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Hip pain in the pre-arthritic patient: a guide for the primary care physician.

History

The history should begin with a detailed account of the onset of symptoms, noting any antecedent traumatic events or change in activities. The patient should be instructed to carefully map out the distribution and quality of pain as this information may help narrow the differential (Figure 1). Sudden onset of pain brought on by a non-contact rotational movement with the foot firmly planted on the ground most commonly suggests a joint sprain or muscle strain, though a more severe mechanism may suggest a tear in the ring of cartilage that lines the rim of the hip socket, called the labrum. A medially directed blow to the lateral hip, sustained in a fall or during play in contact sports, typically results in soft tissue contusion ("hip pointer") with higher energy injuries concerning for articular cartilage injury, or rarely, fractures. (1) Sudden onset groin pain with the sensation of a "pop" while kicking should raise suspicion for an avulsion fracture of the anterior superior iliac spine (ASIS) or anterior inferior iliac spine (AIIS) in the kicking leg and labral injury in the planted leg. (2) In the absence of a traumatic event, acute onset groin pain should raise suspicion for gastrointestinal or genitourinary diagnoses with referred pain to the hip.

Pain that develops insidiously over the course of several months should raise suspicion for an overuse phenomenon such as bursitis or tendonitis, commonly involving the hip flexors, hamstrings, and adductors. (3) Most such patients describe pain upon initiating the offending activity that improves after the warm-up phase only to decompensate with more strenuous activities. In contrast, insufficiency fractures or stress reactions exhibit no such transient improvement and progressively worsen with all load bearing activities. (4,5) Patients with a symptomatic stress reaction typically report an antecedent increase in the duration and/or frequency of activities, as in training for a marathon or returning to sport after a period of non-participation, and fail to take proper measures to condition themselves beforehand.

Painful audible snapping about the anterior/medial groin is typically due to a tight iliopsoas and manifests when the patient actively moves the hip from flexion to extension (internal snapping hip). (6) Alternatively, painful visible snapping about the lateral aspect of the hip due to a tight iliotibial band (ITB) manifests when the patient is asked to circumduct the pelvis as if using a hula hoop, provoking the anterior/posterior snapping of the ITB over the greater trochanter (external snapping hip). (7,8) Painless snapping is relatively common in the athletic population and does not warrant treatment.

Patients with femoroacetabular impingement (FAI) typically present after three to six months of activity related groin pain, which is occasionally accompanied by reproducible clicking or popping due to a labral tear. FAI is very common and present in up to 25% of males with a 95% prevalence of hip shape abnormality in American college football players. (9) It is clear that early recognition, referral and treatment of this problem improve outcomes and activity levels. (10,11) The impingement is multifactorial and typically results from excessive bone about the femoral head/neck junction, excessively deep/malaligned acetabulum (hip socket), rotational malalignment of the extremity, or any combination of the above.12 The pain from FAI is most commonly reported in the groin (88%), and less frequently localized to about the lateral hip and anterior thigh.13 Rarely, certain childhood disorders such as Legg-Calve-Perthes disease or slipped capital femoral epiphysis (SCFE) may result in FAI later in life. Pain is brought on by activities involving repetitive hip flexion, especially with adduction and internal rotation, precipitating a conflict between the rim of the acetabulum and the femoral head/neck junction. With repetitive activities, this bony abutment results in progressive tearing of the interposed labrum and subsequent delamination of the acetabular articular cartilage. Pain is typically worsened with load bearing rotational activities, stair ambulation, or prolonged sitting and abates with rest. (13) Patients characteristically cup the outer aspect of the trochanter with their thumb and forefingers making the shape of a C to indicate that the location of the pain is deep seated within the hip ("C--sign"). The presence of constant aching pain, especially at night, may indicate that articular cartilage damage has already occurred and is a poor prognostic sign for successful joint preserving treatment.

[FIGURE 1 OMITTED]

Hip dysplasia is a congenital disorder wherein the acetabulum is volumetrically deficient and provides inadequate bony coverage to house the femoral head. As such, it is often regarded as being on the opposite end of the spectrum from FAI, although in many instances the two disorders may coexist. (14) Dysplastic patients may be born with partially or completely dislocated hips. Prompt identification and treatment with bracing or casting is often sufficient to restore normal growth and development. The patient's parents may provide key elements of their early childhood history to clue the physician into an underlying diagnosis of dysplasia. (15) In less severe cases, the diagnosis may go unrecognized until adolescence at which time the patient may develop insidiously worsening groin pain with mechanical symptoms due to excessive laxity and inadequate bony coverage. In these intermediate cases, the secondary soft tissue stabilizers including the labrum and iliopsoas tendon assume a more important role in providing coverage for the hip and suffer overuse injuries including tearing and tendonitis, respectively. With continued instability, shear forces across the acetabular articular cartilage may result in early and irreversible degenerative changes. Similar to FAI, dysplastic patients with constant aching arthritic pain fare worse with joint preserving treatment options.

