HIP PAINByNoha Abd El Halim El SawyAss. Prof. PM, Rheum & Rehab.
synovialis ahip jointTheBall & socket,polyaxial,formed by thejointarticulation of therounded head of thelike-and the cupfemurof the pelvis.acetabulumIt forms the primaryconnection between thebones of the lower limbofaxial skeletonand thethe trunk and pelvis
Both joint surfaces arecovered with a strongbut lubricated layercalled articular hyalineexcept acartilagecentral roughdepression on thehead of femur calledthe fovea
-The cuplike acetabulum forms at the unionof three pelvic bones and the joint mayunder the age ofossifiednot be fullyyears
The shape of the socket(acetabulum) is a deep cupshaped cavity with a defect belowcalled the acetabular notch whichis completed by the acetabularligament .A lip of fibrocartilage called labrumacetabulare is also found.The articular cartilages are slipperyand rubbery to allow shockabsorption and provide a smoothsurface to make motion easier.
The joint has a strong but loosefibrous capsule ----- largestROM ( second only to theshoulder) and supports theweight of the body as well
Intracapsular structuresArticular bony surfaceRound ligament(ligamentum teres)Neck of femurSynovial membrane.
LigamentsThe hip joint is reinforced by three mainligaments
-At the front of thejoint, the strongiliofemoral ligamentattaches from the. It isfemurpelvis tooften considered tobe the strongestligament in thehuman body
iliofemoral ligamentFunction of theStrengthens the anterior aspect of thecapsulePrevent hyperextension & excessive lateralrotation of the hip joint.
pubofemoral ligamentTheattaches across the frontof the joint from thepubis bone of the pelvisto the femur. Thisligament is orientatedmore inferiorly than theiliofemoral ligament andreinforces the inferiorpart of the hip jointcapsule
pubofemoral ligamentFunction of theIt supports the inferomedial aspect of thecapsule.It limits excessive abduction of the hip.
The posterior of the hipjoint capsule isreinforced by theischiofemoralthatligamentattaches from theischial part of theacetabular rim to thefemur
Synovial membraneIt lines the inner surface of the fibrouscapsule.It invests the ligamentum teres.It covers the intracapsular non articularparts of the bones but does not extend onthe articular bony surfaces which arecovered by hyaline cartilage.
Nerve supply-Nerve to rectus femoris (femoral nerve).-Br. From the anterior division of obturatornerve.-Nerve to quadratus femoris.
Arterial supplyArterial supply of the head offemur:1- ascending br. Of nutrientartery of the femur reachesthe head through the neck.2-capsular ( retinacular)Bl.v. from trochantericanastomosis.3-arterty of round ligament offemur from the obturatorartery.
Muscles acting on the hip jointHip flexors:-Iliopsoas-rectus femoris-Pectineus.-Sartorius
Hip extensors:-gluteus max.-hamstrings:-biceps femoris-semitendinosis.-semimembranosis.
Abductors:-tensor fascia lata.-gluteus medius.-gluteus minimus.
Bursae-a bursa over thegreater trochanter.-iliopsoas bursa(locatedon the inside).
Causes of hip pain are classified into:1.Causes related to hip joint disorders.2.Causes related to the periarticular softtissues ( in the hip region).3. Extrinsic sources of hip symptoms( referred pain).4. Generalized causes: hip pain may bejust a manifestation of a widespreaddisease.
Analysis of hip pain:History:onset, duration, course, trauma.associated symptoms as fever, malaise,loss of weight, night sweating, otherjoint problems.Associated known disease as TB, otherrheumatic disease as RA, AS etc.
