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The following conditions are highly significant in the elderly:
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osteoarthritis of the hip
aortoiliac arterial occlusion → vascular claudication
spinal dysfunction with nerve root or referred pain
degenerative spondylosis of lumbosacral spine → neurogenic claudication
polymyalgia rheumatica
trochanteric bursitis
fractured neck of femur
secondary tumours
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The impacted subcapital fractured femoral neck can often permit weight-bearing by an elderly patient. No obvious deformity of the leg is present. Radiographs are therefore essential for the investigation of all painful hips in the elderly. Patients often give a story of two falls—the first5 very painful, the second with the hip just ‘giving way’ as the femoral head fell off.
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The displaced subcapital fracture has at least a 40% incidence of avascular necrosis and usually requires prosthetic replacement in patients over 70 years. MRI scan is the investigation of choice if the X-rays are normal. Intertrochanteric fractures are also common (see CHAPTER 133).
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The age of onset is usually 20–50 (average 38 years). Consider this with hip pain and deep groin pain especially with IR in those at risk: corticosteroid use, SLE, sickle cell disease, past hip fracture or dislocation, pregnancy, alcoholic liver disease. Investigate with imaging (as above) and refer.
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Osteoarthritis of the hip
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Osteoarthritis of the hip is the most common form of hip disorder. It can be caused by primary osteoarthritis, which is related to an intrinsic disorder of articular cartilage, or to secondary osteoarthritis. Predisposing factors to the latter include previous trauma, DDH, septic arthritis, acetabular dysplasia, SCFE and past inflammatory arthritis.
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Equal sex incidence
Usually after 50 years, increases with age
May be bilateral: starts in one, other follows
Insidious onset
At first, pain worse with activity, relieved by rest, and then nocturnal pain and pain after resting
Stiffness, especially after rising
Characteristic deformity
Stiffness, deformity and limp may dominate (pain mild)
Pain usually in groin—may be referred to medial aspect of thigh, buttock or knee
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Antalgic gait
Usually gluteal and quadriceps wasting
First hip movements lost are IR and extension
Fixed flexion deformity
Hip held in flexion and ER (at first)
Eventually all movements affected
Order of movement loss is IR, extension, abduction, adduction, flexion, ER
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Careful explanation: patients fear osteoarthritis of hip
Weight loss if overweight
Relative rest
Use crutches for acute pain
Analgesics and NSAIDs (judicious use)
Aids and supports (e.g. walking stick)
Physiotherapy
Physical therapy, including isometric exercises
Hydrotherapy—very useful
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This is an excellent option for those with severe pain or disability unresponsive to conservative measures. Total hip replacement is the treatment of choice in older patients but a femoral osteotomy may be considered in younger patients in selected cases. In selected patients in their 30s and 40s with severe disease, total hip replacement is being performed successfully. A type of total hip replacement called hip resurfacing is becoming more popular in certain situations in patients under 60 years of age; >90% achieve a good result. Most replacements last 15–20 years.
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All conditions involving the hip joint, especially osteoarthritis, can present with groin pain. Consider an unrecognised fracture in neck of femur, psoas abscess, Paget disease, osteitis pubis and hernias. Also consider hip labral or chondral lesions. Hip labral injuries present with inguinal pain or upper anterior thigh pain, and require investigation and referral.
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Acute groin problems include muscular and musculotendinous strains, as well as common overuse sporting injuries such as tendonopathy and tendoperiostitis. These need to be differentiated from referred pain from the lumbosacral spine, hip and pelvis problems such as hip labral injuries. More common acute groin injuries include injuries to the following muscles and their tendons: adductor longus (e.g. musculotendinous strains causing inner thigh pain), rectus femoris, sartorius and iliopsoas. The relatively common adductor muscle or tendon injury results in upper thigh pain, local tenderness and resisted hip adduction. Ultrasound or MRI confirms the diagnosis. Treatment is based on physiotherapy, exercises and possibly a corticosteroid injection
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There are many causes of chronic groin pain, the commonest being bone and joint abnormalities. Important causes involve muscle and musculotendinous lesions, including adductor longus tendoperiostitis, osteitis pubis (pubic symphysis), iliopsoas bursitis, stress fractures (e.g. femoral neck and pubic rami), ‘occult’ inguinal or femoral hernias and referred pain from musculoskeletal disorders of the lumbosacral spine and hip.
