Hip and buttock pain

Probability diagnosis

Traumatic muscular strains

Referred pain from spine

Greater trochanteric pain syndrome

Osteoarthritis of hip

Serious disorders not to be missed

Cardiovascular:

• buttock claudication

Neoplasia:

• metastatic cancer

• osteoid osteoma

Infection:

• septic arthritis

• osteomyelitis

• tuberculosis

• pelvic and abdominal infections: pelvic abscess, pelvic inflammatory disease, prostatitis

Childhood disorders:

• DDH

• Perthes’ disease

• slipped femoral epiphysis

• transient synovitis (irritable hip)

• juvenile chronic arthritis

Pitfalls (often missed)

Polymyalgia rheumatica

Fractures:

• stress fractures femoral neck

• subcapital fractures

• sacrum

• pubic rami

Avascular necrosis femoral head

Femoroacetabular impingement (e.g. exostoses)

Torn acetabular labrum

Sacroiliac joint disorders

Inguinal or femoral hernia

Bursitis or tendonitis:

• greater trochanteric pain syndrome

• ischial bursitis

• iliopsoas bursitis

Osteitis pubis

Neurogenic claudication

Chilblains

Rarities:

• haemarthrosis (e.g. haemophilia)

• Paget disease

• nerve entrapments: sciatica ‘hip pocket nerve’, obturator, lateral cutaneous nerve thigh

Masquerades checklist

Depression

Spinal dysfunction incl. spinal stenosis

Is the patient trying to tell me something?

Non-organic pain may be present. Patient with arthritis may be fearful of being crippled.

Key history

Pain analysis, especially exact site and pain radiation. Associated symptoms such as limp, stiffness, night pain, fever. Past history, family history, obstetric history, drug history.

Key examination

• The traditional method of look, feel, move, measure, test function and look elsewhere

• The patient should be stripped to the underwear to allow maximal exposure

• Also examine lumbosacral spine, sacroiliac joints, groin and knee

Key investigations

• Serological tests: RA factor

• FBE, ESR/CRP

• Radiological tests: plain X-ray (AP) of pelvis to show both hip joints; lateral X-ray (‘frog’ lateral best in children)

• CT or MRI of hip joint

• Needle aspiration of joint if septic arthritis suspected

Diagnostic tips

• True hip pain is felt in the groin, thigh and medial aspect of the knee.

• Disorders of the hip joint commonly refer pain to the knee and thigh.

• Limp has an inseparable relationship with painful hip and buttock conditions.

• Keep in mind the greater trochanteric pain syndrome, especially when middle-aged women complain of hip pain.