Hip Pain

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Hip Pain
Hip pain is a common complaint that can be caused
by a wide variety of problems. The precise
location of your hip pain can provide valuable
clues about the underlying cause. Problems within
the hip joint itself tend to result in pain on
the inside of your hip or your groin. Hip pain on
the outside of your hip, upper thigh or outer
buttock is usually caused by problems with
muscles, ligaments, tendons and other soft
tissues that surround your hip joint. Hip pain
can sometimes be caused by diseases and
conditions in other areas of your body, such as
your lower back or your knees. This type of pain
is called referred pain. Most hip pain can be
controlled with self-care at home.
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Hip Anatomy

• Your hip joint is designed for both mobility and
  stability. The hip joint allows your entire lower
  extremity to move in three planes of motion
• forward and backward
• side to side
• rotating right and left
• Your hip joint provides vital shock absorption to
  the torso and upper body as well as stability
  during standing and other weight-bearing
  activities.
• Your hip is comprised of four main components
• Bones
• Cartilage
• Ligaments
• Muscles
• Hip Bones
• The hip is actually a ball and socket joint,
  uniting two separate bones, the femur (thigh
  bone) with the pelvis. The pelvis features two
  cup-shaded depressions called the acetabulum, one
  on either side of the body. The femur is the
  longest bone in the body and connects to the
  pelvis at the hip joint. The head of the femur,
  shaped like a ball, fits tightly into the
  acetabu- lum, forming the ball and socket joint
  of the hip, allowing the leg to move forward and
  backward, side to side, and rotate right and left.

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Hip Anatomy
HIP CARTILAGE The acetabulum is lined with
cartilage, which cushions the bones during
weightbearing activities and allows the joint to
rotate smoothly and freely in all planes of
movement with minimal friction. HIP LIGAMENTS The
complex system of ligaments that connect the
femur to the pelvis are essential for stability,
keeping the hip from moving outside of its normal
planes of movement. HIP MUSCLES The muscles of
the hip joint have dual responsibilities working
together to provide the power for the hip to move
in all directions, as well as to stabilize the
entire lower extremity during standing, walking,
or other weight-bearing activities. HIP
BURSAS There are large bursas (fluid-filled sacs)
that surround areas of the hip and allow the
muscles and tendons to glide more easily over
bony prominences. Any of these structures can
become inflamed.
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Symptoms

• Depending on the condition that's causing your
  hip pain, you might feel the discomfort in your
• Thigh
• Inside of the hip joint
• Groin
• Outside of the hip joint
• Buttocks
• Sometimes pain from other areas of the body, such
  as the back or groin (from a hernia), can radiate
  to the hip.
• You might notice that your pain gets worse with
  activity, especially if it's caused by arthritis.
  Along with the pain, you might have reduced range
  of motion. Some people develop a limp from
  persistent hip pain.

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Causes

• Hip pain may be caused by arthritis, injuries or
  other problems.
• OSTEOARTHRITIS
• The symptoms of osteoarthritis can vary greatly
  from person to person, but if it affects the hip
  it will typically cause
• mild inflammation of the tissues in and around
  the hip joint
• damage to cartilage the strong, smooth surface
  that lines the bones
• bony growths (osteophytes) that develop around
  the edge of the hip joint
• This can lead to pain, stiffness and difficulty
  doing certain activities.
• There is no cure for osteoarthritis, but the
  symptoms can be eased with several different
  treatments and surgery is often not necessary.

• Osteoarthritis is the most common cause of hip
  pain in those over the age of 50 however, other
  types of arthritis can be present.
• These may include
• rheumatoid arthritis,
• ankylosing spondylitis,
• Reiter's syndrome
• BURSA INFLAMMATION (HIP BURSITIS)
• The trochanteric bursa is a sac on the outside
  part of the hip that serves to protect muscles
  and tendons as they cross the greater trochanter
  (a bony prominence on the femur). Trochanteric
  bursitis describes the inflammation of this
  bursa. The bursa may become inflamed for a
  variety of reasons, often due to minor trauma or
  overuse.

