Anterior Hip Pain

Anterior Hip Pain
Anterior hip pain is a common complaint with many possible causes. Apophyseal avulsion and slipped capital femoral epiphysis should not be overlooked in adolescents. Muscle and tendon strains are common in adults. Subsequent to accurate diagnosis, strains should improve with rest and directed conservative treatment. Osteoarthritis, which is diagnosed radiographically, generally occurs in middle-aged and older adults. Arthritis in younger adults should prompt consideration of an inflammatory cause. A possible femoral neck stress fracture should be evaluated urgently to prevent the potentially significant complications associated with displacement. Patients with osteitis pubis should be educated about the natural history of the condition and should undergo physical therapy to correct abnormal pelvic mechanics. “Sports hernias,” nerve entrapments and labral pathologic conditions should be considered in athletic adults with characteristic presentations and chronic symptoms. Surgical intervention may allow resumption of pain-free athletic activity. Anterior hip pain is a common problem that is frequently difficult to diagnose and treat.1 Determining the exact cause of hip pain can be difficult for several reasons. The multiple structures in the hip have the potential to produce similar pain syndromes; in addition, pain in the hip region may come from deep structures that are not palpable. Pathologic conditions ranging from a benign muscle or tendon strain to a potentially catastrophic femoral neck stress fracture can have similar clinical presentations. This article reviews many of the hip problems in adolescents and adults that present with anterior pain (Table 1). Conditions of the lumbar spine that radiate pain to the anterior hip are not discussed. A brief review of hip pain in adolescents is included. TABLE 1 Condition Presentation Examination findings Imaging and diagnostic studies Basis of diagnosis Treatment Osteoarthritis Groin pain on activity; gradual worsening of pain; limp Pain and decreased range of motion on internal rotation and extension Radiographs: joint space narrowing, sclerosis, osteophytes Clinical findings, confirmed with radiographs Initially, oral analgesics and exercise Joint arthroplasty for end-stage disease Inflammatory arthritis Pain in the morning; activity limitation; systemic involvement Generalized joint involvement; enthesopathy; skin or bowel symptoms Elevated erythrocyte sedimentation rate and C-reactive protein level Arthrocentesis: white blood cell count in joint fluid of mm3 Radiographs: erosions, osteopenia Clinical and laboratory findings Significant improvement with NSAIDs NSAIDs and exercise; with disease progression, antirheumatic drugs Muscle and tendon strains Acute mechanism; localized pain occurring immediately Local swelling and tenderness, ecchymosis, weakness MRI or ultrasonography Clinical findings with imaging if needed Rest, ice, compression, progressive rehabilitation Address errors in training, technique and mechanics. Tendonitis Overuse; delayed onset, pain localized and worsening with activity Local swelling and tenderness, crepitus “snapping,” weakness MRI or ultrasonography Clinical findings with imaging if needed Same as for strains Femoral neck stress fracture Impaired bone metabolism; overuse; worsening hip and thigh pain; progressive limitation of activity Pain on internal rotation and with hopping; regional muscle guarding Radiographs: often normal Confirmed with imaging Nonweight-bearing; urgent orthopedic referral for displaced fracture Bone scans: highly sensitive MRI: better specificity than bone scans Sports hernia (occult hernia or tear of oblique aponeurosis) Chronic groin pain (i.e., particularly common in soccer, rugby and ice hockey); pain worse with “cutting” and sprinting Tenderness at superficial inguinal ring Herniography may identify occult hernia. Clinical findings Herniorrhaphy Repair of aponeurosis Obturator or ilioinguinal nerve entrapment Same as for sports hernia but with adductor weakness or spasm Adductor tenderness; decreased sensation Electromyelography Obturator nerve block Clinical findings and diagnostic tests Surgical release of fascial entrapment of nerve Osteitis pubis Midline pubic pain with radiation to hip; pain worse with striding and pivoting Direct tenderness; painful adduction; limited rotation and obliquity Radiographs: widening of symphysis; sclerosis; cyst formation Bone scans “hot” over symphysis Clinical and imaging findings Seven to 10 months of rest, along with hip adductor and rotator stretching Address sacroiliac function. Acetabular labral tears Injury; chronic deep, sharp hip pain; intermittent “catch” or “giving way” of the hip Tenderness on internal rotation and extension; click on Thomas test Magnetic resonance arthrography Clinical and imaging findings Hip arthroscopy Relief of pain with injection of local anesthetic Definitions In this article, the term “anterior hip pain” is applied to symptoms extending medially to the pubic symphysis, laterally to the anterior superior iliac spine, superiorly to the lower abdomen and inferiorly to the proximal 5 to 10 cm of the anterior thigh (Figure 1). The term “groin” refers to the inferomedial aspect of the anterior hip. Pelvic muscle apophyseal attachments. The region defined as the anterior hip and groin is outlined by a box. Adolescents Although adults and adolescents have many of the same hip problems, special consideration must be given to skeletal immaturity in young persons. Open physes are weaker than surrounding bone or tendon and are therefore susceptible to acute and chronic injuries. APOPHYSEAL INJURY In the adolescent, acute muscle contraction about the hip can result in avulsion of an apophysis (an ossification center at the attachment of tendon to bone). Whereas overuse is likely to result in tendonitis in an adult, it is more likely to cause apophysitis in the adolescent. Muscles with pelvic apophyseal attachments are illustrated in Figure 1 and listed in Table 2. TABLE 2 Muscles Apophyseal attachment Internal and external obliques Iliac crest Sartorius Anterior superior iliac spine Rectus femoris Anterior inferior iliac spine Hamstrings* Ischium Iliopsoas Lesser trochanter Symptoms of acute apophyseal injury include localized pain and swelling over the affected area, muscle weakness and limited range of motion. Radiographs should be obtained as part of the initial evaluation of suspected apophyseal injuries. Nondisplaced or minimally displaced fractures can be treated conservatively.2 However, if displacement is present, orthopedic referral is recommended because the degree of displacement warranting open reduction and external fixation remains unclear.3 Initial conservative treatment includes ice application, rest and relaxation of the involved tendon. Gradual pain-free range of motion is initiated as tolerated. Crutches may be used to assist with ambulation for up to three weeks as pain-free range of motion is achieved. Local treatment modalities, including application of ice, heat, electrical stimulation and ultrasound, may be useful. Gentle, progressive resistance training should follow. Limited sports participation, as tolerated, is possible by four to eight weeks after the injury. A return to competitive activity can be considered after eight to 10 weeks if the radiographs demonstrate maturing callous, range of motion and strength are normal, and participation in the sport-specific activity causes no pain.4 EPIPHYSEAL INJURY Adolescents are also at risk for epiphyseal injuries in response to acute or chronic trauma. Slipped capital femoral epiphysis is a developmental injury that must be considered in any adolescent who presents with hip pain. Symptoms are not always related to a specific event. Typically, overweight male adolescents who are in a period of rapid growth present with hip pain, medial knee pain or a limp. In most patients, pain occurs with passive internal rotation of the flexed hip. In patients with slipped capital femoral epiphysis, anteroposterior (AP) and frog-leg lateral radiographs demonstrate physeal widening with or without medial displacement of the femoral head. Depending on the severity of the injury, there may appear to be superior migration of the femoral neck at the level of the physis. When slipped capital femoral epiphysis is diagnosed, all weight should be taken off the affected hip, and the patient should be referred immediately to an orthopedist for surgical stabilization. The contralateral hip should also be evaluated, because bilateral injury is present in as many as 40 percent of patients.5 Original article and pictures take http://www.aafp.org/afp/1999/1015/p1687.html site