Differential diagnosis for hip pain

Hip Osteoarthritis
Presentation
>55 years old Persistent pain localised to the groin and buttock or may radiate down the leg (no lower than the knee) May have referred knee pain Worse with prolonged use eg weight bearing activities such as walking and standing. Also prolonged sitting with hip in flexion Stiffness after prolonged rest Early morning stiffness not usually lasting for longer than 30 minutes Eased with rest and NSAIDs For severe OA hip: Analgesia and NSAIDs as appropriate X-ray to confirm diagnosis and severity of OA Orthopaedic referral if pain and function still severely limited and meets criteria for hip replacement

Greater trochanteric pain syndrome (lateral soft tissue hip pain)

Presentation
Chronic lateral hip or buttock pain which may spread down lateral thigh to the knee Aggravated by lying on the affected side May have coexisting low back pain Females more than males More prevalent in 40-60 years Aggravated by prolonged standing, getting up from sitting, sitting crossed legged, climbing stairs, running/high impact activity Usually unilateral but can be bilateral Mechanism of injury - can be secondary to acute trauma or insidious onset due to overuse/ repetitive activity Possibly related to obesity

Assessment
Painful loss of medial rotation Loss of other hip ROM normally abduction, lateral rotation and extension Antalgic gait/Trendelenberg gait Positive Trendelenberg Pain reproduced on flexion and adduction of hip Stiff accessory glides

Management
For mild to moderate OA hip: Analgesia and NSAIDs as appropriate X-ray to confirm diagnosis and severity of OA MSK assessment for mild-mod Orthopaedic referral Treatment to include information on OA, exercises (local muscle strengthening and stretching and aerobic), pacing advice, joint protection advice, assistive devices eg stick, shoe horns etc, insoles if indicated, weight management, advice on heat and cold, TENS (NICE guidelines)

Assessment
Localised tenderness on palpation greater trochanter Single leg standing for 30 secs reproduces pain Internal rotation test reproduces pain - hip flexed to 90 and laterally rotated as much as possible without reproducing pain. Resist return to neutral. Positive result - lateral hip pain reproduced Pain on resisted hip abduction Positive Trendelenberg

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Management
NSAIDs and analgesia as appropriate MSK referral Injection (if no response to blind steroid injection consider referral for ultrasound scan plus guided injection) Orthopaedic referral

Other hip differential diagnosis

Red flags Avascular necrosis Femoroacetabular impingement Suspected groin strain

References

Differentiation from lumbar spine pathology

Some patients may have a coexisting lumbar spine pathology that is a separate problem to the lateral hip pain. These patients need to be differentiated from patients with lateral hip pain that is referred from the lumbar spine. Radicular pain from lumbar spine would: Be reproduced on lumbar spine movements Positive SLR

NICE guidelines - osteoarthritis CG59 2008 Simms et al 1999 Assessment and treatment of hip osteoarthritis. Manual Therapy. 4(3), pp.136-144. Del Buono et al 2011 Management of the greater trochanteric pain syndrome: a systematic review. British Medical Bulletin Lequesne et al (2008) Gluteal tendinopathy in refractory greater trochanter pain syndrome: diagnostic value of two clinical tests. Arthritis Care and Research. 59(2), pp.241-246 Greater trochanteric pain syndrome: A review of the anatomy, diagnosis and treatment. Anaesthesia and Analgesia.108(5), pp.1662-1670

Leeds Community Healthcare NHS Trust, February 2012 ref: 0390/S

www.leedscommunityhealthcare.nhs.uk/msk