[FIGURE 2 OMITTED]

Physical Examination

(Figure 2)

In this article we outline a simple and focused physical examination that is of great practical value in the primary care setting. In the retrospective study conducted by Byrd and Jones, 40 patients had clinical assessment and focused physical examination with definitive diagnosis of intra-articular hip pathology confirmed with magnetic resonance imaging and hip arthroscopy. They reported that the clinical assessment/focused physical exam was great for determining the existence of the intra-articular hip pathology with a reported 98% sensitivity. (16) The overarching intent of the focused exam is to ensure timely recognition of consequential diagnoses, preventing the morbidity of delayed referral to an orthopaedic specialist. A secondary goal is to empower family physicians to initiate conservative management for relatively common benign diagnoses.

By taking an active role in treating these disorders, primary care physicians can ensure that severe cases, appropriate for referral, will be evaluated in a more timely fashion.

The examination is begun with an attempt to discern whether the pain is coming from an intra-articular (FAI, labral tear, cartilage injury, etc.) or extra-articular diagnosis (muscle/tendon strains, snapping hip, referred pain). (17) One of the most sensitive findings for true intraarticular hip disease is decreased or painful internal rotation of the affected hip as compared to the unaffected side. The patient is seated on the exam table with knees flexed. The examiner gently internally rotates the affected hip by stabilizing the knee and pushing laterally on the foot until moderate resistance is encountered or the patient cannot tolerate further motion due to pain. The position of the leg relative to the vertical axis acts as a goniometer allowing a crude visual estimation of the degrees of internal rotation. A side-to-side difference greater than 15 degrees, especially if the patient's pain is reproduced at terminal internal rotation, is highly suggestive of true intra-articular hip disease (Figure 2A). A second highly sensitive finding in patients with intra-articular hip disease is pain with resisted straight-leg-raise, also known as a positive Stinchfield maneuver. (18) The patient, positioned supine on the exam table, is instructed to actively raise the leg with the knee extended. The examiner then applies downward pressure on the leg while the patient resists by flexing the hip. Pain with this maneuver, especially if localized to the anterior hip or groin, is highly suggestive of intra-articular pathology. Lastly, if the patient experiences painful popping or clicking with either of the above maneuvers, one should suspect structural injury to the labrum or articular cartilage. (19)

The patient's gait pattern can reveal much about the severity and nature of the underlying diagnosis. (3) The typical young patient with hip pathology will ambulate with a rather unremarkable gait.

Any discernible limp or lurch is concerning for stress fracture/ reaction, structural injury, or severe muscle or tendon injury including partial/complete tear. Hip flexor tendonitis or strain may present with a shortened stride length on the unaffected side due to limited hip extension on the affected side. Abductor weakness or tendonitis typically manifests in a drop of the unaffected hip while standing on the affected side (Trendelenburg sign) or in a lurch to the affected side.

Radiographic Findings

Proper radiographic evaluation of the hip requires specialized views with which most x-ray technicians are unfamiliar. As such, we recommend obtaining simple screening x-rays including AP pelvis and dedicated AP/frog-leg lateral of the affected hip only if the physician suspects a diagnosis of arthritis or acute fracture. Given the subtle nature of most radiographic findings associated with pre-arthritic hip pain, the specialized views are best left for the orthopaedist to obtain and interpret. Similarly, advanced imaging with MRI, CT, or bone scan should be deferred to the expertise of the orthopaedic surgeon to reduce cost and radiation exposure for the patient.

Criteria for Referral

Certain "red flags" prompt referral to an orthopaedic surgeon without delay (Table 1). Competitive athletes require an accelerated approach to diagnosis and treatment in order to minimize time away from sport.

In the setting of a high energy traumatic event, superficial soft-tissue contusions and joint sprains confound the evaluation making it more difficult to identify underlying bony or cartilaginous injury. Any indication of an unstable cartilage tear, as suggested by the presence of sharp and severe groin pain with associated mechanical symptoms (e.g. clicking, catching, locking, giving way) prompts early referral. If a patient who ambulates at baseline develops a significant limp or inability to bear weight, keep a low threshold for referral as most benign diagnoses do not preclude normal ambulation. Referral to a GI or GU specialist may be warranted for cases of referred pain to the groin. Lastly, any patient with painful range of motion, difficulty bearing weight, and fevers/chills should be referred to the emergency department for evaluation to rule out septic arthritis.