Site of pain:True hip pain: is felt mainly in the groinand in front or inner aspect of the thigh.Pain is often referred to the knee ( pain inthe knee may be the predominant featureof a hip disorder).Referred pain to the hip: Pain referredfrom the spine is felt mainly in the glutealregion down the back or the outer aspectof the thigh.Relieving and aggravating factors:It ↑ by walking and activities necessitatehip flexion or rotation and ↓ by rest
1. Causes related to hip joint disorders:Acetabulum and proximal femur: fracture , primary or metastatictumors, osteonecrosis of the femoral head ,Perthes’ disease, slippedupper femoral epiphysis and osteoporosis.Articular surfaces: transient synovitis of the hip, pyogenic arthritis, TB,rheumatological diseases as RA , AS and osteoarthritis.2. Causes related to periarticular soft tissue disorders:a) Bursae: greater trochanteric bursitis and iliopsoas bursitis.b) Tendons and fascia: hamstring, adductor and rotator tendinitis andtightness of fascia lata.c) Hernias: inguinal and femoral hernias.3. Extrinsic causes ( referred pain):a) spine and sacroiliac joint.b) abdominal and pelvic structures.c) major vessel occlusion.
1) Fractures:* Site: femoral neck, acetabulum and pubic ramus.* Causes: direct trauma, stress # in distancerunners and pathological # e.g. OP.* Manifestations: Pain in the hip region, externalrotation deformity, shortening of the affected limb,adduction attitude due to pain .* Treatment : it differs according to the site andtype of # and the age.2) Primary and metastatic tumors:* 1ry: the most common is multiple myeloma.* 2ry: from tumors of the breast, lung, prostate,kidney and thyroid gland.* Manifestations: joint pain, pathological #,malaise, weight loss and inguinal lymphadenopathy.
Transient synovitisIt’s a short term affection of the hip, ofuncertain cause, characterized clinically byunilateral hip pain, limp & limitation of hipmovement.Cause: unknownc/p:<10 y, boys. presenting with pain in groin& thigh, limping, limitation of movement.X-ray: normal. Ultrasonography of the hip mayreveal joint effusion. ESR may be slightly elevated.Full recovery within 3-6 wksTreatment: bed rest, analgesics.DD with other hip problems.
Pyogenic arthritisUncommon in hip.Mostly in children, usually secondary to osteomyelitis.Organism: staph/strep (blood born infection) or spreadfrom adjacent OM.Acute inflammation in joint tissues with effusion of pus.Healing with restoration to normal may occur butpermanent destruction & damage may occur in olderchildren & adult bony ankylosis may result.c/p:-infants: in 1st year, present with anxiety, unwellness &pyrexiaon examination; restricted hip movement, abscesspointing at skin surface in buttocks or thigh withconstitutional manifestations . x-ray; soft tissue shadow, destruction of capitalepiphysis of femur, leading to gradual hip dislocation.
#in older children & adults: onset is acuteor subacute with hip pain, severe limping,joint swelling & restricted painfulmovementx-ray: widening space betweenacetabulum & femoral head due to pus,later: narrowing & destruction of articularfinally bony ankylosis ofcartilage andjoint.#-treatment:bed rest and joint rest.antibiotics therapyjoint aspirationintra-articular injectionof antibiotics
Rheumatoid arthritisHip affection is uncommon in RA ,but occur insevere cases.It may be bilaterally.The main symptoms are pain and limitation ofmovement aggravated by activity.Swelling can not be detected clinically because it isa deeply seated joint.Fixed flexion or adduction deformity may develop.Gluteal &thigh muscles are wasted.By imaging: narrowing of joint space by destructionof articular cartilage with inward protrusion ofsoftened medial wall of acetabulumDegenerative changes may superimpose on top ofinflammation leading to 2ry OA.
Tuberculous arthritisHip is most frequently affected by TB.Usually a child 2-5 yrs or a young adult.Main symptoms pain & limp, impaired general condition.Examination: synovial thickening is palpable ,limitation of allhip movement, gluteal &thigh ms are wasted & sometimes coldabscess is palpable in upper thigh or buttock.Imaging: early; bone rarefaction with preserved joint space.later; articular cartilage erosion leading to permanentjoint destruction.Diagnosis : history of contact with TB. presence of tuberculous lesion elsewhere. cold abscess. characteristic radiographic changes. +ve synovial membrane biopsy.
