Chapter 65: Hip, buttock and groin pain

Pain in the hip, buttock, groin and upper thigh tends to be interrelated. Patients often present complaining of pain in the ‘hip’ but point to the buttock or lower back as the site of their pain. Most pain in the buttock has a lumbosacral origin. Pain originating from disorders of the lumbosacral spine (commonly) and the knee (uncommonly) can be referred to the hip region, while pain from the hip joint (L3 innervation) may be referred commonly to the thigh and the knee. Disorders of the abdomen, retroperitoneal region and pelvis may cause hip and groin pain, sometimes mediated by irritation of the psoas muscle.

A summary of the diagnostic strategy model is presented in TABLE 65.1.

Probability diagnosis

The commonest cause of hip and buttock pain presenting in general practice is referred pain from the lumbosacral spine and the sacroiliac joints.¹ The pain is invariably referred to the outer buttock and posterior hip area (see FIG. 65.2). The origin of the pain can be the facet joints of the lumbar spine, intervertebral disc disruption or, less commonly, the SIJs. Much of this pain is inappropriately referred to as ‘lumbago’, ‘fibrositis’ and ‘rheumatism’.

Trauma and overuse injuries from sporting activities are also common causes of muscular and ligamentous strains² around the buttock, hip and groin.

The hip joint is a common target of osteoarthritis. This usually presents after 50 years of age but can present earlier if the hip has been affected by another condition.

Serious disorders not to be missed

The major triad of serious disorders—cardiovascular, neoplasia and severe infections—are applicable to this area albeit limited in extent.

Aortoiliac occlusion

Ischaemic muscle pain, including buttock claudication secondary to aortoiliac arterial occlusion, is sometimes confused with musculoskeletal pain. An audible bruit over the vessels following exercise is one clue to diagnosis.

Neoplasia

Primary tumours including myeloma, lymphoma and sarcoma, can arise rarely in the upper femur and pelvis (especially the ileum). However, these areas are relatively common targets for metastases, especially from the prostate, breast and lung.

Infection

Some very important, at times ‘occult’, infections can develop in and around the hip joint.

Osteomyelitis is prone to develop in the metaphysis of the upper end of the femur and must be considered in the child with intense pain, a severe limp and fever. Tuberculosis may also present in children (usually under 10 years) with a presentation similar to Perthes disease.

Transient synovitis or ‘irritable hip’ is the most common cause of hip pain and limp in childhood.

Inflammation of the side wall of the pelvis as in a deep pelvic abscess (e.g. from appendicitis), pelvic inflammatory disease (PID) including pyosalpinx, or an ischiorectal abscess, can cause deep hip and groin pain and a limp. This pain may be related to irritation of the obturator nerve.

Retroperitoneal haematoma can cause referred pain and femoral nerve palsy.

Childhood disorders that must not be missed include:

• DDH and acetabular dysplasia

• Perthes disease

• SCFE

• stress fractures of the femoral neck

Inflammatory disorders of the hip joint that should be kept in mind include:

• rheumatoid arthritis

• juvenile chronic arthritis (JCA)

• rheumatic fever (a flitting polyarthritis)

• spondyloarthropathy

Pitfalls

There are many pitfalls associated with hip and buttock pain and these include the various childhood problems. Fractures can be a pitfall, especially subcapital fractures.

SIJ disorders are often missed, whether it be the inflammation of sacroiliitis or mechanical dysfunction of the joint.

Inflammatory conditions around the hip girdle are common and so are often misdiagnosed. These include the common gluteus medius tendonitis and trochanteric bursitis (greater trochanteric pain syndrome).

Polymyalgia rheumatica commonly causes shoulder girdle pain in the elderly but pain around the hip girdle can accompany this important problem.

Chilblains around the upper thighs occur in cold climates and are often known as ‘jodhpur’ chilblains because they tend to occur during horse riding in very cold weather.

Nerve entrapment syndromes require consideration. Meralgia paraesthetica is a nerve entrapment causing pain and paraesthesia over the lateral aspect of the hip (see FIG. 66.3, CHAPTER 66).

An interesting modern phenomenon is the so-called ‘hip pocket nerve’ syndrome. If a man presents with ‘sciatica’, especially confined to the buttock and upper posterior thigh (without local back pain), consider the possibility of pressure on the sciatic nerve from a wallet in the hip pocket. This problem is occasionally encountered in people sitting for long periods in cars (e.g. taxi drivers). It appears to be related to the increased presence of plastic credit cards in wallets (see FIG. 65.3).

