Recurrent Hip Area Pain in an Adult
Hip area pain is a common presentation in the middle-aged and elderly, and the patient will often attribute it to osteoarthritis. This diagnosis may well be correct, although the differential is wide – besides, the patient’s view of what actually constitutes the ‘hip’ may be at odds with the anatomical truth. The differential for the child with hip pain is very different – see the 'Limp in a child' section.
- Muscular/Ligamentous Strain
- Trochanteric Bursitis
- Referred from Back
- Meralgia Paraesthetica
- Inflammatory Arthritis
- Avascular Necrosis
- Complications of a Total Hip Replacement (e.g. Loosening, Infection)
- Spinal Stenosis
- Iliotibial Band Syndrome
- Acetabular Labral Tear
- Impacted Fracture
- Bony Pathology (e.g. Secondaries, Paget’s)
Key distinguishing features of the most common diagnoses
|Muscular/ ligament||Osteoarthritis||Trochanteric Bursitis||Referred from Back||Meralgia Paraesthetica|
|Pain Lying on Affected Side||Possible||No||Yes||No||No|
|Painful Hip Movement||Yes||Yes||Possible||No||No|
|Pain Mainly in Groin||Possible||Yes||No||Possible||No|
|Coexisting Back Pain||No||Possible||No||Yes||No|
Possible: FBC, CRP, autoantibodies, HLA-B27, alkaline phosphatase, urinalysis.
Small Print: Arthroscopy, bone scan, lumbar spine MRI (all in hospital).
- X-ray: May show evidence of osteoarthritis, avascular necrosis, fracture, dislocation, hip replacement loosening and bony pathology. Spinal X-ray may reveal spinal pathology as a cause.
- FBC, CRP: CRP may be elevated and Hb reduced in inflammatory arthritis. CRP and WCC raised in infection of joint prosthesis.
- Autoantibodies: For clues about the aetiology of inflammatory arthritis.
- HLA-B27: A high prevalence in spondoarthritides.
- Alkaline phosphatase: Raised in Paget’s disease.
- Urinalysis: May reveal proteinuria or haematuria if there is renal involvement in inflammatory arthritis.
- Arthroscopy: Diagnostic and potentially therapeutic in labral tear.
- Bone scan: May reveal bony secondaries.
- Lumbar spine MRI: For evidence of spinal stenosis; might reveal other causes of pain referred from spine.
- Check what the patient means by ‘hip’. Most don’t realise that the hip joint is actually in the groin.
- An X-ray may not be necessary, even if the clinical picture suggests hip arthritis – but the patient may well expect one, so ensure it is at least discussed.
- Examine the patient standing up – this may reveal a hernia as the cause.
- Localised lateral pain aggravated by lying on the affected side is likely to be caused by trochanteric bursitis.
- Remember the possibility of loosening or infection in joint replacements.
- Consider avascular necrosis if a patient on long-term steroids develops severe hip pain.
- Beware that the elderly can sometimes remain weight bearing – albeit with pain and a limp – after an impacted hip fracture.
- Significant depression may aggravate or result from hip arthritis pain – consider a trial of antidepressants.