Ankylosing spondylitisIt is an inflammatory disease and one of the sero –vespondyloarthropathies.It is primarily a disease of the spine and sacroiliac joint.It affects the proximal joints especially the hips.One or both hips may be affected with pain and stiffness whichimprove by exercises.Hip involvement may be so severe--------- hip replacement isindicated.Treatment: Medical: NSAIDS, DMARDs and biological therapy.Physical therapy:A corner stone in the management of AS: hydrotherapy, ROM,breathing exercises etc.Surgical treatment: hip replacement.
OsteoarthritisOA of hip is one of the causes of severe disablement in elderly.Causes:-disease or damage of joint surface accelerates degeneration(acetabular fracture, Perthes’ disease, SUFE, osteonecrosis).-2ry to developmental dysplasia or congenital sublaxation.-idiopathic.Pathology:-articular cartilage is worn away at sites where wt. is transmitted-the underlying bone is hard & eburnated. Also osteophytesformation may occur.-diminution of joint space.C/P: The patient is usually elderlypain in groin & front of the thigh and commonly in the knee. Painis worsened by walking &relieved by restjoint stiffness & limited ROM.fixed deformity (flexion, adduction, lat. Rotation).shortening due to loss of joint space.
Imaging:diminution of joint space, subchondralbone sclerosis, osteophyte formation atjoint margin.Treatment:#Conservative treatment:-relative rest in early stages.-analgesic, NSAIDS, ABCS.-physiotherapy: local heat, coldtherapy, exercise to strengthen ms &preserve ROM.-IA injection: as hyaluronic.#Operative treatment: arthroplasty,osteotomy, arthrodesis
Perthes’ diseaseIT IS OSTEOCHONDRITIS OF THE EPIPHYSIS OF THE FEMORAL HEADIt is a condition in children characterized by a temporaryloss of blood supply to femoral head. Without an adequateblood supply, the rounded head of femur dies.It is temporary softened and may become deformed.-Perthes’ disease usually is seen in children between 5 -10yrs of age. It is five times more common in boys than ingirls.-Etiology:unknown.most popular theory is temporary interruption of bloodsupply to femoral head leading to multiple episodes ofinfarction.
stages (2-3 years):1) Ingrowth of new blood vessels and removal of deadbone by steoclasts.2) New bone is laid down on the dead trabeculae withgradual constitution of the bone nucleus.3) Remodeling --- but bone necrosis and replacementis not uniform ---- so the nucleus appearsfragmented on X-ray.4) Net result is deformation of the epiphysis andflattening of the femoral head.
Four Stages of Perthes’ disease: Femoral head becomes more densewith possible fracture of supportingbone. Fragmentation and reabsorption ofbone. Reossification when new bone hasregrown. Healing, when new bone reshapes.Phase I takes about 2-6 months,Phase 2 takes one year or more, andPhase 3 and 4 may go on for manyyears.
C/P:limping with antalgic gait.mild pain at hip area in thegroin (usually unilateral) orthigh with insidious onset.Moderate limitation of allhip movement with pain andspasm if movement is forced.N.B: no impact on generalhealth but secondary OA ofthe hip develops later on.Diagnosis:by x-rays and MRI ( earlydiagnosis)
Treatment:Nonsurgical treatment:- anti-inflamatory medication.-Crutches are used for non-weight bearingtreatment for pain.-Range of motion exercises may be givenat home.- abduction splint (leg in abduction,int. rotation or abd., flexion by plastercast or braces to keep femoral head inacetabulum).Surgical treatment:-varus femoral osteotomy to redirectfemoral head in acetabulum-pelvic osteomy to redirectacetabulum over femoral head.