Conservative Treatment

(Table 2)

The vast majority of patients may be safely treated with conservative management appropriate for the underlying diagnosis. Patients suspected of having an overuse injury (muscle/tendon strain, bursitis, stress reaction, etc.) should be instructed to reduce participation in the offending activity, take nonsteroidal anti-inflammatory drugs (NSAIDs) regularly for a period of 1-2 weeks, and visit a physical therapist for gentle stretching exercises and modalities to reduce inflammation. Therapists should be instructed to focus stretching on the ITB, adductors, and hip flexors. Strengthening may be gradually instituted when pain has improved and return-to-activity may be planned when the patient is appropriately conditioned. Important muscle groups to focus on for strengthening include hip abductors, gluteus maximus, and the core abdominal musculature.

A maintenance home exercise program, including stretching, is paramount to prevent recurrence. Patients whose pain persists for 6 weeks or longer despite these conservative measures are appropriate for referral to an orthopaedic surgeon.

Summary

This article highlights common diagnoses for young adults with pre-arthritic hip pain in an effort to demystify the evaluative process.

By providing clear criteria for referral to an orthopaedic surgeon, we aim to empower primary care and family practice physicians to safely initiate conservative treatment when appropriate. Ultimately, this practice will reduce costs and time delays associated with orthopaedic consultation for common and benign injuries while ensuring that patients with more severe diagnoses are seen in a timely fashion.

References

(1.) Hall M, Anderson J. Hip pointers. Clinics in sports medicine. Apr 2013; 32(2):325-330.

(2.) Boyce SH, Quigley MA. Simultaneous bilateral avulsion fractures of the anterior superior iliac spines in an adolescent sprinter. BMJ case reports. 2009; 2009.

(3.) Grumet RC, Frank RM, Slabaugh MA, Virkus WW, Bush-Joseph CA, Nho SJ. Lateral hip pain in an athletic population: differential diagnosis and treatment options. Sports health. May 2010; 2(3):191-196.

(4.) Thomas A, Mason F, Deshpande S. An unusual presentation of femoral neck fracture in a young patient. Journal of surgical case reports. 2014; 2014(12).

(5.) Lin JC, Wu CC, Lo C, et al. Mortality and complications of hip fracture in young adults: a nationwide population-based cohort study. BMC musculoskeletal disorders. 2014; 15:362.

(6.) Bureau NJ. Sonographic evaluation of snapping hip syndrome. Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine. Jun 2013; 32(6):895-900.

(7.) Reich MS, Shannon C, Tsai E, Salata MJ. Hip arthroscopy for extra-articular hip disease. Current reviews in musculoskeletal medicine. Sep 2013; 6(3):250-257.

(8.) Lewis CL. Extra-articular Snapping Hip: A Literature Review. Sports health. May 2010; 2(3):186-190.

(9.) Fernandez M, Wall P, O'Donnell J, Griffin D. Hip pain in young adults. Australian family physician. Apr 2014; 43(4):205-209.

(10.) Skendzel JG, Philippon MJ, Briggs KK, Goljan P. The effect of joint space on midterm outcomes after arthroscopic hip surgery for femoroacetabular impingement. The American journal of sports medicine. May 2014; 42(5):1127-1133.

(11.) Meftah M, Rodriguez JA, Panagopoulos G, Alexiades MM. Long-term results of arthroscopic labral debridement: predictors of outcomes. Orthopedics. Oct 2011; 34(10):e588-592.

(12.) Grant AD, Sala DA, Schwarzkopf R. Femoro-acetabular impingement: the diagnosis-a review. Journal of children's orthopaedics. Mar 2012; 6(1):1-12.

(13.) Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H. Clinical presentation of patients with symptomatic anterior hip impingement. Clinical orthopaedics and related research. Mar 2009; 467(3):638-644.

(14.) Goldstein RY, Kaye ID, Slover J, Feldman D. Hip dysplasia in the skeletally mature patient. Bulletin of the Hospital for Joint Disease. 2014; 72(1):28-42.

(15.) Woodacre T, Dhadwal A, Ball T, Edwards C, Cox PJ. The costs of late detection of developmental dysplasia of the hip. Journal of children's orthopaedics. Aug 2014; 8(4):325-332.

(16.) Byrd JW, Jones KS. Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients. The American journal of sports medicine. Oct-Nov 2004; 32(7):1668-1674.

(17.) Reiman MP, Thorborg K. Clinical examination and physical assessment of hip joint-related pain in athletes. International journal of sports physical therapy. Nov 2014; 9(6):737-755.