Paget disease can involve the upper end of the femur and the pelvis. Increased pain may indicate a fracture or malignant change causing osteosarcoma.

General pitfalls

• Failure to test the hips of neonates carefully and follow up developmental dysplasia of the hip.

• Misdiagnosis of arthritis and other disorders of the hip joint because of referred pain.

• Overlooking an SCFE or a stress fracture of the femoral neck in teenage boys, especially athletes. If an X-ray shows that the epiphysis is fusing or has fused, arrange a technetium bone scan.

Seven masquerades checklist

The one outstanding masquerade is spinal dysfunction, which is the most likely cause of pain in the buttock. Many dermatomes meet at the buttock and theoretically pain in the buttock can result from any lesion situated in a tissue derived from L1, L2, L3, S2, S3 and S4.¹ Symptoms from L3 can spread from the outer buttock to the front of the thigh and down the leg, over the medial aspect of the knee to the calf. Such a distribution is common to an L3 nerve root lesion and arthritis of the hip.

Furthermore, dysfunction of the facet joints and sacroiliac joints can refer pain to the buttock. The relatively common L1 lesion due to dysfunction at the T12–L1 spinal level can lead to referred pain over the outer upper quadrant of the buttock and also to the groin (see FIG. 65.2).

Psychogenic considerations

Cyriax¹ claims that the hip shares with the back and the shoulder ‘an enhanced liability to fixation’ for psychological reasons. This problem is often related to work compensation factors and overpowering stresses at home. A common finding in psychoneurotic patients complaining of buttock and thigh pain is 90° limitation of flexion at the hip joint. The importance of testing passive movements of the hip joint is obvious, for often such limitation of flexion is combined with a full range of rotation. In arthritis of the hip joint internal rotation is invariably affected first.

Such patients often walk into the office with a marked limp and leaning on a thick stick. It requires great skill to evaluate and manage them tactfully and successfully.

On the other hand, patients with genuine osteoarthritis fear being crippled and ending in a wheelchair. They require considerable education and reassurance.

History

Pain associated with hip joint pathology is usually described as a deep aching pain, aggravated by movement and felt in the groin and anteromedial aspect of the upper thigh, sometimes exclusively around the knee (see FIG. 66.1 in CHAPTER 66). A limp is a frequent association.

An obstetric history in a woman may be relevant for sacroiliac pain.

Key questions

• Can you tell me how the pain started?

• Could you describe the pain?

• Point to where the pain is exactly.

• Does the pain come on after walking for a while and stop as soon as you rest?

• Is there any stiffness, especially first thing in the morning?

• Do you have any difficulty climbing stairs?

• Do you get any backache?

• Do your movements feel free?

• Do you have a limp?

• Do you have a similar ache around the shoulders?

• Have you had an injury such as a fall?

• Have you lost any weight recently?

• Do you have night pain?

• Do you have trouble with shoes and socks?

• How far can you walk?

• Is it painful to lie on the affected side at night?

• Did you have a hip problem as a child?

• Does the pain respond to any treatments?

Examination

Follow the traditional methods of examination of any joint: LOOK, FEEL, MOVE, MEASURE, TEST FUNCTION, LOOK ELSEWHERE and X-RAY. The patient should strip down to the underpants to allow maximum exposure.

Inspection

Ask the patient to point exactly to the area of greatest discomfort. Careful observation of the patient, especially walking, provides useful diagnostic information. Note any antalgic (painful) gait—if walking with a limp, the leg adducted and foot somewhat externally rotated, osteoarthritis of the hip joint is the likely diagnosis.

If called to a patient who has suffered an injury such as a fall or vehicle accident, note the position of the leg. If shortened and externally rotated (see FIG. 65.4a), a fractured neck of femur is the provisional diagnosis; if internally rotated, suspect a posterior dislocation of the hip (see FIG. 65.4b). With anterior dislocation of the hip, the hip is externally rotated.

Get the patient to lie supine on the couch with the anterior superior iliac spines (ASISs) of the pelvis placed squarely and note the shape and position of the limbs. Look for muscle wasting.

Palpation

Feel one to two finger breadths below the midpoint of the inguinal ligament for joint tenderness. Check for trochanteric bursitis, gluteus medius tendonitis and other soft tissue problems over the most lateral bony aspect of the upper thigh.

