Hip and pelvic pain and Rheumatic disease 4.25/5 (4)

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Hip pain. Illustration: Injurymap. CC BY-SA 4.0

Definition

Among adults over the age of 60, 14% have hip pain almost every day. Hip pain goes beyond very important daily functions such as walking and standing. In addition, the pain will affect the quality of life. However, diagnosing the underlying cause is not always easy. The pain may be radiating from the back, abdomen or knees. In the hips are mucositis (bursitis), pinching of the joint capsule (femoroacetabular impingement) and Osteoarthrtitis is among the most common causes. In younger people, injuries to tendons and joint capsules due to overload (sports) are most often seen. Hip pain can also be part of more common (generalized) pain, such as Fibromyalgia. Rheumatic inflammation of the joint is less common, but can be the cause of hip pain in all age groups. Hip pain can be divided into three main groups depending on where the symptoms originate from: 1) Joint disease, 2) Joint capsule and tendons, 3) Areas outside the hip joints. Hip pain is most often examined by a general practitioner / GP, physiotherapist and orthopedist (medical specialist). In case of signs of arthritis (arthritis), rheumatological assessment is recommended.

Examinations for hip pain

Medical history should include further questioning of symptoms such as location, duration and development over time. How is daily function affected? Is there prior injury or illness in the back, abdomen, groin, knees, muscles or nervous system?  

Clinical examination can assess gait function (limping?), movement in the hip joints during rotation, stretching and bending. Normal range of motion is flexion (bend) 100 °, extension (stretch) 30 °, abduction 40 ° and adduction 20 ° (movement outwards and inwards towards the body, respectively). Inward and outward rotation at 45 ° flexion is 20 °. The muscles in the pelvis and thighs are inspected and assessed for power failure. Signs of nerve damage are observed. If necessary, supplement with more detailed tests. Groin and abdominal area are assessed.

Laboratory tests may include tests for inflammation (CRP, SR), cell counts (hemoglobin, white blood cells (leukocytes), platelets (platelets), liver and kidney function tests (ALP, AST, ALT, gamma-GT and creatinine, eGFR), respectively. if arthritis (arthritis), additional tests are relevant.

Imaging with X-ray, ultrasound, CT or MRI done based on medical history and results of clinical and laboratory examinations.

Causes of hip and pelvic pain

Arthritis

  • Pain in the groin and in the front of the hip when moving and loading
  • By different arthritis / synovitis
  • Pain and reduced movement upon examination
  • Blood tests with increased CRP and SR
  • Imaging with ultrasound and MRI

Osteoarthritis

  • Pain in the groin and anterior part of the hip when moving and loading
  • Stiffness and pain during and after stress
  • Pain radiates to the groin
  • Reduced mobility during examination
  • Imaging with X-ray, CT or MRI

Avascular necrosis (osteonecrosis)

  • Can be triggered spontaneously and in case of femoral neck fracture. High doses of cortisone (Prednisone) is a risk factor
  • Pain in the hip is typical
  • Laboratory tests are usually normal
  • Imaging with MRI. (The X-ray is often normal in the first weeks)

Hernia

  • Due to the fact that connective tissue is weakened, often for unknown reasons, so that it bulges out in the groin or down into the punk (scrotum) in men.
  • Basically, the condition is painless. Eventually, pressure and reduced blood circulation can occur, so one has to have surgery.
  • Laboratory tests are normal.
  • The diagnosis is often made by clinical examination
  • Imaging is mostly done with ultrasound, although the condition is also seen on MRI and CT scans

Bursitis (Bursa inflammation)

  • The pain on the front of the hip with iliopsoas bursitis and on the outside of the hip with trochanter-bursitis
  • Laboratory tests are usually normal. If (less frequently) infection or related arthritis is also present, CRP and SR will be elevated

Fracture (Fracture) in femoral neck (between hip joint and femur)

  • Suddenly burning pains so that the leg can not be loaded.
  • The foot is often rotated outwards
  • May be difficult to detect among old with many symptoms
  • Blood tests are often normal or may show slightly elevated CRP
  • The diagnosis is made by X-ray examination

Dysplasia

  • Congenital hip injury that causes osteoarthritis eventually
  • Diagnosis by X-ray examination

Fibromyalgia

  • Daily pain in both legs, arms and parts of the neck and / or back
  • Most often women
  • Laboratory tests and imaging are normal

Gluteus muscle failure (pelvic floor muscle dysfunction)

  • Pain from the back and side of the pelvis
  • Unclear how the pain occurs (reference: Sadler S, 2019)
  • Weak muscle can be clinically detected by Trendlenburgs characters. One stands on one leg and observes that the pelvis on the opposite is lowered. Normally the pelvis should be kept stably horizontally or slightly raised.
  • Laboratory tests and imaging are expected to be normal.

