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ASSESSING ADULT HIP PROBLEMS


The three main symptoms which can arise from a hip problem are pain, mechanical symptoms and stiffness.

Pain:

Vast majority of the hip problems present as pain. However, it can be quite difficult to be sure that the hip is the source of pain as the hip joint is deep seated and pain around the hip joint can be produced from a multitude of sources apart from the hip joint itself. Moreover two problems can co-exist (for example back pain and hip pain).

As a rule of thumb pain over the back of the hip/buttock area/posterior thigh is usually due to referred pain from a back problem. It is very common for the patient s to tell that they have a hip pain but when asked they will point to the back of the hip joint. They will also often have lower back pain.

Pain from the hip joint is usually felt in the groin area. However, the pain from the hip joint may also be felt as pain over the anterior thigh and also to the front of the knee. You probably would have heard of anecdotal cases where a patient with a knee pain had a normal knee x-ray only to be found to have a hip problem causing the knee pain! Hence the important for examining the hip joint in all cases of knee pain.

The following is an example of a hip problem presenting as knee pain. This patient was referred as having right knee pain of two weeks duration and increasing difficulty in weight bearing following a minor twisting injury. Had knee x-rays in casualty and was admitted to the ward as he was not able to weight bear. I reviewed him during the trauma ward round in the morning (which is usually quite busy). He was tender over the medial joint line and also in the patellofemoral compartment. There was no significant effusion in the knee. AP, lateral and skyline view of the right knee revealed only mild to moderate arthritis.  Even during the log rolling test the patient complained only of knee pain (over the front of the knee and in the supra-patellar area)!

Knee x-rays showed only mild to moderate arthritis
Knee x-rays showed only mild to moderate arthritis

Still I was not entirely convinced that the knee arthritis was the cause of his inability to weight bear. Fortunately, the patient said “I had a hip replacement many years ago but it has been absolutely fine and there has been no problem doc!” I requested hip xrays AP and lateral and to my surprise the hip replacement was completely loose and in addition, he also had a peri-prosthetic fracture of the femoral shaft (more clear in the lateral view). Subsequently, I did a full revision hip replacement with a long stem bypassing the fracture site.

AP hip x-ray showing loose hip replacement and lateral x-ray showing the peri-prosthetic fracture
AP hip x-ray showing loose hip replacement and lateral x-ray showing the peri-prosthetic fracture

C Sign

As the hip joint is deep seated, it is difficult for the patient to point to the area of pain. One of the common ways a hip joint pain is described by the patient is by  the “C sign” (the patient places the fingers in front of the hip and the thumb over the lateral aspect).

Patient with hip impingement demonstrating the “C sign” when asked to show the location of her pain without any prompting
Patient with hip impingement demonstrating the “C sign” when asked to show the location of her pain without any prompting

Tendonitis can also produce groin pain, other general surgical causes like hernia, vascular problem etc may also cause groin pain and these need to be excluded. Neurological problems like meralgia paraesthesia can also produce pain near the hip and radiating to the thigh.

Exacerbating factors:

Hip pain due to arthritis often is increased with activity even with level walking as well as standing for prolonged period. As it progresses it also can present at night and at rest.  

Hip pain can also be increased by activities involving flexion of the hip including sitting for a while, getting up from a chair (which can produce a catching sensation), climbing stairs, getting in and out of the car (often the patient has to lift the thigh using their hand and shuffle across), trying to put their sock/cut toe nails/tying laces etc., While pain from an arthritic hip can be exacerbated by the above activities, in the absence of arthritis (in young patients) it may be due to impingement syndrome of the hip with or without a labral tear.  

Pain over the outer aspect of the hip can be present from many sources including the hip joint. However, if the pain can be localised to the greater trochanter, it is often due to greater trochanteric bursits (this can be a recalcitrant condition to treat but generally the treatment is in the form of physiotherapy and steroid injection). It is also now being recognised that in a small proportion of the cases, the pain may be in fact due to a partial rupture of the abductors (similar to the rotator cuff tear in the shoulders) and some may benefit from surgical repair.

Mechanical symptoms:

Although not common, some patients with a hip problem may complain of mechanical symptoms like clicking or snapping and a feeling as if the hip is coming out of the joint. It could be due to an obvious problem like snapping iliotibial band syndrome (where a tight iliotibial band moves forwards and backwards over the greater trochanter ). The snapping could be felt and often seen when the patient flexes and extends the hip and the patient can themselves demonstrate it).

Other causes of clicking/snapping are more difficult to diagnose. The causes could be extraarticular or intraarticular. Extraarticular problems like psoas tendon snapping can present as groin pain when flexing and extending the hip and the patient may feel a snapping sensation. Increasingly, intraarticular problems like a labral tear are being recognised as a cause of clicking sensation which can occur with bending activities or twisting. This could be part of impingement syndrome of the hip as well as a sequelae of childhood disorders like dysplastic hip. Very rarely, recurrent locking sensation may occur due to the presence of a loose body.

