Treatment Algorithms

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Christian P. Christensen, Joseph C. McCarthy, and Jo-ann Lee

During the history and physical, the clinician should note whether the hip pain is primarily in the anterior groin, in the buttocks or posterior thigh, or in the lateral aspect of the hip and thigh. Though there is some overlap, each of these regions has particular etiologies of pain associated with it.

Anterior Pain

If patients with acute anterior groin pain following injury have negative radiographs and are able to ambulate and bear some weight, they deserve a trial of analgesics and rehabilitation, as the majority of them will improve. If they do not demonstrate some improvement within 2 weeks, the physical examination and radiographs should be repeated. Radiographs can demonstrate a stress fracture, osteonecrosis, or even cancer that was not evident on previous films. If radiographs continue to be normal, strong consideration should be given to an MRI, which can demonstrate bone edema due to an impending stress fracture or stage I osteonecrosis.

Patients thought to have chronic anterior hip pain can generally be divided into those who are tender and those who have mechanical symptoms. Rarely, disc or nerve root pathology in the upper lumbar levels can refer causalgic pain via the L2-L3 dermatomes.1 Many patients with anterior groin or thigh pain are "weekend warriors" who present with a chronic strain of the rectus femoris or the iliopsoas musculature. Usually, such patients have made the diagnosis but seek medical attention because they are not getting well as quickly as they think they should. These patients generally require reassurance, and should be instructed in stretching and strengthening exercises. Rarely, some patients who think they have a "pulled muscle" will have an avulsion fracture noted on plain films at the rectus femoris origin, ie the anterior inferior iliac spine or at the insertion of the iliopsoas on the lesser trochanter. These patients do well with conservative therapy.

Patients with adductor tendinitis will often have anterior and medial pain and tenderness at the muscle's origin on the pubis, and will often have increased pain with resisted active adduction of the lower extremity. These patients often have a history consistent with overuse or muscle strain and can typically be treated successfully with analgesics and rehabilitation. Tenotomy of the adductor longus tendon may result in good long-term functional outcomes in patients who are not helped with conservative management.2

Iliopectineal bursitis, or iliopsoas bursitis, can also be responsible for pain due to inflammation of the bursa that lies beneath the iliopsoas muscle and tendon as they pass over the pelvic brim. Patients typically present with the hip flexed, externally rotated, and abducted in order to minimize symptoms. This condition typically responds to rest and local heat. Cortisone injections can sometimes work on this condition as well.1 Osteitis pubis and athletic pubalgia are conditions in the lower abdomen that can result in groin pain. Patients with osteitis pubis will have pain in the lower abdomen or groin that is greatly increased by resisted adduction of the lower extremity. This overuse injury often occurs in high-level athletes and is initially treated conservatively with ice and analgesics. Later, the patient is treated with stretching exercises. Only rarely do cases not improve with conservative treatment. (See Chapter 2.) Instability of the pubic symphysis demonstrated radiographically by flamingo views has been documented in recalcitrant cases.3

Abnormalities of the abdominal wall, including small inguinal hernias or microtears of the internal oblique muscle, can result in "athletic pubalgia" and be an overlooked source of groin pain in athletes. The evaluation of these patients is difficult, and radiographs are typically normal. Treatment includes NSAIDs, rest, and avoidance of provocative activities. Cases that do not improve with conservative management may be successfully treated with a modified Bassini herniorrhaphy.4

Pubic instability associated with pain and sometimes clicking can be due to excess motion at the pubic symphysis. This instability is usually secondary to trauma during childbirth, but can also be due to repetitive microtrauma in the athlete. Flamingo view radiographs can confirm this diagnosis when alternating weightbearing views demonstrate 2 mm or more

Gyn exam

? Ovarian cyst

GYN consult

Previous surgery in area +

Tenderness +

Consider

Ilioinguinal nerve entrapment

Adult Hip Pain Without Obvious Plain X-ray Diagnosis

New pain without injury

Buttock/Posterior thigh

Anterior groin/thigh

Tender spine t

Decreased Spine

? Compression fx

Valsalva

Inguinal Hernia

Surg. consult

History/Physical, localized discomfort

- Cannot walk or bear weight -

Stress fx

- Nondisplaced femoral neck fx

Osteonecrosis

Transient osteoporosis

Lateral hip/thigh

Pulsating mass

Pseudoaneurysm

Vascular consult

Radiating Sx

(weakness in Abd/ER)

