diagnostic Imaging

• Radiographs– Anterior-Posterior view– Frog leg view– STANDING films to r/o early OA

• Bone scan: stress fxs• CT: subtle fractures• MRI: soft tissue, stress fx• Arthrogram: labral tears

Anterior Hip Pain

• Differential Dx– Osteoarthritis – Inflammatory arthritis – Muscle and tendon strains – Tendonitis – Femoral neck stress fracture – Sports hernia (Occult hernia or tear of oblique aponeurosis) – Obturator or ilioinguinal nerve entrapment – Osteitis pubis – Acetabular labral tears

Hip Ultrasound

• Indications for a hip examination– Include, but are not limited to:

• soft tissue injury• tendon pathology• arthritis• soft tissue masses or swelling• nerve entrapment• effusion• bone injury

Hip Ultrasound

• Specifications of a hip examination– Patient’s body habitus

• lower frequency transducer may be required

– Spatial resolution • decreases with a decrease in the transducer frequency

– operator should use the highest possible frequency that provides adequate penetration

Hip Ultrasound

• Anterior approach– Patient positioning:

• supine with the hip in mild external rotation

– Planes:• Sagittal oblique plane parallel to the long

axis of the femoral neck – femoral head, neck, and joint effusion

• Sagittal and axial planes – labrum, iliopsoas tendon and bursa, femoral

vessels, sartorius and rectus femoris muscles

• The above structures are then scanned in the axial plane, perpendicular to the original scan plane

—Sonograpthy of normal hip jointLongitudinal

Fessell D P et al. AJR 2000;174:1353-1362

©2000 by American Roentgen Ray Society

Hip Ultrasound

• Anterior Approach– Dynamic evaluation of snapping hip syndrome

• Anterior: iliopsoas tendon as it passes over superior pubic bone

• Lateral: iliotibial band crosses the greater trochanter

Hip Ultrasound

• Lateral approach– Patient positioning:

• lateral decubitus

– Planes:• axial and coronal (longitudinal)

– greater trochanter, greater trochanteric bursa, gluteus muscles, and tensor fascia lata

• dynamic evaluation of iliotibial band syndrome

Hip Ultrasound

• Medial approach– Patient positioning:

• 45-degree knee flexion, external rotation (frog-leg position)

– Planes:• Sagittal oblique and axial planes

– (adductor muscles, pubic bone and insertion of rectus abdominis)

Hip Pathology• Snapping Hip

– Iliopsoas– Iliotibial Band

• Trochanter– Trochanteric Bursitis– Gluteal Tendons

• Athletic Pubalgia– Sports Hernia– Direct Hernia– Indirect Hernia

• Hip Osteoarthritis• Iliopsoas Bursitis• Iliopectineal Bursitis

• Femoroacetabular Impingement

• Acetabular Labral Tear• Adductor

– Strain– Tear

• Quadriceps– Strain– Tear

• Hamstrings– Strain– Tear

• Ischial Bursitis

Anterior Hip Pain

• Differential Dx– Osteoarthritis – Inflammatory arthritis – Muscle and tendon strains – Tendonitis – Femoral neck stress fracture – Sports hernia (Occult hernia or tear of oblique aponeurosis) – Obturator or ilioinguinal nerve entrapment – Osteitis pubis – Acetabular labral tears

Margo K, et al. Evaluation and management of hip pain: An algorithmic approach J Fam Pract. 2003, 52:8

Hip Pathology

• Snapping Hip– Iliopsoas– Iliotibial Band

• Trochanter– Trochanteric Bursitis– Gluteal Tendons

• Femoroacetabular Impingement

• Acetabular Labral Tear

Hip Pathology

• AIIS Avulsion• Quadriceps

– Strain– Tear

• Adductor– Strain– Tear

• Athletic Pubalgia– Sports Hernia– Direct Hernia– Indirect Hernia

Hip

• Anterior Recess– Anterior and posterior

layers• Fibrous tissue + minute layer

of synovium• Hyperechoic• Each 2-4 mm thick

• Radiology 1999; 210: 499

Hip Effusion

• Separation of anterior and posterior layers (1)• Capsule distention at femoral neck > 7 mm or

difference of 1 mm from opposite side (2)• Extension & abduction improves visualization

