Anterior Hip Pain

Adult Predominant Pathology

Femoral Neck Stress Fracture: Female with h/o osteopenia risk factors presents with deep anterolateral hip/groin pain with weight bearing after sudden increase in physical activity. No fevers. Pain with greater trochanter palpation, active leg raise, log roll test, hopping.

  • X-ray showing cortical disruption

  • MRI showing early bony edema

  • Refer to orthopedics; evaluate for management with PT vs. surgery

  • Pt advised to increase vitamin D intake

Femoroacetabular Impingement: Pt with h/o athletic involvement presents with insidious onset anterolateral hip pain provoked by rising from seated position. Positive FADIR and FABER tests on exam.

  • Radiography shows Cam or pincer deformity, acetabular retroversion, coxa profunda

  • PT x2-3 months; refer to orthopedics if no improvement s/p PT

Hip Labral Tear: Pt with h/o hip dislocation presents with painful hip catching/clicking with weight bearing. Pain radiates to lateral hip/anterior thigh/groin/buttock; no fevers. Antalgic gait, loss of internal rotation, positive FADIR and FABER tests on exam.

  • Consider hip x-ray prior and or MRI prior to magnetic resonance arthrography

  • Refer to orthopedics pending imaging

  • Notes

    • FADIR test

      • Knee flexion; adduction and internal rotation of leg

      • Sensitivity: 75-96%

    • FABER

      • Knee flexion; abduction and external rotation of leg

      • Sensitivity: 88%

    • Magnetic resonance arthrography

      • Gold standard test

      • Sensitivity 90%, accuracy 91%

Hip Osteonecrosis: Elderly pt with h/o limited motion presents with gradual onset of constant/deep/aching hip stiffness worse with prolonged standing/weight bearing. Decreased ROM and pain with extremes of motion on exam.

  • Plain radiographs show asymmetrical joint-space narrowing, osteophytes, subchondral sclerosis/cyst formation

  • Nonpharmacologic intervention: Weight loss (5% or more), exercise, physical therapy

  • Acetaminophen 650 to 1,000 mg four times per day

  • BMP to evaluate renal function prior to starting regular NSAID use

  • Ibuprofen 600 mg TID PRN, Naproxen 500 mg BID PRN, Diclofenac 50 mg TID PRN

  • Intra-articular lidocaine/triamcinolone (10mg) injection

  • Refer to surgery

Iliopsoas Bursitis: Pt with h/o athletic involvement presents with anterior hip pain. Reports intermittent catching/snapping/popping sensation; no fevers. Pain/snapping sensation with hip extension on exam.

  • No bony involvement on radiography

  • U/S showing bursitis, tendinopathy with fluid collection

  • Conservative management x4-6 weeks; pt advised to use NSAIDs, ice, heating pad for pain relief PRN

  • Deep bursa involvement: Refer to orthopedics as corticosteroid injection may provide additional relief

Transient Synovitis vs. Septic Arthritis

[3-8 y/o child] vs. [adult with h/o DM, RA, recent hip surgery] presents with acute onset, atraumatic anterior hip pain. Reports fevers; non-weight bearing due to pain. Unilateral limited ROM, positive log roll test.

  • Obtain CBC, ESR, CRP

  • Obtain MRI to differentiate septic arthritis vs. transient synovitis

    • If no evidence of septic arthritis, start ibuprofen

    • If effusion present on MRI, aspirate and send for culture

  • If MRI non-diagnostic, consider arthrocentesis of affected joint

  • Start ibuprofen

Notes

  • Commonly occurs in two populations

    • Pediatrics

      • Common between ages 4-11 years

      • Most common between ages 3-8 years

    • Adults with risk factors including

      • Diabetes mellitus

      • Rheumatoid arthritis

      • Recent hip surgery

  • Diagnosis

    • Fever only occurs in 60% of patients and is less common in the immunocompromised and elderly

    • Probability of a septic hip:

      • Weight bearing and CRP < 20: < 1%

      • Non-weight bearing and CRP > 20: 74%

    • Arthrocentesis is the diagnostic test of choice; imaging is not sensitive enough to rule out the condition

  • Ibuprofen shortens duration of transient synovitis; dosing will be age-dependent

Posterior Hip Pain

Piriformis syndrome: Pt with no h/o trauma presents with buttock pain with posterior thigh radiation. Pain worse with sitting/walking. No weakness, bowel/bladder dysfunction. Positive log roll test, sciatic notch tenderness on exam.

  • MRI shows no disc herniation

  • Refer to physical therapy

  • Consider orthopedics referral if pain does not improve s/p PT

Sacroiliac joint dysfunction: Pt with h/o minor sacral injury presents with posterior hip pain localized to sacroiliac joint that radiates to lumbar back/buttock/groin. Pt is currently pregnant. Sacroiliac pain elicited with palpation, positive FABER test.

  • Tylenol PRN for pain

  • Re-evaluate if pain persists s/p delivery

Greater Trochanteric Bursitis

Middle-aged F with presents with lateral hip pain that radiates down lateral thigh. Trendelenburg gait and pain with palpation over greater trochanter on exam.

  • Dynamic U/S showing iliotibial band snapping over greater trochanter

  • Acetaminophen 2g/day x2 weeks followed by NSAIDs if pain persists

  • Pain persisting for 4+ weeks: Local injection of bursa with 40mg methylprednisolone/5mL 1% lidocaine

  • Consider surgery if pain persists for greater than 1 year

Meralgia Paresthetica

Obese pt with h/o wearing restrictive clothing presents with numbness/tingling/burning of anterior thigh. Pt advised to lose weight and wear less restrictive clothing