Piriformis syndrome J

^ Acute

Analgesics/PT 1

? injection Strains/Avulsion fx hamstrings r~

Improve

Analgesics/PT

Repeat PE/X-ray

Improve

X-ray

Osteonecrosis Pubic ramus stress for Transient osteoporosis

- Improve

Acute

Chronic

J Tender

Adductor tendonitis lliopeclineal bursitis Osteitis pubis Pubic instability (post partum) lliopsoas avulsion fx or strain Athletic pubalgia

Mechanical Sx

Tender

Non lender y

Abductor muscle strain or Trochanteric avulsion fx

. , _ Analgesics/PT Mechanical Sx gluteus maximus

Sl jt DJD

Piriformis release

Analgesics/PT

Bursitis submaximus bursa obturator intemus ischial bursa i

Injection

Extra-articular

Snapping psoas

Analgesics/PT

Spine evaluation

Systemis signs: PID, nephrolithiasis, epididymitis, testicular torsion, UTI +

ER/Internist

Psoas recession f

I-MRI w/ Gadolinium

X or high contrast

Loose body, Synovial chondromatosis PVNS

Tender _i r

Repeat PE/X ray, consider MRI

Analgesics/PT

Injection

Mechanical Sx

Improve

Intra-articular

Extra-articular^

Snapping IT band, Trochanteric bursitis

Injection

Analgesics/PT

Radiating \

Meralgia paraesthetic

Chondral flap Labral tear _i lliotibial band recession

Acute

Chronic

Bursitis

Chronic

Improve

Analgesics/PT

Figure 4.1. An algorithm for the evaluation and treatment of non-arthritic hip pain in young patients.

displacement of the symphysis. NSAIDs and compression shorts can often help alleviate symptoms, but surgical intervention is occasionally required to treat the instability.5

Mechanical symptoms such as buckling, locking, and giving way are frequent in patients with chronic anterior groin pain. An effort must be made during the physical examination to decide whether the mechanical symptoms are intra- or extra-articular. The chief extra-articular cause is "snapping hip syndrome." (See Chapters 1 & 2.) The snapping psoas can be confirmed by placing the patient in the supine position and having him or her recreate the "snapping" by moving the hip from a flexed and abducted position to an extended and adducted position. The examiner can then corroborate the diagnosis by asking the patient to repeat the maneuver and successfully blocking the iliopsoas from "snapping" with digital pressure over the femoral head. Iliopsoas bursography followed by fluoroscopic examination of the hip has been described, but is rarely required for diagnosis.6

Typically, this condition responds to NSAIDs and avoidance of the activities that cause the snapping. For chronic, painful snapping, stretching exercises and cortisone injections usually help. Rarely, lengthening of the iliopsoas tendon through an anterior approach is required for recalcitrant cases. A similar clinical picture can be created by a bony prominence at the iliopectineal ridge, an exostosis of the lesser trochanter, or by a chronically inflamed iliopsoas bursa. These conditions generally respond to similar conservative modalities.6

Patients who complain of clicking, locking, or giving way tend to have labral tears or loose bodies. Additionally, a positive Thomas flexion to extension test on preoperative exam correlates positively with acetabular labral tear noted at ar-throscopy.7 Intra-articular sources of mechanical symptoms are generally evaluated with an MRI with gadolinium or high-contrast material in the joint. Marcaine or lidocaine injected intra-articularly with the contrast can often provide temporary relief, confirming that the source of discomfort is within the joint. High-quality MRIs with specialized sequences can frequently demonstrate chondral flaps, labral tears, loose bodies, synovial chondromatosis, or pigmented villonodular syn-ovitis (PVNS). In general, these conditions respond poorly to conservative management and can be confirmed and simultaneously treated by hip arthroscopy.

Posterior Pain

Patients with buttock and/or posterior thigh pain can often be divided into those with radiating symptoms and others with tenderness. Patients with radiating symptoms often have a positive straight leg raise, indicating a possible herniated disc requiring a consult from a spine surgeon. Radiating symptoms can also be caused by a piriformis syndrome.8 These patients will complain of buttock pain and/or sciatica that can increase with physical activity, including simple adduction and internal rotation. Sitting on hard surfaces can predispose to piriformis pain, causing a "hip pocket neuropathy" or "wallet neuritis." A positive Pace sign, demonstrated by weakness in resisted abduction and external rotation, confirms the diagnosis. Rectal examination also reveals tenderness over the piriformis tendon. This condition is typically treated with analgesics and stretching the piriformis muscle with hip internal rotation, adduction, and flexion. Corticosteroid injections have been described medially,9 laterally,10 and cau-dally11 and can provide diagnostic data and simultaneous therapeutic benefit. Using CT scan guidance to perform these injections is a good idea for those who are less experienced. Cases refractory to conservative management require piri-formis release to relieve the pressure on the underlying sciatic nerve.12