Cancer in the skeleton

  • Metastases when spreading to the skeleton are serious for the prognosis. Causes pain in the pelvis and hips, general skeletal pain and new fatigue.
  • Men are most vulnerable because approx. 80% of cancers with spread to the skeleton are due to prostate cancer.
  • Laboratory tests may show slightly increased CRP and SR and other abnormal findings. High PSA in prostate cancer.
  • Imaging with ultrasound, CT, MRI or PET / CT may be relevant.
  • Tissue sample (biopsy) is crucial to ensure the diagnosis.

Joint capsule damage (rupture)

  • Pain in the front of the hip
  • May occur without cause. Running disposes
  • Laboratory tests are normal
  • Difficult to diagnose, even with supplementary regular MRI examination. MRI species program with injected contrast agent in the joint itself is the best imaging diagnostics (reference: Phawa S, 2014)

Luxation (hip out of joints)

Meralgia paresetica

  • Pain and numbness on the outside (lateral) of the thigh.
  • Injuries with pressure on the nerve in the pelvis are the most common cause. Rarely, the association with diabetes and neuropathy is another cause.

Muscle damage ("stretching")

  • Injury to the hip flexors (flexors) causes pain in the front of the hip and increased symptoms when one stretches the leg (backwards)
  • Damage to the hip extensors (extensors) or rotator cuff muscles causes pain in the back of the hip and increased symptoms during bending (flexion) or during rotation.
  • laboratory tests are normal
  • Imaging with MRI can show the damage

Iliotibial band syndrome

  • Pain unilaterally on the outside (laterally) of the hip and especially down towards the knee. Triggered after overload such as marathon running and hard training.
  • The pain may be stabbing and gradually increase with strain
  • The diagnosis is based on medical history and clinical examination
  • Laboratory tests and imaging are normal.

Sciatica

  • Pain radiating from the back, but pain down in one leg (without back pain) is also common.
  • Pain located behind the hip joint may occur, although symptoms from the leg and foot are more common.
  • The cause is often intervertebral disc prolapse with nerve compression.
  • Suspicion of diagnosis on the basis of medical history and clinical examination (Lasegues test, reflexes, sensitivity).
  • Laboratory tests are normal.
  • Imaging with a lumbar spine MRI is often crucial to the diagnosis.
  • Particularly in the elderly, it is important to rule out similar conditions, including cancer and infections

Osteomyelitis

  • Infection in the skeleton
  • Often, weakened immune system
  • Laboratory tests will show high levels of infection (CRP and SR). Puncture and bacterial examination confirm the diagnosis
  • Imaging with MRI gives strong suspicion of the condition

Piriformis syndrome

  • Pain and numbness in the back of the hip with radiance down the leg. Deterioration when sitting and walking.
  • It is believed to be due to compression of the sciatic nerve in the course of the pelvis (at the piriformis muscle)
  • Laboratory tests and imaging are often normal.
  • It is important to rule out other causes, such as intervertebral disc herniation in the back sciatica, inflammation of the iliosacral joint (including by Ankylosing spondylitis) and disease of the hip joint.

Sakroiliitt

  • Young people (uncommon after age 40).
  • Pain deep in the pelvis, typically worst in the morning, improvement with strain (inflammatory back pain)
  • Arthritis between the back and the pelvis that can be the start of Ankylosing spondylitis
  • Blood tests may show slightly increased CRP and SR and most have HLA-B27 (genetic predisposing factor)
  • Imaging. MRI of the pelvis shows early changes, but with the risk of overdiagnosis if uncertain result. CT of the iliosacral joint ensures the diagnosis.

Tendonitis

  • Overload, often during sports or particularly stressful work
  • Pain when pressing over the tendon.
  • Laboratory tests normal
  • Imaging with MRI often shows signs of inflammation

Septic arthritis

  • Infection of the hip joint causes severe pain (except for some special bacteria such as tuberculosis or Kingella kingae infection in young children.
  • Increased risk by reduced immune response (Diabetes, drugs, HIV)
  • Laboratory tests show clearly elevated inflammation tests such as CRP and SR.
  • Puncture of the joint with bacterial examinations is crucial for the diagnosis.
  • Imaging with MRI can give a strong suspicion of infection

Literature


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