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Probability diagnosis

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Traumatic muscular strains

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Referred pain from spine

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Greater trochanteric pain syndrome

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Osteoarthritis of hip

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Serious disorders not to be missed

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Cardiovascular:

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  • buttock claudication

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Neoplasia:

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  • metastatic cancer

  • osteoid osteoma

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Infection:

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  • septic arthritis

  • osteomyelitis

  • tuberculosis

  • pelvic and abdominal infections: pelvic abscess, pelvic inflammatory disease, prostatitis

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Childhood disorders:

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  • DDH

  • Perthes’ disease

  • slipped femoral epiphysis

  • transient synovitis (irritable hip)

  • juvenile chronic arthritis

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Pitfalls (often missed)

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Polymyalgia rheumatica

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Fractures:

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  • stress fractures femoral neck

  • subcapital fractures

  • sacrum

  • pubic rami

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Avascular necrosis femoral head

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Femoroacetabular impingement (e.g. exostoses)

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Torn acetabular labrum

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Sacroiliac joint disorders

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Inguinal or femoral hernia

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Bursitis or tendonitis:

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  • greater trochanteric pain syndrome

  • ischial bursitis

  • iliopsoas bursitis

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Osteitis pubis

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Neurogenic claudication

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Chilblains

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Rarities:

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  • haemarthrosis (e.g. haemophilia)

  • Paget disease

  • nerve entrapments: sciatica ‘hip pocket nerve’, obturator, lateral cutaneous nerve thigh

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Masquerades checklist

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Depression

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Spinal dysfunction incl. spinal stenosis

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Is the patient trying to tell me something?

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Non-organic pain may be present. Patient with arthritis may be fearful of being crippled.

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Key history

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Pain analysis, especially exact site and pain radiation. Associated symptoms such as limp, stiffness, night pain, fever. Past history, family history, obstetric history, drug history.

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Key examination

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  • The traditional method of look, feel, move, measure, test function and look elsewhere

  • The patient should be stripped to the underwear to allow maximal exposure

  • Also examine lumbosacral spine, sacroiliac joints, groin and knee

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Key investigations

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  • Serological tests: RA factor

  • FBE, ESR/CRP

  • Radiological tests: plain X-ray (AP) of pelvis to show both hip joints; lateral X-ray (‘frog’ lateral best in children)

  • CT or MRI of hip joint

  • Needle aspiration of joint if septic arthritis suspected

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Diagnostic tips

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  • True hip pain is felt in the groin, thigh and medial aspect of the knee.

  • Disorders of the hip joint commonly refer pain to the knee and thigh.

  • Limp has an inseparable relationship with painful hip and buttock conditions.

  • Keep in mind the greater trochanteric pain syndrome, especially when middle-aged women complain of hip pain.

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