Movements

• Passive movements with patient supine (normal range is indicated):

  • – flexion with patient’s knees flexed (compare both sides): 0–125°

  • – external rotation (knee and hip extended in adults): 0–45°

  • – internal rotation (knee and hip extended in adults): 0–45°

  • – abduction (stand on same side—steady pelvis): 0–45°

  • – adduction (should see the patella of the opposite leg): 0–30°

In children it is most important to measure rotation and abduction/adduction with the knee and hip flexed to detect early Perthes disease or SCFE.

• Patient prone:

  • – extension (one hand held over SIJ): 0–20°

Note: Osteoarthritis of the hip typically affects internal rotation (IR), extension and abduction first.

Measurements

• True leg length (ASIS to medial malleolus)

• Apparent leg length (umbilicus to medial malleolus)

Note:

• Unequal true leg length = hip disease on shorter side

• Unequal apparent leg length = tilting of pelvis

Feel the height of the greater trochanter relative to the ASIS to determine if shortening is in the hip or below.

Test function including gait and special tests

Gait:

• Antalgic gait—shortened stance phase of affected leg, as patient doesn’t want to stand on it, indicates pain with weight-bearing

• Coxalgic gait—upper torso shifts towards painful side due to pain in the hip

• Trendelenburg gait (the gluteus medius lurch)—similar to coxalgic but pelvis tilts

• Trendelenburg test—tests hip abductors (gluteus medius): the non-weight-bearing hemipelvis drops if abnormal

• Thomas test—tests for fixed flexion deformity

• Squeeze test for osteitis pubis

• Femoroacetabular impingement^2,3 (FAI)—get the patient to hold the hip in 90° of flexion and maximal internal rotation. Then bring the leg into adduction (FADIR test). Reproduction of pain is a positive test and indicates intra-articular hip pathology such as labral tears and a cam or Ganz (bone outgrowth) lesion. The FABERE test (see later in chapter) also tests for this pathology. FAI causes anterior groin and trochanteric regional pain.

Look elsewhere

Examine the lumbosacral spine, SIJs, groin and knee. Consider hernias and possibility of PID. Feel pulses and test for femoral bruits.

Investigations

These can be selected from:

• serological tests: RA factor, FBE, ESR, C-reactive protein

• radiological:

  • – plain AP X-ray of pelvis showing both hip joints

  • – lateral X-ray (‘frog’ lateral best in children)

  • – X-ray of lumbosacral spine and SIJs

  • – CT scan: hip joint, pelvis, lumbosacral spine

  • – MRI scan: stress fracture, early avascular necrosis, early osteomyelitis, labral tears of hip joint, metastases, soft tissue tumours

  • – isotope bone scan; useful for whole body bony metastases

• needle aspiration of joint: if septic arthritis suspected

Role of ultrasound

Ultrasound diagnosis is now sensitive in children in detecting fluid in the hip joint, and can diagnose septic arthritis and also localise the site of an osteomyelitic abscess around a swollen joint. It can accurately assess the neonatal hip joint and confirm the position of the femoral head in children <6 months. Ultrasound is used less since increased availability of MRI.

Hip disorders have an important place in childhood and may present with a limp when the child is walking. These important disorders include:

• DDH

• congenital subluxation of hip and acetabular dysplasia

• transient synovitis

• Perthes disease

• septic arthritis/osteomyelitis

• SCFE

• pathological fractures through bone cyst

The important features of hip pain in children are summarised in TABLE 65.2.

Developmental dysplasia of the hip

In DDH, previously known as congenital dislocation of the hip, the underdeveloped femoral head dislocates posteriorly and superiorly. DDH is described as transiently unstable or as a mild subluxation (1 in 80 hips at birth, which stabilises in a few days) and frankly dislocated (1 in 800 hips).⁴ Risk factors include the ‘5 Fs’: female, first born, family history, foot abnormalities, ‘funny’ delivery (breech or transverse), as well as oligohydramnios and caesarean section.

Clinical features

• Females:males = 6:1

• Asymmetry in 40%

• Bilateral in one-third

• Tight adductors and short leg evident

• Diagnosed early by Ortolani and Barlow tests (abnormal thud or clunk on abduction); test usually negative after 2 months

• Ultrasound excellent (especially up to 6 months) and more sensitive than clinical examination

• X-ray difficult to interpret up to 3 months, then helpful

  Note:

  1. When diagnosed and treated from birth it is possible to produce a normal joint after a few months in an abduction splint.