(3)• Avoid Internal Rotation of hip during assessment:

capsule thickens• (1) Radiology 1999; 210: 499• (2) Scand J Rheum 1989; 18:113• (3) Acta Rad 1997; 38: 867

-Hip joint longitudinal-Hypoechoic hip effusion

Fessell D P et al. AJR 2000;174:1353-1362

©2000 by American Roentgen Ray Society

Hip Joint

Hip Joint: Effusion

• Cannot predict infection by ultrasound

• 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

• S/Sx: pain w/ walking, low-grade fever• Tx: relative rest, analgesics

Iliopsoas Bursitis• Located anterior to the hip• Can be visualized in transverse plane at the

level of femoral head– Immediately medial to iliopsoas tendon

• Communicates with hip joint in up to 15%– Number is increased with abnormal hip joint

• Bursa may be distended with simple fluid, complex fluid or synovitis– Ranges from anechoic to hyperechoic– May distend into abdomen

• Should not be confused with intra-abdominal or psoas abscess

• Bursitis: presence of pain with transducer pressure– Increased flow on color/power Doppler– Distention out of proportion to hip joint recess

Iliopsoas bursitis

• Cause: overuse of hip flexors• S/Sx:

– anterior hip pain, +/- snap– preferred position of hip in flex/ER, – TTP to deep palpation anteriorly, – pain with passive hip extension

• Tx: relative rest, ice, brief NSAID, stretching of iliopsoas, – +/- steroid injection (preferably w/

guidance)

Iliopsoas Bursitis

Iliopsoas Tendon

Osteitis Pubis• Repetitive trauma to pubic symphysis due to

overuse– Running/cutting, esp soccer, football, basketball

• Signs & Symptoms– insidious onset dull anterior groin pain; may radiate– TTP over Pubic Symphysis– +/- pain w/ resisted Adduction or passive Abduction

• Treatment– relative rest, brief NSAID, cross-training– stretching/strength rehab– consider steroid injection

Osteitis Pubis

• Radiographs

Athletic PubalgiaSports “hernia”

• TTP lower abd wall– No palpable hernias

• Co-incident injuries– Adductor tendinopathy– Osteitis pubis

• Imaging: consider MRI to r/o other conditions– Dynamic US helpful?

• Tx: relative rest, flexibility, strength surgery if refractory

Muscle strains

• Adductors, gluteals, quads, hamstring tears usually from overstretching during eccentric contraction, esp when muscle fatigued

• Risk factors– Early in season– Muscle imbalance, inflexibility, inadequate warmup

• S/Sx: localized pain and TTP, +/- swelling or ecchymosis , rarely palpable muscle defect, and decreased ROM– Graded I, II, III similar to sprains

• Xrays to r/o avulsion fxs if near muscle origins; MRI if suspected complete tear

• Tx: PRICEMM, Rehab (ROMstrengthcardiosport-specific tng)

Quadriceps Contusions

• Direct blow to muscle causes tissue damage• S/Sx: localized TTP, +/-ecchymosis

– Grade I: knee flexion >90– Grade II: knee flexion 45-90– Grade III: knee flexion <45

• Tx: PRICE; avoid NSAID 48 hrs– Max knee flexion, wrap in place 24 hrs– Crutches, gradual WB, rehab (ROMstrength)– RTP when FROM, 90%+ strength, activity w/o

pain• Complications:

– Compartment syndrome (acute)– Myositis ossificans (chronic)

• Slowly enlarging mass, redness, increasing pain• Xrays + 3-4 weeks, BS/US sooner

Stress Fractures

• Caused by repetitive overuse stresses– RF’s: training errors, females, inadequate footwear, intrinsic

factors– Pelvic, femoral neck, femoral shaft

• S/Sx: insidious pain w/ activity; +/- local TTP or pain w/ hop test, +/- decreased ROM

• Xrays first, MRI or BS if neg but suspected• Tx

– Femoral: immediate NWB, Ortho referral• Tension sidesurgery

– Pelvic/femoral shaft: painless relative rest; graduated WB, strength/stretching rehab, address other RF’s

Hip fractures• Most common through

femoral neck, various traumatic causes

• S/Sx: pain, swelling, and loss of function

• Involved leg shortened and externally rotated

• Tx: Ortho referral, surgery

Hip Dislocation• Femoral head usually goes

posteriorly• common mechanism: knee to

dashboard during traffic collision• S/Sx: extreme pain, obvious

deformity, unwilling to move the extremity; position typically flexion, adduction, and internal rotation (FAdIR)

• Tx: emergent reduction in ER under sedation (Ortho STAT!)