(18.) Poultsides LA, Bedi A, Kelly BT. An algorithmic approach to mechanical hip pain. HSS journal: the musculoskeletal journal of Hospital for Special Surgery. Oct 2012; 8(3):213-224.

(19.) Garrison JC, Osler MT, Singleton SB. Rehabilitation after arthroscopy of an acetabular labral tear. North American journal of sports physical therapy: NAJSPT. Nov 2007; 2(4):241-250.

(20.) Gamradt SC, Brophy RH, Barnes R, Warren RF, Thomas Byrd JW, Kelly BT. Nonoperative treatment for proximal avulsion of the rectus femoris in professional American football. The American journal of sports medicine. Jul 2009; 37(7):1370-1374.

(21.) Lustenberger DP, Ng VY, Best TM, Ellis TJ. Efficacy of treatment of trochanteric bursitis: a systematic review. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. Sep 2011; 21(5):447-453.

(22.) Almekinders LC. Tendinitis and other chronic tendinopathies. The Journal of the American Academy of Orthopaedic Surgeons. May-Jun 1998; 6(3):157-164.

(23.) Sierra RJ, Trousdale RT, Ganz R, Leunig M. Hip disease in the young, active patient: evaluation and nonarthroplasty surgical options. The Journal of the American Academy of Orthopaedic Surgeons. Dec 2008; 16(12):689-703.

Yusif Mohammed, MSII

Joan C. Edwards School of Medicine, Marshall University

Zain N. Qazi, MD

Orthopaedic Research Fellow, Marshall University

Franklin D. Shuler, MD, PhD

Professor, Orthopaedic Trauma Vice Chairman, Orthopaedic Research Medical Director, Senior Fracture Program, Marshall University

Tigran Garabekyan, MD

Assistant Professor, Assistant Program Director, Marshall University, Department of Orthopaedic Surgery

Corresponding Author: Franklin D. Shuler MD, PhD, Marshall University, Department of Orthopaedic Surgery, 1600 Medical Center Drive, Suite G-500, Huntington, WV 25701. E-maikshulerf@marshall.edu
Table 1: Red flags prompting early
referral

Criteria for Early Referral

Competitive athlete (High functional demand)
High energy trauma (MVC, FFH)

Sharp and severe groin pain with mechanical
symptoms (clicking, catching, locking, giving
way)

Significant limp or inability to bear weight

Painful passive ROM, pain with weight bearing,
fever/chills

Suspicion for referred GI/GU pain

MVC--motor vehicle collision, FFH--Fall from height, ROM Range
of motion, GI--Gastrointestinal, GU--Genitourinary

Table 2 (1,15,20-23): Conservative management for hip disorder

Conservative Management

Disorder           Treatment                 Notes

Iliac Crest        Rest, Ice, NSAIDs *,      Anesthetic injection
Contusion          Rehabilitation,           may be considered for
                   Injection                 rapid return to play in
                                             competitive athletes

Avulsion           Protected weight
fracture           bearing up to 6 weeks
                   with hip in flexion for
                   2 weeks, Ice, NSAIDs*,
                   PT/ROM with
                   rehabilitation

Trochanteric       Activity modification,    Conservative care cures
Bursitis           PT, Weight loss, NSAID,   90%
                   Steroid injection(s)**

Tendonitis         Activity modification,    Consider etiology:
                   NSAIDs*, Steroid          overuse, age,
                   injection** of limited    vascularity. Discuss
                   volume                    expectations (chronic
                                             pain), avoid
                                             immobilization

Coxa Saltans       Same as tendonitis,       Painless requires
"Snapping          Stretching, Steroid       assurance. Remain
hip"               injection**               active below threshold
                                             for symptoms

Femoroacetabular   Activity modification,    If injection provides
Impingement        avoid positions of        transient relief, do
(FAI)              impingement (deep         not delay surgical
                   flexion), NSAIDs*, PT,    treatment so as to
                   diagnostic                prevent onset of
                   corticosteroid            arthritis
                   injection**

Dysplastic Hip     Referral to a             Early referral is key
                   specialist

* Monitorfor NSAID side effects (Gl ulcer, nephrotoxicity, and
hepatotoxicity)

** Steroid injection after other modalities have failed and for acute
exacerbation of symptoms. Maximum of 2-3 with 3 months between
(monitorfor hyperglycemia, connective tissue atrophy). Steroid
injection for snapping hip currently has little evidence based
support.
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Title Annotation:FOCUS: Primary Care
Author:Mohammed, Yusif; Qazi, Zain N.; Shuler, Franklin D.; Garabekyan, Tigran
Publication:West Virginia Medical Journal
Date:Sep 1, 2016
Words:2952
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