A practical approach to hip pain for the internist with Dr Ted Parks, orthopedic surgeon

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).

Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Credits

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

Time Stamps

00:00 CME announcement, disclaimer, intro and guest bio
04:05 Guest one-liner; advice for teachers and learners
08:30 Case of hip pain, review of hip anatomy, and the three buckets of hip pain
15:35 Greater trochanteric pain syndrome
16:20 The zebras of hip pain
18:12 Physical exam for hip pain
21:33 Hip osteoarthritis: imaging and initial therapy
24:18 Hip injections: Do steroids work? What about hyaluronic acid?
29:00 Who needs hip replacement surgery? How long will it last?
32:30 Greater trochanteric pain syndrome
35:58 Lumbar spine versus hip pain from OA
38:58 Hip replacement technology: materials; etiology of component loosening and need for re-operation
42:03 Take home points and outro

Hip Pain Pearls

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 Pain Show Notes

Hip Anatomy: It’s basic

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 Three Buckets of Hip Pain

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).

Osteoarthritis

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).

Evaluation for OA:

Pain will be in the groin area, classically, with intra-articular sources such as hip osteoarthritis. Patients with osteoarthritis will have a positive “windshield wiper test” (see below for exam description). An AP pelvis x-ray will show unaffected and affected side for comparison and can clearly demonstrate osteoarthritis, which can be a visual tool for patients. An x-ray is not required before starting conservative treatment.

Hip OA Treatment:

NSAIDS reduce inflammation and the amount of synovial fluid, which decreases capsular stretch. BUT, these are not great for long term use because of systemic side effects (Marcum et al. 2010).

Physical therapy may help flexibility by increasing joint capsule compliance, and can reduce pain in response to swelling (Parks 2017).

Use of injectables for hip pain

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).

Joint replacements and bearing surfaces: What’s the deal?

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.

Greater Trochanteric Pain Syndrome (GTPS)

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.

GTPS Treatment:

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.

Back pain described as “hip”

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.

The Other 10% of Patients: The Zebras of Hip Pain

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.

Physical Exam of the Hip

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.

And for more on orthopedics in primary care, check out our other episodes:

#59 Back pain and Sciatica: Straighten out your practice with Dr Chris Miles

#98: Knee Pain: History, exam, bracing, x-rays, and injectables with Dr Ted Parks

#124 The Shoulder – Simplify Your Approach with Dr Carlin Senter

Goals and Learning Objectives

Goals

Listeners will develop an approach to managing common orthopedic complaints–in particular about the hip–in the primary care setting.

Learning objectives

After listening to this episode listeners will…

Identify the most important questions to ask about hip pain
Perform a high yield physical exam to evaluate hip complaints
List what tests to order to improve diagnostic accuracy in hip pain
Learn when to refer to orthopedics for hip pain and who can be treated in primary care
Identify red flags in hip complaints

Disclosures

Dr Parks reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Comments

May 7, 2019, 12:15am Toan Nguyen MD writes:
One of the best episodes. Great job!!
May 7, 2019, 4:28pm Eugenio - Medical Student writes:
All those MSK episodes were great. Hopefully you'll do episodes on the Elbow/Hand/Wrist/Foot/Ankle in the future!
- May 12, 2019, 11:53pm Matthew Watto, MD writes:
  Thanks very much and yes we do plan to cover those in the future
May 9, 2019, 10:33pm Peter Lange writes:
I really enjoyed this episode and the clinical acumen of your guest cannot for a moment be faulted, but... The explanation of the patholophysiology of osteoarthritis was very biomechanical/biomedical, and did a disservice to all the other means of treating pain of osteoarthritis in a multi-disciplinary approach. That approach cannot explain the marked discrepancy between radiographic findings, pain and disability, nor the failure of many cases to progress, or the acute exacerbations of osteoarthritis with inflammation often seen. I highly recommend the work of Paul Dieppe UK rheumatology researcher for a more comprehensive approach.
- May 12, 2019, 11:53pm Matthew Watto, MD writes:
  Thanks for reaching out - that conversation is currently a topic on twitter. Check Dr. Brigham's handle to get more if interested @BrighamSk. Thanks for the expert rec.
May 19, 2019, 12:03am Kim Oja writes:
I'm a new NP working in primary care, and I listen to The Curbsiders religiously. Literally the day after hearing this episode a patient presented in clinic with hip pain, which I diagnosed as greater trochanteric pain syndrome in about ten seconds flat. I then administered my first cortisone injection. Just before performing the injection I refreshed myself on the technique by reading about it in my copy of Dr. Parks' Practical Office Orthopedics, which I'd bought after hearing the episode on knee pain. Many thanks to Dr. Parks and all the Curbsiders. You are great mentors.
- May 19, 2019, 11:18pm Matthew Watto, MD writes:
  Thank you for the great feedback and for sharing. How timely! Dr. Parks is wonderful and we really appreciate your feedback and support!!
May 24, 2019, 1:16am Ivan Dominguez Casillas writes:
Awesome !!! It follows a rule "if you can't easily explained you don't understand anything " Thanks

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#149: Hip Pain for Primary Care