  2. Every baby should be examined for DDH during the first day of life then regularly and before discharge from hospital and at the 6-week check.⁴ The Ortolani and Barlow tests remain important means of detecting an unstable or dislocated hip, but ultrasound is becoming more important and is recommended for high-risk babies (e.g. breech, family history of DDH).

Screening examination

Carry out the examination on a large firm bench with the baby stripped. Relaxation is essential; give the baby a bottle if necessary. Be gentle and have warm hands.

With the legs extended any asymmetry of the legs, especially any shortening, or skin creases is noted.

• Hold the leg in the hand with knee flexed—thumb over groin (lesser trochanter) and middle finger over greater trochanter (see FIG. 65.5). Steady the pelvis with the other hand.

• Flex hips to about 90°, gently abduct to 45° (note any clunk or jerk as hip reduces).

• As one hand stabilises the pelvis, grasp the knee of the relevant leg, then flex the hip to 90°, abduct 10–20°.

• With gentle but firm backward pressure, rock the femur backwards and forwards on the pelvis by pressing forward with the middle finger and backwards with the thumb. Note any jerk or clunk as hip ‘goes out’ of the acetabulum. If the femoral head displaces, there is dislocation.

Plain X-ray has little or no place in the diagnosis of DDH in the neonatal period.⁵ Ultrasound imaging is recommended. Early referral for treatment is essential. If not detected early the femoral head stays out of the acetabulum and after the age of 1 year the child may present with delay in walking or a limp. The diagnosis is then detected by X-ray.

Treatment (guidelines)

• DDH must be referred to a specialist⁴

• 0–6 months—Pavlik harness or abduction splint

• 3–18 months—reduction (closed or open) and cast (pelvic spica)

• >18 months—open reduction and possible osteotomy

  Slings are not recommended

Note: Despite early treatment some cases progress to acetabular dysplasia (underdevelopment of the ‘roof’ of the hip joint) and to premature osteoarthritis. Thus a follow-up X-ray of the pelvis during teenage years should be considered for anyone with a history of DDH.

Perthes disease

Perthes disease results in the femoral head becoming partly or totally avascular (i.e. avascular necrosis).

Clinical features

• Males:females = 4:1

• Usual age 4–8 years; range 2–12 years (rarely 2–18 years)

• Sometimes bilateral

• Presents as a limp and aching (hip or groin pain)

• May be knee pain

• ‘Irritable’ hip early

• Limited movement in abduction and IR

X-ray. Joint space appears increased and femoral head too lateral: typical changes of sclerosis, deformity and collapse of the femoral capital epiphysis may be delayed.

Management

• Refer urgently (provide crutches)

• Aim is to keep femoral head from becoming flat

• Choice of treatment depends on severity of the condition and age of the patient

If untreated, the femoral head usually becomes flat over some months, leading to eventual osteoarthritis. Some untreated cases of Perthes disease heal and have a normal X-ray.

Transient synovitis

This common condition is also known as ‘irritable hip’ or observation hip and is the consequence of a self-limiting synovial inflammation.

Clinical features

• Child aged 3–8 years (usually 6 years)

• Sudden onset of hip pain and a limp

• Child can usually walk but with pain (some may not)

• May be history of trauma or recent URTI or viral illness

• Painful limitation of movements, especially abduction and rotation

• Blood tests and X-rays normal (may be soft tissue swelling); ESR may be mildly elevated

• Ultrasound shows fluid in the joint

Differential diagnosis. This includes septic arthritis, JCA, Perthes disease.

Outcome. It settles to normal within 7 days, without sequelae.

Treatment. Refer early. Treatment is bed rest or the use of crutches and analgesics. Follow-up X-ray is needed in 4 to 6 months to exclude Perthes disease. Aspiration under general anaesthetic may be needed to exclude septic arthritis.

Slipped capital femoral epiphysis

One problem of the displaced capital epiphysis of the femoral head (SCFE) is when some patients develop avascular necrosis despite expert treatment. Diagnosis of the condition before major slipping is important. This necessitates early consultation with the teenager experiencing hip or knee discomfort and then accurate interpretation of X-rays.

Clinical features

• Adolescent 10–15 years, often obese

• Most common in the oversized and undersexed (e.g. the heavy prepubertal boy)

• Bilateral in 20%

• Limp and irritability of hip on movement

• Anterior hip (groin) pain

• Knee pain

• Hip rotating into external rotation on flexion and often lies in external rotation (ER)

• Most movements restricted, especially IR

Any adolescent with a limp or knee pain should have X-rays (AP and frog view) of both hips (see FIG. 65.6). Otherwise, this important condition will be overlooked. SCFE is graded I to IV. The femoral head is located posterior-inferior.