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Investigations include X-ray of the pelvis, tomography of the pubic symphysis (to detect osteitis pubis and pubic instability), bone scan to detect stress fractures or osteitis pubis, herniography and imaging such as CT scan, MRI or ultrasound.
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Hip labral tears and FAI9,10
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Acetabular labral tears are becoming better recognised in motor accident victims, dancers and athletes, especially with the use of MRI and hip arthroscopy. Patients may complain of sharp impingement pain in the hip and/or groin and of painful clicking, catching or locking. The impingement test should be performed (see earlier in chapter). X-rays will exclude bony hip pathology while MRI is the radiological investigation of choice. According to Paoloni, examination after hip joint anaesthetic injection is the gold standard for diagnosing hip pathology.11 Refer for possible surgical treatment through hip arthroscopy. However, there are no proven effective treatments for FAI and hip labral tears, so any interventions should be approached cautiously.3
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Pain arising from SIJ disorders is normally experienced as a dull ache in the buttock but can be referred to the groin or posterior aspect of the thigh. It may mimic pain from the lumbosacral spine or the hip joint. The pain may be unilateral or bilateral. It is worse in loading situations, e.g. walking, running, getting in and out of cars.
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There are no accompanying neurological symptoms such as paraesthesia or numbness but it is common for more severe cases to cause a heavy aching feeling in the upper thigh.
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Causes of SIJ disorders
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Inflammatory (the spondyloarthropathies)
Infections (e.g. TB, Staphylococcus aureus—rare)
Osteitis condensans ilii
Degenerative changes
Mechanical disorders
Post-traumatic, after sacroiliac disruption or fracture
Childbirth—in postnatal period
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The SIJs are difficult to palpate and examine but there are several tests that provoke them.
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Direct pressure. With the patient lying prone a rhythmic springing force is applied directly to the upper and lower sacrum respectively.
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Winged compression test. With the patient lying supine and with arms crossed, ‘separate’ the iliac crests with a downwards and outwards pressure. This compresses the SIJs.
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Lateral compression test. With hands placed on the iliac crests, thumbs on the ASISs and heels of hand on the rim of the pelvis, compress the pelvis. This distracts the SIJs.
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Patrick or FABERE test. This method can provoke the hip as well as the SIJ. The patient lies supine on the table and the foot of the involved side and extremity is placed on the opposite knee (the hip joint is now flexed, externally rotated and abducted). The knee and opposite ASIS are pressed downwards simultaneously (see FIG. 65.7). If low back or buttock pain is reproduced the cause is likely to be a disorder of the SIJ.
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Unequal sacral ‘rise’ test. Squat behind the standing patient and place hands on top of the iliac crests and thumbs on the posterior superior iliac spines (PSIS). Ask the patient to bend slowly forwards and touch the floor. If one side moves higher relative to the other a problem may exist in the SIJs (e.g. a hypomobile lesion in the painful side if that side’s PSIS moves higher).
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Mechanical disorders of the SIJ
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These problems are more common than appreciated and can be caused by hypomobile or hypermobile problems.
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Hypomobile SIJ disorders are usually encountered in young people after some traumatic event, especially women following childbirth (notably multiple or difficult childbirth), or after a heavy fall onto the buttocks, as well as in those with structural problems (e.g. shortened leg). Pain tends to follow rotational stresses of the SIJ (e.g. tennis, dancing). Excellent results are obtained by passive mobilisation or manipulation, such as the non-specific rotation technique with the patient lying supine.12
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Hypermobile SIJ disorders are sometimes seen in athletes with instability of the symphysis pubis, in women after childbirth and in those with a history of severe trauma to the pelvis (e.g. MVAs, horse riders with foot caught in the stirrups after a fall). The patient presents typically with severe aching pain in the lower back, buttocks or upper thigh. Such problems are difficult to treat and manual therapy usually exacerbates the symptoms. Treatment consists of relative rest, analgesics and a sacroiliac supportive belt.