Tenderness about the buttock or the posterior thigh should be divided into acute and chronic cases. Acute cases are often caused by avulsion fractures or myotendinous strains of the hamstrings or gluteus maximus. Avulsion fractures can generally be seen on plain radiographs. Strains can often be delineated only by tenderness about the region with an appropriate history. Both avulsion fractures and strains can generally be treated with analgesics and rehabilitation. Hamstring tears are high-energy injuries that are not be confused with strains. These patients are very debilitated, have diffuse ec-chymosis and pain in the posterior thigh, and often require repair of the hamstrings.

Chronic tenderness in the buttock and posterior thigh is often due to either bursitis or sacroiliac degenerative joint disease. Sacroiliac degenerative joint disease should be confirmed with a Ferguson view demonstrating arthritis in the joint. This condition can generally be treated with NSAIDS, steroid injections, and rehabilitation. Septic sacroilititis is an uncommon entity but should be kept in mind, and a hip pyarthrosis has to be ruled out. Patients will generally be im-munocompromised, have a history of drug abuse, a recent respiratory or genitourinary infection, or will have had some seemingly insignificant trauma in the region, eg acupuncture, tattoo, or intramuscular injection.13

Ischial gluteal bursitis is frequently noted on the underside of the ischium where the patient sits. Obturator internus bur-sitis is located posteriorly on the lateral aspect of the obturator foramen. The submaximus bursa is located beneath the glu-teus maximus on top of the short external rotators just behind the greater trochanter, and this too can become inflamed and cause pain. All of these bursae can be diagnosed and cured simultaneously with a lidocaine and corticosteroid injection.14

Lateral Pain

Lateral hip and thigh pain should initially be classified into acute and chronic injuries. Acute injuries are notable for tenderness or mechanical symptoms. The tender region is usually on or around the greater trochanter, and an accurate history should help delineate whether the injury was caused by a direct or indirect mechanism. If the region of maximal tenderness is right over the proximal portion of the greater trochanter, the AP radiograph should be evaluated closely in order to rule out a trochanteric avulsion fracture. If the radiograph is negative, the patient likely has a strain or tear of the gluteus medius at its insertion on the greater trochanter. Both of these injuries can be treated conservatively with crutches or a cane in order to minimize the resultant limp from this sort of injury. Acute injuries can often have mechanical symptoms, such as buckling or locking, associated with them. These mechanical symptoms are due to intra-ar-ticular lesions, though extra-articular causes, such as a snapping iliotibial band, should be ruled out. Conditions suspicious for intra-articular etiologies warrant an MRI with gadolinium with lidocaine or marcaine. Positive intra-artic-ular findings demonstrated on MRI and temporary pain relief due to the anesthetic agents injected are generally managed using hip arthroscopy.

Patients with chronic lateral hip and thigh pain should be divided into those with radiating symptoms, those with mechanical symptoms, and those with tenderness over the lateral aspect of the hip. Patients with radiating symptoms may have myalgia paresthetica due to pressure or damage to the lateral femoral cutaneous nerve. These patients are typically handled with analgesics and rehabilitation. Rarely, injections can benefit people with this condition.

Patients with chronic mechanical symptoms should be examined carefully in order to delineate whether the source is intra- or extra-articular. Patients with intra-articular causes are typically managed with an MRI, followed by hip arthroscopy if intra-articular pathology is identified. A snapping iliotibial band is the primary case of extra-articular mechanical symptoms on the lateral aspect of the hip. (See Chapters 1 and 2.) Patients with a snapping iliotibial band often improve with a corticosteroid injection to decrease the inflammation in the bursa underlying the iliotibial band. This often improves the patient's symptoms, with concurrent rehabilitation aimed at stretching and strengthening the iliotibial band. Avoiding provocative activities is imperative for these patients. Rarely, the patient fails to improve with conservative management. In these cases, possible operative intervention includes trochanteric bursa excision and iliotibial band recession.6

Most patients with lateral hip and thigh pain have tenderness due to trochanteric bursitis. In this case, the bursa underlying the iliotibial band on top of the greater trochanter becomes chronically inflamed, causing pain and sometimes crepitus on hip flexion and extension. The condition can be diagnosed and treated with a lidocaine and corticosteroid injection. The lidocaine injection within the bursa anesthetizes the bursa and relieves the patient's symptoms and discomfort. The steroid helps control the inflammation long term. Patients will occasionally require a reinjection, and very rarely will go on to open debridement of the bursa in the operating room.