Osteonecrosis( avascular necrosis)Necrosis of bone of femoral head may be a complication of trauma,fracture of femoral neck , but may be a non-traumatic or idiopathicosteonecrosis is thought to be result of an ischemic episodeaffecting the bone and marrow tissue and may cause progressivecollapse of femoral head in young adults.Cause:unknown .Fat embolism, intravascular coagulation.history of steroid therapy or alcohol addiction.patients receiving immuno-suppressive therapy following organtransplantation.Pathology:the bone necrosis does not involve the entire femoral head, butcommonly occupies a wedge shaped segment beneath the superiorweight baring surface. This may result in subchondral fracture withsubsequent collapse of articular surface and a progression tosecondary OA.
C/P:The patient is usually young or middle aged, willpresent with increasing pain in the hip or thigh duringstanding or walking (limping). When bony collapse hasoccurred, there may be marked restriction of hipmovement with secondary contractures and limbshortening.Diagnosis:MRI in early stage show low intensity focus in theaffected femoral head.x-ray: narrowing of joint space with flattening ofweight bearing surface of head and underlying area ofsclerosis in the bone.Treatment: surgical.
Slipped upper femoral epiphysisThis is affection of late childhood in which the upper femoralepiphysis is displaced from its normal position upon the femoralneck. The displacement occurs at the growth plate( epiphysial line)and in both sides.Cause:Unknown. The condition is often associated with overweight fromendocrine dysfunction, but in other cases the pt is of normal build.Pathology:The junction between the capital epiphysis and the neck of femurloosens. With the downward pressure of wt bearing and the upwardpull of muscles on the femur the epiphysis displaced from its normalposition. Displaced is always backward & downward , so that theepiphysis comes to lie at the back of femoral neck.C/P:The patient is between 10 and 20 years of age.gradual onset of pain in the hip with limp. Pain is felt mainly in thekneeon examination: limitation of certain hip movement (flexion,abduction &medial rotation).
Diagnosis:x-ray shows slight displacement of theepiphysis in lateral radiograph.Complication:-osteonecrosis.-OA in severe displacement.Treatment: surgical.
Periarticular structures:a) Trochanteric bursitis: inflammation of the bursa between the greatertrochanter and the tendon of gluteus maximus and medius.It is common in elderly. Or in young individuals who perform activitiesas walking, running and biking. Manifestations: pain over the greatertrochanter which may radiate down the outer aspect of the thigh. Insevere cases there is limping and stiffness of the hip. Diagnosis:imaging to exclude other causes. Treatment: NSAIDS, physicaltherapy, local steroid injection and rarely surgical removal of theinflamed bursa.b) Iliopsoas tendinitis:Inflammation and irritation of the iliopsoas tendon due to overuse ofrepititive microtruamata in sport activities.c) Iliopsoas bursitis:Inflammation of the bursa underneath the tendon.
Extrinsic causes of hip pain:Features of referred pain: pain is felt at the hip region but local hipexamination is completely free i.e. no local tenderness, nolimited ROM, imaging study is free as well. Abnormalities can bedetected in the original site of pain e.g. spine, SIJ etc.a) Disorders of the spine:Discogenic pain may refer to the gluteal region and the lateralaspect of the thigh.b) Disorders of sacroiliac joint:They include: TB, pyogenic arthritis and AS.Pain is diffuse and felt over the gluteal area and may extend tothe posterior aspect of the thigh ( sciatica-like pain).
c) Disorders of the abdomen and pelvis:Examples: deep peri appendicular abscess------ irritation of theobturator nerve and irritative spasm of the hip muscles whichoriginate from the abdomen and pelvis as psoas major, iliacus,pyriformis and obturator internus.Pain may be associated with limited ROM due to musclespasm.Careful history taking, examination and investigation reveal theproper diagnosis.d) Occlusive vascular disease:Examples: thrombosis of the abdominal aorta or mainbranches.Pain is elicited by activity and relieved by rest.The femoral pulse is weak or absent. Other lower limbarteries may be strong.