Identify and treat the most common causes of hip pain in the outpatient setting with returning guest, Dr Ted Parks. A large majority of hip pain in the office setting will be due to one of three conditions (hip osteoarthritis, greater trochanteric pain syndrome, and lumbo-sacral back pain). Learn to easily identify these conditions, how to initiate conservative treatment, and more about hip replacements. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST).
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Written and produced by: Molly Heublein MD, Nora Taranto MS4
CME questions by: Molly Heublein MD, Nora Taranto MS4
Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD, Molly Heublein MD
Edited by: Matthew Watto MD, Emi Okamoto MD
Guest Presenter: Ted Parks MD
Hip anatomy is very simple: It’s a ball in a bowl-shaped socket. There’s a little rim of “gristle” around the socket rim (the labrum). There’s also a bump on the lateral side of the femur that can cause pain when the IT band rubs up against it. These are the parts that matter 90% of the time when a patient comes in with hip pain.
Hip osteoarthritis is easy to identify on clinical exam with reduced motion & painful internal/external rotation in a middle-older aged patient.
Patients often complain of “hip” pain when they actually have low back pain
Hip arthroplasty relieves hip pain from osteoarthritis very well, and prostheses will likely last the lifetime when placed in those 60 years and older.
“Greater trochanteric pain syndrome”, the new name for greater trochanteric bursitis, is a common cause of lateral hip pain.
Hip anatomy is very simple. The most proximal femur is the ball, in a socket of the pelvis. The bone is cushioned with a smooth, numb ring of cartilage, called the labrum. On the lateral side of the bone is the greater trochanter, and the iliotibial band runs over it from the pelvis to below the knee.
The vast majority of patients presenting to the office setting with hip pain will have 1 of 3 common conditions: osteoarthritis (OA), greater trochanteric pain syndrome, or a lumbo-sacral back pain problem (Parks 2017, data collected in his own clinic showed upwards of 90% of patients who presented with hip pain suffered from one of these three conditions).
This is a “wear and tear” problem, in which cartilage gets worn down with activity. Once cartilage is gone, the rough part of bones beneath the cartilage start to rub against one another and cause pain (because unlike cartilage, bone has nerve endings in it). As bones rub together (or the articular cartilage becomes rough as it wears down) the capsule is irritated. Consequently, the joint increases synovial fluid production. This stretches the joint capsule and contributes to pain. Risk Factors include increased joint activity (lots of running, for example) and age (>50-60 years old).
Corticosteroid injections can reduce pain temporarily. Per Dr. Parks’ expert opinion, we should likely be starting with these as our first-line treatment since 1) Hip OA pain is chronic, 2) Chronic use of NSAIDS is not generally recommended, 3) Long-term side effects of steroid injections are relatively minimal, and 4) Ultimately, hip OA is definitively treated with hip replacement, so steroids won’t be used without end.
Steroid injections do have some systemic effects (hyperglycemia, among other symptoms), and may cause some softening of soft tissue structures/articular cartilage (McAlindon et al 2017), but are generally quite safe when given every 4 months (Raynauld et al 2003 and Dr. Parks’ expert opinion). These injections may help control pain as a bridge to joint replacement. Hip injections should be done with imaging guidance given the small joint capsule size: either ultrasound, xray, or fluoroscopy (Dr Parks’ expert opinion).
Viscosupplementation (hyaluronic acid) injection is non-FDA approved for the hip. Dr Parks DOES NOT recommend that it be used off-label for hip pain. Efficacy shows them to be comparable to placebo (Leite et al. 2018).
Hip arthroplasty works well when conservative treatments have been exhausted. It has relatively high patient satisfaction scores and low complication rates. Dr Parks notes: If patients are over age 60, their hip replacement will likely last the rest of their lifetime. Between ages 50-60 years, patients may need a revision(s), but will generally do well. A patient younger than 50 may need multiple surgeries over their life, so Dr Parks discourages hip replacement in for those under age 50.
Currently, joint prostheses are metal with polyethylene socket liners- these shed “wear particles” which are unfortunately the same size as bacteria and stimulate an immune response. Over many years this can cause a softening of the bone around the hip prosthesis, which can become loose. On x-ray this can be seen as a lucency between the bone and prosthesis. (Read more about this at the end of Chapter 3: The Hip in Dr. Parks’ textbook Practical Office Orthopedics!)
The ideal goal for a joint prosthesis is a durable low friction surface that doesn’t generate wear particles. Metal on metal prosthesis design was popular around 2000-2007, however they caused toxic metal levels and were removed from the market. Ceramic on ceramic bearings can squeak or break. Active research is looking into new modalities for safe and durable joint replacements.
GTPS is a common cause of lateral hip pain. The pathophysiology and anatomy: the iliotibial (IT) band, a “strap” of connective tissue, runs along the seam of your pants from pelvis to knee. As we age, the IT band becomes stiffer and can rub over the greater trochanteric bursa, causing inflammation. On exam, patients will be tender over greater trochanter with direct pressure.
Previously this was called “greater trochanteric bursitis”, but now it is better named “greater trochanteric pain syndrome” (Speers et al 2017), because symptoms may be caused by insertional tendonitis of gluteus muscles, rather than always caused by bursitis.
Exercises that stretch the IT band are the mainstay of treatment. Patients can be taught stretches to do at home or attend physical therapy. If this doesn’t improve the pain, a corticosteroid injection can work very well also (though the effect may be comparable to placebo, Nissen et al. 2019) and is very simple for PCPs to perform- basically the easiest of MSK injections. Surgical treatments for GTPS have poor outcomes and should not be recommended.
Many patients will complain of “hip” pain that’s actually lower back. If the pain involves the buttock, the back, or radiates down into the leg, especially below the knee, the lower back may be the cause.
Many of these patients are older, and may have both OA of the hip and the lumbar spine on imaging. It can be hard to sort out which is which. Trying a hip joint space corticosteroid injection under radiologic guidance to see what proportion of pain is relieved can help differentiate the source of the pain (Deshmukh et al. 2010). If the source of the pain remains multifactorial or unclear and conservative measures have failed, Dr Parks starts with the hip replacement given that it has a much higher patient satisfaction than back surgery.
Examples include avascular necrosis of the femoral head, labral tear, femo-acetabular impingement. If a patient is not getting better, or if their clinical constellation doesn’t make sense, consider one of these “zebras”. Unfortunately, there are no red flags to screen for on history that can reliably diagnose these. An MRI arthrogram can help to rule many of these in or out (Rajeev et al. 2018). It would be reasonable to refer to the ortho clinic if concerned about these conditions.
The Windshield Wiper Test, can be done in 8 seconds. Seat your patient with their hip flexed to 90 degrees and knee flexed to 90 degrees. Then, rotate the femur internally and externally by moving the calf like a windshield wiper. Compare to contralateral side for pain and range of motion. This test is very sensitive for inflammation within the hip joint/capsule.
Next, palpate the greater trochanter for pain. Have patient lay with their symptomatic side up. Palpate the lateral hip to find a bony prominence. Compare the tenderness to contralateral side, as this may be tender in healthy patients.
See Dr. Parks’ hip exam in this short video.
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Listeners will develop an approach to managing common orthopedic complaints–in particular about the hip–in the primary care setting.
After listening to this episode listeners will…
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