Rarely, tenderness on the lateral aspect of the hip just proximal to the greater trochanter can be due to inflammation of the submedius bursa. This bursa is generally located deep to the gluteus medius tendinous insertion on the greater trochanter, and also responds well to injection. More commonly, tenderness just proximal to the greater trochanter occurs secondary to a tendinopathy of the gluteus medius. This conditon generally responds to therapy and nonsteroidals.

Conclusion

Most hip pain in skeletally mature patients without an obvious radiographic diagnosis is due to musculotendinous injury and resolves with conservative treatment. The first step in management is an accurate history and physical. Usually, this is followed by a standard radiographic series and occasionally by laboratory studies. Most patients with intra-articular pathology will have anterior groin pain. Patients with mechanical symptoms should be treated aggressively by an orthopedic surgeon. Patients with intra-articular sources of buckling and locking should be imaged with a specialized MRI with gadolinum or high contrast in order to rule out in-tra-articular pathology. Many hip surgeons will add Marcaine or lidocaine to the dye if they are not sure if the source of pain is inside the joint or outside. These patients are the most likely to be helped by hip arthroscopy and should be treated aggressively. Patients with new anterior hip pain without obvious injury should be queried and closely examined to rule out general surgical, gynecological, urological, or vascular sources. Patients with posterior thigh and buttock pain should be evaluated closely to rule out spine etiologies. Patients with lateral hip and thigh pain generally have symptoms due to problems associated with the greater trochanter or iliotibial band, and generally respond to conservative measures. In all, it is important to evaluate these patients with care initially and to reevaluate them if they are not better within 2-3 weeks. One must follow a stepwise progression in the management of these complicated patients in order to better utilize health care dollars and to prevent excessive long-term disability and pain.

References

1. Hodges DL, McGuire TJ, Kumar VN. Diagnosis of hip pain, an anatomic approach. Orthop Rev 1987;16(2):109-113.

2. Akermark C, Johansson C. Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes. Am J Sports Med 1992;20(6):640-643.

3. Batt ME, McShane JM, Dillingham MF. Osteitis pubis in collegiate football players. Med Sci Sports Exerc 1995;27(5):629-633.

4. Taylor DC, Meyers WC, Moylan JA, Lohnes J, Bassett FH, Gar-rett WE, Jr. Abdominal musculature abnormalities as a cause of groin pain in athletes. Inguinal hernias and pubalgia. Am J Sports Med 1991;19(3):239-242.

5. Delaunay C, Roman F, Validire J. [Pubic osteoarthropathy caused by symphyseal instability or chronic painful symphysi-olysis: treatment by symphysiodesis. Apropos of a case and review of the literature]. Rev Chir Orthop Reparatrice Appar Mot 1986;72(8):573-577.

6. Allen WC, Cope R. Coxa saltans: The snapping hip revisited. J Am Acad Orthop Surg 1995;3(5):303-308.

7. McCarthy JC, Busconi B. The role of hip arthroscopy in the diagnosis and treatment of hip disease. Orthopedics 1995;18(8): 753-756.

8. Parziale JR, Hudgins TH, Fishman LM. The piriformis syndrome. Am J Orthop 1996;25(12):819-823.

9. Pace J, Nagle D. Piriformis Syndrome. West J Med 1976;124: 435-439.

10. Kirkaldy-Willis WH, Hill RJ. A more precise diagnosis for low-back pain. Spine 1979;4(2):102-109.

11. Mullin V, de Rosayro M. Caudal steroid injection for treatment of piriformis syndrome. Anesth Analg 1990;71(6):705-707.

12. Hughes SS, Goldstein MN, Hicks DG, Pellegrini VD, Jr. Ex-trapelvic compression of the sciatic nerve. An unusual cause of pain about the hip: report of five cases. J Bone Joint Surg Am 1992;74(10):1553-1559.

13. Hodgson BF. Pyogenic sacroiliac joint infection. Clin Orthop 1989(246):146-149.

14. Swezey RL. Obturator internus bursitis: a common factor in low back pain. Orthopedics 1993;16(7):783-785; discussion 785-786.

Section II

Operative Preparation

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