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Causes
HIP FRACTURE Falls are the most common reason
that elderly people break a hip. The fracture is
due to a combination of two effects of
aging,osteoporosis (thinning of bones) and a loss
of balance. These two risk factors are the
potential cause of many falls. Occasionally, the
bone may spontaneously break due to osteoporosis
and become the cause of the fall. Bones may also
weaken because of other diseases that have
affected the hip bones. A pathologic hip fracture
describes this situation, and osteoporosis is but
one cause. Other potential causes of bone
weakening are cancer within the bones, benign
tumors and cysts, Paget's disease, and inherited
diseases of bone. When health-care professionals
talk about a hip fracture, they really mean a
fracture of the proximal or upper part of the
femur. Fractures of the acetabulum are less
common and usually are due to major trauma like a
motor-vehicle collision or a fall down a flight
of stairs. The precise location of the fracture
is important, because it guides the decision of
the orthopedic surgeon as to which type of
operation is needed to repair the injury. Aside
from a fall, any trauma can potentially cause a
hip fracture. Depending upon the mechanism of
injury, the femur may not break rather, a
portion of the pelvis (often the pubic ramus) may
be fractured. The initial pain may be in the hip
area, but examination and X-rays may reveal a
source different than the hip joint as a cause of
hip pain. Trauma can also cause a hip dislocation
in which the femoral head loses its relation-
ship with the acetabulum. This is almost always
associated with an acetabular (pelvic bone)
fracture however, in patients with hip
replacements, the artificial hip may dislo- cate
spontaneously.
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Causes

• LESS COMMON CAUSES OF HIP PAIN
• Less commonly, the cause of hip pain may be
• the bones of the hip rubbing together because
  they're abnormally shaped a condition called
  femoroacetabular impingement
• a tear in the ring of cartilage surrounding the
  socket of the hip joint known as a hip labral
  tear
• hip dysplasia where the hip joint is the wrong
  shape or the hip socket is not in the correct
  position to completely cover and support the top
  of the leg bone
• an infection in the bone or joint, such as septic
  arthritis or osteomyelitis see your GP
  immediately if you have hip pain and fever
• reduced blood flow to the hip joint, causing the
  bone to break down a condition known as
  osteonecrosis
• a hamstring injury- a strain or tear to the
  tendons or large muscles at the back of the thigh
• an inflamed ligament in the thigh, often caused
  by too much running known as iliotibial band
  syndrome, this is treated with rest
• An inguinal hernia
• Hip Dislocation

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Referred hip pain

• Hip pain may not originate in the hip itself but
  may be felt there due to issues in adjacent
  structures.
• A hernia or defect of the abdominal wall may
  cause pain in the front part of the hip. A hernia
  occurs when there is a weakness or tear in an
  area where muscles of the abdominal wall come
  together. They are named according to their
  location inguinal (groin) hernias are most
  common. Femoral hernias are another type of
  hernia that might also cause hip pain.
• Peripheral nerves can become inflamed, causing
  hip pain. Meralgia paresthetica occurs when the
  lateral femoral cutaneous nerve of the thigh
  becomes irritated. This condition is seen most
  commonly in pregnancy, in people wearing tight
  clothes, or in people with diabetes.
• Sciatica, or inflammation of nerve roots from the
  spinal cord, may also present with hip pain.
  There are a variety of reasons for the sciatic
  nerve to become inflamed, including spinal
  stenosis due to osteoarthritis of the lumbar
  spine, ruptured or bulging disks in the vertebral
  column of the back, and spasms of the muscles
  that support the low back. Piriformis syndrome
  describes sciatic nerve inflammation that causes
  buttock and posterior hip pain due to sciatic
  nerve irritation as it travels through the
  buttock muscles.