Management

• Cease weight-bearing and refer urgently to an orthopaedic surgeon. Also refer if the clinical signs indicate SCFE but the X-rays look normal.

• If acute slip, gentle reduction via traction is better than manipulation in preventing later avascular necrosis.

• Once reduced, pinning is performed.

Septic arthritis

Septic arthritis of the hip should be suspected in all children with acutely painful or irritable hip problems. These patients may not be obviously sick on presentation, particularly in infants <2 years. A negative needle aspiration does not exclude septic arthritis. If sepsis is suspected it is better to proceed to an arthrotomy if clinically indicated.

The irritable hip syndrome should be diagnosed only after negative investigations, including plain films and ultrasound, full blood examination, ESR and bone scan. Needle aspiration has to be considered but irritable hip is often diagnosed without it, by observing in hospital in traction. If a deterioration or elevated temperature develops, needle aspiration with or without arthrotomy is indicated.

Avulsion bony injuries

Forceful contraction of muscles originating around the pelvis can lead to avulsion at their origin in those with skeletal immaturity. This causes acute pain and muscular dysfunction:

• anterior superior iliac spine (sartorius)

• anterior inferior iliac spine (long head rectus femoris)

• ischial tuberosity (hamstrings)

• lesser trochanter (psoas)

Management includes X-ray and referral. As a rule, surgical reattachment is not required.

The little athlete

The most common problem in the little athlete is pain or discomfort in the region of the iliac crest or anterior or superior iliac spines, usually associated with traction apophysitis or with acute avulsion fractures.⁷ There is localised tenderness with pain on stretching and athletes should rest until they can compete without discomfort.

If there are persistent signs, pain in the knee, hip irritability or restricted range of motion, X-rays should be ordered to exclude serious problems such as SCFE or Perthes disease.

The following conditions are highly significant in the elderly:

• 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

Subcapital fractures

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.

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).

Avascular necrosis

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.

Osteoarthritis of the hip

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.

Clinical features

• 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

Examination

• 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

Treatment

• 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

Surgery

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.

Groin pain

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.

Acute groin pain

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

Chronic groin pain

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.

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.

Hip labral tears and FAI^9,10

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

Sacroiliac pain

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.

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.

Causes of SIJ disorders

• 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

Examination

The SIJs are difficult to palpate and examine but there are several tests that provoke them.

Direct pressure. With the patient lying prone a rhythmic springing force is applied directly to the upper and lower sacrum respectively.

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.

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.

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.

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).

Mechanical disorders of the SIJ

These problems are more common than appreciated and can be caused by hypomobile or hypermobile problems.

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

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.

Greater trochanteric pain syndrome¹³

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.

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.

Clinical features

• 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

Treatment¹²

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.

• 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.

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.

Fascia lata syndrome

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.

Ischial bursitis

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.

Clinical features

• Severe pain when sitting, especially on a hard chair

• Tenderness at or just above the ischial tuberosity

Treatment

• Infiltration into the tender spot of a mixture of 4 mL of 1% lignocaine and 1 mL of LA corticosteroid (avoid the sciatic nerve)

• Foam rubber cushion with two holes cut out for the ischial prominences

Snapping or clicking hip (coxa saltans)

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.

Causes

• 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

Treatment

The basics of treatment are:

• explanation and reassurance

• exercises to stretch the iliotibial band¹³

Occasionally surgery is necessary to lengthen the iliotibial band.

• 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.

• Clinical evidence or suspicion of severe childhood disorders: DDH, Perthes disease, septic arthritis, SCFE or osteomyelitis

• Undiagnosed pain, especially night pain

• Any fractures or suspicion of fractures such as impacted subcapital fracture or stress fracture of the femoral neck

• Patients with true claudication in buttock, whether it is vascular from aortoiliac occlusion or neurogenic from spinal canal stenosis

• Patients with disabling osteoarthritis of the hip not responding to conservative measures; excellent results are obtained from surgery to the hip

• Any mass or lump

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Bursitis and tendonitis of outer hip

• Hip: osteoarthritis

<http://www.ddheducation.com>

Healthy Hips Australia. <www.healthyhipsaustralia.org.au/>.