AVN of Femoral Head

• Causes:– Trauma: fxs, hip dislocation, surgery– Medical conditions (numerous)

• S/Sx: nonspecific hip pain, may radiate to knee; exam may be relatively unremarkable, with decr IR/ER as dz advances

• Xrays usually diagnostic >3mo duration; MRI or BS if normal

• Tx: make pt NWB and refer to Ortho– Conservative tx vs hip replacement depending on severity

THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO. 1 - JANUARY 2001

Pelvic Apophysitis

Pelvic Apophysitis• Cause: overuse at tendinous insertion at

apophysis– Iliac crest > ASIS, AIIS, lesser troch, greater troch,

ischial tuberosity• S/Sx: localized pain, TTP, pain w/ passive

stretch of attached muscle• Xrays to r/o avulsion fxs• Tx: relative rest (rare crutches), ice, brief

NSAID?, cross training, strength rehab, flexibility

Pelvic Avulsion Fractures• Caused by violent contraction of the attaching

muscle in skeletally immature athlete– Sprint, jump, soccer, gymnast, dancer, football– Ischial tuberosity > AIIS > ASIS > iliac crest, lesser troch,

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

Lateral Hip Pain

• Differential Dx– Greater trochanteric pain syndrome– Iliotibial band syndrome– Meralgia paresthetica

Hip Pointer

• 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

• Tx: relative rest, ice, brief NSAID, ITB stretching, +/- steroid injection– Address biomechanical defects above

Trochanteric Bursitis

• Trochanteric fluid seen posterolateral to GT and deep to Gluteus Maximus– Best visualized if distended– Distention does not indicate

inflammation• However is suggestive

– Pain with probe pressure & increased flow on color/power Doppler

• Increases likelihood of inflammation->Bursitis

Greater Trochanter Gluteus Medius and Minimus

Trochanteric BursaCoronal Axial

Posterior Hip Pain• Posterior Hip

– Expand Differential to include Back Pain

– Evaluate for “red flags”

Posterior Hip Pain

• Differential Dx– Lumbar spine disease

• Degenerative disc disease• Facet arthropathy• Spinal stenosis

– Sacroiliac joint disorders– Hip extensor and external rotator muscle

pathology• Piriformis Syndrome

– Aortoiliac vascular occlusive disease (rare)

Piriformis Syndrome

• Pain due to sciatic nerve compression at piriformis

• Cause: trauma, prolonged sitting, overuse; anomalies in 15-20%

• S/Sx: – dull buttock pain +/- radiation into

leg– TTP over mid-buttock– Pain worse with passive IR or

resisted ER

-Tx: relative rest, ER stretching, +/- steroid injection

Hip Pathology

• Hamstrings– Strain– Tear

• Ischial Bursitis• Iliopsoas Bursitis

Ischial bursitis

• Cause: excessive friction over ischial tuberosity, or direct blow (hematoma, scarring)

• S/Sx: pain with sitting, TTP over ischial tuberosity, pain w/ passive hip flexion and active/resistive hip extension

• Xray to r/o fractures in traumatic hx• Tx:

– Ice, padding, brief NSAID– Prolonged: steroid injection– Refractory: surgical excision

Lumbar and Sacroiliac Pathology

• Significant Cause of Pathology referring to posterior hip and thigh– Lumbar Pathology

• Lumbar Discogenic Pain• Lumbar Facet Arthropathy• Lumbar Radicular Pain• Lumbar Stenosis• Lumbar Spondylosis

– Sacroiliac Pain• Sacroilitis

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.