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Hip Pain in children

• Children who complain of leg or hip pain should
  be taken seriously and not be ignored. If the
  pain is persistent, if a limp is present, or if
  the child has a fever, a health-care professional
  should be contacted.Potential concerns in
  children with hip pain include
• a slipped capital femoral epiphysis, a condition
  in which the bone growth plate of the femoral
  head shifts out of place,
• Legg-Calvé-Perthes disease, or avascular necrosis
  of the femoral head,
• juvenile rheumatoid arthritis, or Still's
  disease.
• If a fever is present, septic arthritis or an
  infection of the hip joint may be present. This
  may be due to a virus or bacteria. Symptoms
  include fever, pain, limping, and sometimes
  refusal to walk. Viral infections are the most
  common cause of synovitis in infants and resolve
  without treatment. If the care provider is
  concerned that the cause of synovitis may be a
  bacterial infection, urgent orthopedic
  consultation and evaluation may be needed in this
  situation.

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When to Contact a Medical Professional

• If you are unsure of the cause of your symptoms,
  or if you do not know the specific treatment
  recommendations for your condition, you should
  seek medical attention.Treatment of hip pain must
  be directed at the specific cause of your
  problem. Some signs that you should be seen by a
  doctor include
• Inability to walk comfortably on the affected
  side
• Injury that causes deformity around the joint
• Hip pain that occurs at night or while resting
• Hip pain that persists beyond a few days
• Inability to bend the hip
• Swelling of the hip or the thigh area
• Signs of an infection, including fever, redness,
  warmth
• Any other unusual symptoms

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Diagnostic

• During the physical exam, your doctor is likely
  to
• Inspect your hip for swelling, pain, tenderness,
  warmth and visible bruising
• Check range of motions leg in different
  directions
• IMAGING TESTS
• In some cases, your doctor might suggest tests
  such as
• X-ray. Your doctor may first recommend having an
  X-ray, which can help detect bone fractures and
  degenerative joint disease.
• Computerized tomography (CT) scan. CT scanners
  combine X-rays taken from many different angles,
  to create cross-sectional images of the inside of
  your body. CT scans can help diagnose bone
  problems.
• Ultrasound. This technology uses sound waves to
  produce real-time images of the soft tissue
  structures within and around your hip, and how
  they are working.

• Magnetic resonance imaging. MRI uses radio waves
  and a powerful magnet to create 3-D images of the
  inside of your hip. This test is particularly
  useful in revealing injuries to soft tissues such
  as ligaments, tendons, cartilage and muscles.
• LAB TESTS
• If your doctor suspects an infection, gout or
  pseudogout, you're likely to have blood tests and
  sometimes arthrocentesis, a proce- dure in which
  a small amount of fluid is removed from within
  your hip joint with a needle and sent to a
  laboratory for analysis.

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• SELF-CARE AT HOME
• If you don't immediately need to see a doctor,
  consider managing and monitoring the problem at
  home. The following advice may be helpful
• Gentle exercise. While certain exercises may
  cause some discomfort, in general, exercise is
  much more likely to help than to do any
  significant harm.
• Weight loss. Taking off just 5 to 10 pounds (2.25
  to 4.5 kilograms) can make a significant
  difference in the amount of pain or discomfort
  you experience.
• Rest. Avoid repeated bending at the hip and
  direct pressure on the hip. Try not to sleep on
  the affected side and avoid prolonged sitting.
• Pain relievers. Over-the-counter pain relievers
  such as acetaminophen (Tylenol, others),
  ibuprofen (Advil, Motrin, others) and naproxen
  sodium (Aleve) may help ease your hip pain.
• Ice or heat. Use ice cubes or a bag of frozen
  vegetables wrapped in a towel to apply cold
  treatments to your hip. Conversely, a warm bath
  or shower may help prepare your muscles for
  stretching exercises that can reduce pain.
• If self-care treatments don't help, make an
  appointment with your doctor.