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Greater trochanteric pain syndrome13
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Pain around the lateral aspect of the hip is a common disorder, and is usually seen as lateral hip pain radiating down the lateral aspect of the thigh in older people engaged in walking exercises, tennis and similar activities. It is analogous in a way to the shoulder girdle, where supraspinatus tendonitis and subacromial bursitis are common wear-and-tear injuries.
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The cause is tendonopathy of the gluteus medius tendon (considered to be the main pathology), where it inserts into the lateral surface of the greater trochanter of the femur and/or gluteus minimus tendon with or without inflammation of the trochanteric bursa. Weakness of these abductor muscles has been demonstrated. The degenerative tendon may tear, rupture or become detached. The pain of this condition tends to occur at night, especially after activity such as long walks and gardening. X-rays are usually normal but ultrasound may demonstrate the pathology.
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Older person especially female >45–50 years
Pain on outside hip referred to as far as foot
Pain on lying on hip at night
Pain climbing stairs, getting in and out of car
Limp
Localised tenderness on outer border of thigh
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A trial of NSAIDs (weigh the risks) is worthwhile and physiotherapy involving hip-strengthening exercises is first-line treatment. Injection therapy, including under ultrasound, is also very effective and facilitates exercises.
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Method of injection without ultrasound
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Determine the points of maximal tenderness over the trochanteric region and mark them. (For tendonopathy, this point is immediately over or above the superior aspect of the greater trochanter—see FIG. 65.8).
Inject aliquots of a mixture of 1 mL of long-acting corticosteroid with 4–5 mL of local anaesthetic into the tender area, which usually occupies an area similar to that of a standard marble.
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The injection may be very effective for a variable time. Follow-up management includes sleeping with a small pillow under the involved buttock, sleeping on a sheepskin rug, and stretching the gluteal muscles with knee–chest exercises, which are the key to relief.12 Advise the patient to walk with the feet turned out—‘the Charlie Chaplin gait’. One or two repeat injections over 6 or 12 months may be required. Surgical intervention such as iliotibial band release ± bursectomy may be necessary. Local application of ice and massage therapy may provide relief. Massaging the site with fingers, a soft drink bottle or a tennis ball (while lying on the side) may also be effective.
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Pain in the lateral thigh can be caused by inflammation of the fascia lata. It is often due to overuse or weak musculature around the hip. Treatment is relative rest and physiotherapy.
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Tailor’s bottom or ‘weaver’s bottom’, which is occasionally seen, is a bursa overlying the ischial tuberosity. Irritation of the sciatic nerve may coexist and the patient may appear to have sciatica.
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Severe pain when sitting, especially on a hard chair
Tenderness at or just above the ischial tuberosity
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Snapping or clicking hip (coxa saltans)
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Some patients complain of a clunking, clicking or snapping hip, either palpable and/or audible. This represents an annoying problem that may cause pain in the groin or thigh. It is more common in females with a wide pelvis.
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A taut iliotibial band (tendon or tensor fascia femoris) slipping backwards and forwards over the prominence of the greater trochanter
or
The iliopsoas tendon snapping across the iliopectineal eminence at the anterior brim of the pelvis
The gluteus maximus sliding across the greater trochanter
Joint laxity
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The basics of treatment are:
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Occasionally surgery is necessary to lengthen the iliotibial band.
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The patient lies on the ‘normal’ side and flexes the affected hip, with the leg straight and a weight around the ankle (see FIG. 65.9), to a degree that produces a stretching sensation along the lateral aspect of the thigh.
This iliotibial stretch should be performed for 1–2 minutes, twice daily.
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