Evaluation and management of hip pain: an algorithmic approach

Journal of Family Practice, August, 2003 by Katherine Margo, Jonathan Drezner, Daphne Motzkin

With the Thomas test, the contralateral hip is flexed, and the symptomatic hip is moved from hill flexion to till extension. A deep click palpated may be indicative of a labral tear.

The snapping hip maneuver (Figure 6) may also be helpful in diagnosing the cause of pain. Loss of sensation to the anterolateral thigh is consistent with meralgia paresthetica.

[FIGURE 6 OMITTED]

Palpation. Finally, palpate over specific structures, such as the hip flexor muscles, greater trochanter, iliotibial band, and gluteus medius muscle, to further localize the source of pain. For instance, tenderness may be present over the anterior soft tissues in a hip flexor muscle strain or iliopsoas bursitis, and over the greater trochanter in trochanteric bursitis.

* WHEN DIAGNOSTIC IMAGING IS BENEFICIAL

In most cases, a thorough history and physical examination are adequate to establish a diagnosis. In the Lamberts study, (5) only 16% of hip complaints required imaging for further elucidation. Table 2 summarizes use of imaging studies with different disorders.

X-ray studies

Patients with a history of traumatic injury, osteoporosis, cancer, high-dose corticosteroid exposure, or alcohol abuse are at higher risk of such bony hip pathology as fracture, osteoarthritis, or avascular necrosis. These patients should undergo x-ray studies during their initial evaluation. An anteroposterior pelvic radiograph and a lateral radiograph of the hip are appropriate.

Although no specific patient age has been identified as a threshold for ordering x-ray studies, we recommend that all patients older than 65 years with new-onset hip pain undergo such studies.

We also recommend x-ray films for a patient of any age who has chronic severe hip pain.

Magnetic resonance imaging

Advanced imaging may be required when initial conservative therapy is not effective or x-ray findings are unrevealing. Although computed tomography (CT) scan and bone scan have roles in the evaluation of some hip disorders, MRI has emerged as the study of choice in diagnosing hip pathology, especially in athletes. (13)

MRI offers valuable information regarding occult bony and cartilage injury such as stress fractures, avascular necrosis, and osteoarthritis, as well as soft tissue abnormalities such as muscle tears and bursitis. In a retrospective study of patients with suspected hip fracture but negative plain film results, MRI showed occult femoral fractures in 37% of patients, occult pelvic fractures in 23%, and associated soft-tissue abnormalities such as muscle edema and hematoma or joint effusion in 74%. (26)

Other imaging tests

In cases of suspected labral or intra-articular pathology, MR arthrography, anesthetic intra-articular injection and examination under local anesthesia, or diagnostic arthroscopy may be needed. (16) These are relatively new techniques that help diagnose disorders not previously recognized.

* TREATMENT

Depending on the presumed cause of pain, treatment options include activity modification, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, corticosteroid injections, physical therapy, and, if necessary, walking support.