Treatment
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Treatment If your hip pain doesnt improve with
simple medications such as paracetamol and
ibuprofen, you should see your doctor for further
advice. They may recommend the following
treatments. DRUGS Non-steroidal
anti-inflammatory drugs (NSAIDs) Your doctor may
prescribe you stronger NSAIDs to help ease the
pain. Like all drugs, NSAIDs can sometimes have
side-effects, but if youre taking prescription
NSAIDs your doctor will take precautions to
reduce the risk of these. Bisphosphonates Bisphosp
honates are used to treat Osteoporosis and
Pagets Disease. They work by slowing bone loss,
which reduces the risk of hip fractures.
Depending on the type of bisphosphonate, you may
need to take them by mouth (but not with food),
or they may be given by intravenous infusions,
which is a slow injection into a
vein. Bisphosphonates are often used to treat
osteoporosis.
Steroid injections Steroid injections can help
hip problems if theyre caused by inflammatory
joint pain or inflamed bursae. The injections are
often given with a local anaesthetic, and theyre
usually very helpful in treating trochanteric
bursitis. Iliopsoas tendinitis can also be
treated with steroid injections, but the
injection will need to be done by a radiologist
because the ilipsoas tendon is so deep. A
snapping iliopsoas tendon can be treated with
steroid injec- tions which are done under
videofluoroscopy (a type of x-ray) to make sure
the injection is in the right place.
Ultrasoundguided injections are also becoming
more popular.
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Treatment PHYSIOTHERAPY AND OCCUPATIONAL
THERAPY Physiotherapy may help you to maintain
your hip movements with gentle range of movement
exercises and activities. A physiotherapist can
also suggest specific exercises to maintain or
improve the strength of the muscles around the
hip joint. They may advise you about the best way
to walk with your hip pain and may help you to
use a stick or crutch. Youll need to use the
stick in the opposite hand to your affected hip
and make sure that its the correct height for
you, so its important to see a physiotherapist
before you start using one. If you think your
work or certain activities you do might be the
main cause of your pain, its worth discussing
this with an occupational therapist. Theyll be
able to advise on how to change your movements to
help prevent pain continuing or returning. If
your place of work has an occupational health
department, they may also be able to help.
SURGERY Not everybody with hip pain will need
surgery, but hip fractures almost always need
fixation, which stabilises the bone and helps it
to heal, or replacement of the ball of the hip.
Hip fractures often occur in elderly people, and
they can take a long time to fully recover from.
People can often be in hospital for a couple of
weeks or more to get over the fall and the
operation, and many often need extra help at home
after discharge.
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Treatment Hip replacement surgery If your hip
pain is caused by arthritis and its getting
worse, your doctor may talk to you about hip
replacement. Hip replacement is an extremely good
treatment for arthritis-related hip pain, and
modern techniques make the operation very safe
with good outcomes. Nowadays, many people only
need to stay in hospital for a few days after
their hip replacement, but it may be helpful if
somebody is available to stay with you for a
couple of weeks as your mobility and confidence
improves. Physiotherapists will help you become
mobile when youre in hospital, and theyll help
you practise getting in and out of bed, out of
chairs and up and down stairs safely. If youre
being considered for hip replacement, its
important that youre in good health before the
operation. Youll probably be referred to the
hospital for an assessment before the operation
and theyll check your general health. Your
surgeon will talk to you about the operation
itself, and youll meet the physiotherapists and
occupational therapists wholl be involved in
your treatment after surgery. The outcomes of hip
replacements are extremely good 90 or more of
people who have had a hip replacement find their
pain is greatly reduced. Modern hip replacements
should last many years around 80 of cemented
hips should last for 20 years. Revision
surgery If your hip replacement becomes loose,
infected or otherwise fails, its possible to
have surgical treatment. Modern revision surgery
techniques are developing quickly and most failed
hip replacements can be dealt with, which can
restore function and activity. Revision surgery
is carried out by specialists in the field.
Youll be in hospital longer than for your first
hip replacement, and it might take longer to
recover. Youll need physiotherapy after revision
surgery to help you gain confidence in your new
joint, and youll need someone to help you out
for a couple of weeks or more when you go
home. Acetabular labrum surgery A torn acetabular
labrum can be repaired by surgical reshaping of
the hip. In some cases this procedure can be
performed through just a small incision
(arthroscopically), so your joint doesnt have to
be opened up. This is also known as keyhole
surgery, and it can be done as a day case or
one-night stay in hospital. Youll need between
one and two months off work. We dont yet know
what the long-term effects of acetabular labrum
surgery are, but you may get better hip movement
as a result of it.