Stiffness:

While pain is the predominant symptom which is given importance in assessing the hip symptoms and stiffness alone is not usually an indication for surgery, stiffness can also be quite disabling particularly in young and active patients with an arthritic hip. I specifically ask patients whether they can do activities like cutting their toe nails, putting their socks, tying their shoe nails etc., Ironically, very stiff hip while quite disabling may not have much pain as there is very little movement in the hip joint.

Examination:

Generally I start with the gait (antalgic gait, Trendelenburg gait, short leg gait etc.,). I examine the back if there are back symptoms. Weakness of the hip abductors could be assessed by Trendelenburg test.

What is the Trendelenburg Test Click to Read

Trendelenburg Test:   The patient is asked to stand on one leg for 30 seconds without leaning to one side. You observe to see if the pelvis stays level during the one-leg stance. In a positive Trendelenburg test, the pelvis drops towards the unsupported side. Another easier way of doing the test is to stand in the front of the patient and ask the patient to place his/her hands on to your hands and check the one-leg stance. In a positive Trendelenburg test, the patient puts more pressure on your hand to on the side opposite to the weight bearing leg. It can be confirmed by checking whether the pelvis drops on that side.

The test essentially evaluates the function of the hip abductors and could be positive with abductor tear, superior gluteal nerve palsy, as well as defective function of the hip abductors due to inadequate “lever” (for example supra trochanteric shortening in severe osteoarthritis or dysplastic hip). However, it should be notes that if the hip is painful, it would be unrealistic to expect the patient to do a prolonged single stance weight bearing test without support!

In this video the patient can be seen applying more pressure with her left hand when standing on her left side. She did have MRI proven abductor tear.  

Then I check for any area of tenderness – for example greater trochanteric bursitis. However, as the hip joint is deep seated, it is difficult to elicit tenderness in majority of cases by palpation.  

The key step in examination of the hip joint is assessment during movement. I start with log rolling of the hip (the leg is rolled in internal rotation and external rotation with the knee in extension). This essentially isolates the hip joint from the back and knee and is a very sensitive test for hip pathology. Often in hip arthritis, the internal rotation is the first movement to be decreased and can be compared easily with the opposite side (in unilateral problems) and attempted internal rotation beyond the restriction often reproduces the groin pain. Log rolling usually does not produce pain in non arthritic problems like hip impingement, labral problems, psoas tendonitis etc.

What is the Log Rolling Test Click to Read

Log rolling: A very sensitive test to identify possible hip pathology (but not specific). With the hip in extension, the leg is gently rolled internally and externally. Reproduction of groin pain particularly during internal rotation suggest hip problem. However, it is likely to be negative in cases like hip impingement where the pain occurs in flexion activities.

Flexion of the hip is assessed and this often produces pain in the groin in patients with hip problems. In impingement syndrome of the hip, flexion to 90 degrees in neutral abduction and adduction and neutral rotation is often painless. But the pain is reproduced when the hip in 90 degree flexion is adducted and internally rotated. This is called as “positive impingement test”. (while this can be positive in many cases including arthritis, absence of pain in with other movements including log rolling and absence of arthritis in the x-rays  in a young patient  with groin pain may suggest the possibility of impingement syndrome/labral problem). The leg length is also assessed clinically.

What is the Impingement Test Click to Read

Impingement test: This is suggestive of hip impingement. The patient is placed supine on the examination table. The affected hip and knee are flexed to 90 degrees. The hip is then adducted and internally rotated in the flexed position. In a positive test, a sudden, often sharp pain is felt in the hip (reproducing the patient’s symptoms). However , it is important to understand that this manoeuvre  would be painful in a  number of hip conditions including hip arthritis although in those cases other movements are also likely to be painful.

Diagnosis:

Even after the examination, it is quite often difficult to be sure about the exact diagnosis of the problem and the main goal at the end of the examination  is to come to a reasonable conclusion to the source of pain (back,  intra-articular hip problem, extra- articular hip problem etc.,)  and a probable differential diagnosis based on the age, clinical findings etc. 

Radiological investigations:

If a hip problem is suspected I suggest the following x-rays prior to orthopaedic opinion

1. In patients in whom arthritis is suspected – x-ray pelvis with both hips AP with calibration and a lateral hip x-ray of the affected hip

2. In young adults in whom a non-arthritis hip problem is suspected – x-ray pelvis with both hips and a horizontal beam lateral x-ray of the affected hip

While majority of the hip problems like arthritis will be self evident in plain x-rays, further special investigations  including MRI scan, MR arthrogram, CT scan, ultrasound and local anaesthetic diagnostic injection  may be required in some cases.

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