Hip pain1

1. بسم الله الرحمن الرحيم

2. HIP PAIN By Noha Abd El Halim El Sawy Ass. Prof. PM, Rheum & Rehab.

3. The hip joint is a synovial ,polyaxial, Ball & socket joint formed by the articulation of the rounded head of the femur and the cup-like acetabulum of the pelvis. It forms the primary connection between the bones of the lower limb and the axial skeleton of the trunk and pelvis.

4. Both joint surfaces are covered with a strong but lubricated layer called articular hyaline cartilage except a central rough depression on the head of femur called the fovea

5. -The cuplike acetabulum forms at the union of three pelvic bones and the joint may not be fully ossified under the age of 25 years.

6. The shape of the socket (acetabulum) is a deep cup shaped cavity with a defect below called the acetabular notch which is completed by the acetabular ligament . A lip of fibrocartilage called labrum acetabulare is also found. The articular cartilages are slippery and rubbery to allow shock absorption and provide a smooth surface to make motion easier.

7. The joint has a strong but loose fibrous capsule ----- largest ROM ( second only to the shoulder) and supports the weight of the body as well.

8. Intracapsular structures Articular bony surface Round ligament(ligamentum teres) Neck of femur Synovial membrane.

9. Ligaments The hip joint is reinforced by three main ligaments.

10. -At the front of the joint, the strong iliofemoral ligament attaches from the pelvis to femur . It is often considered to be the strongest ligament in the human body.

11. Function of the iliofemoral ligament Strengthens the anterior aspect of the capsule Prevent hyperextension & excessive lateral rotation of the hip joint.

12. The pubofemoral ligament attaches across the front of the joint from the pubis bone of the pelvis to the femur. This ligament is orientated more inferiorly than the iliofemoral ligament and reinforces the inferior part of the hip joint capsule.

13. Function of the pubofemoral ligament It supports the inferomedial aspect of the capsule. It limits excessive abduction of the hip.

14. The posterior of the hip joint capsule is reinforced by the ischiofemoral ligament that attaches from the ischial part of the acetabular rim to the femur

15. Synovial membrane It lines the inner surface of the fibrous capsule. It invests the ligamentum teres. It covers the intracapsular non articular parts of the bones but does not extend on the articular bony surfaces which are covered by hyaline cartilage.

16. Nerve supply -Nerve to rectus femoris (femoral nerve). -Br. From the anterior division of obturator nerve. -Nerve to quadratus femoris.

17. Arterial supply Arterial supply of the head of femur: 1- ascending br. Of nutrient artery of the femur reaches the head through the neck. 2-capsular ( retinacular) Bl.v. from trochanteric anastomosis. 3-arterty of round ligament of femur from the obturator artery.

18. Muscles acting on the hip joint Hip flexors: -Iliopsoas -rectus femoris -Pectineus. -Sartorius

19. Hip extensors: -gluteus max. -hamstrings: -biceps femoris -semitendinosis. -semimembranosis.

20. Abductors: -tensor fascia lata. -gluteus medius. -gluteus minimus.

21. Adductors: -adductor longus. -adductor brevis. -adductor magnus. - Pectineus.

22. Medial rotators: -g.medius. -g.minimus.

23. Lateral rotators: -g.max. -adductor muscles. -sartorius. -other lateral rotators: -Gemellus Superior -Obturator Internus - Gemellus inferior -Obturator Externus Quadratus -

24. Bursae -a bursa over the greater trochanter. -iliopsoas bursa( located on the inside).

25. Causes of hip pain are classified into: Causes related to hip joint disorders. Causes related to the periarticular soft tissues ( in the hip region). Extrinsic sources of hip symptoms ( referred pain). Generalized causes: hip pain may be just a manifestation of a widespread disease.

26. Analysis of hip pain: History: onset, duration, course, trauma. associated symptoms as fever, malaise, loss of weight, night sweating, other joint problems. Associated known disease as TB, other rheumatic disease as RA, AS etc.

27. Site of pain: True hip pain: is felt mainly in the groin and in front or inner aspect of the thigh. Pain is often referred to the knee ( pain in the knee may be the predominant feature of a hip disorder). Referred pain to the hip: Pain referred from the spine is felt mainly in the gluteal region down the back or the outer aspect of the thigh. Relieving and aggravating factors: It ↑ by walking and activities necessitate hip flexion or rotation and ↓ by rest

28. Causes related to hip joint disorders: Acetabulum and proximal femur: fracture , primary or metastatic tumors, osteonecrosis of the femoral head ,Perthes ’ disease, slipped upper femoral epiphysis and osteoporosis. Articular surfaces: transient synovitis of the hip, pyogenic arthritis, TB ,rheumatological diseases as RA , AS and osteoarthritis. Causes related to periarticular soft tissue disorders: a) Bursae: greater trochanteric bursitis and iliopsoas bursitis. b) Tendons and fascia: hamstring, adductor and rotator tendinitis and tightness of fascia lata. c) Hernias: inguinal and femoral hernias. 3. Extrinsic causes ( referred pain): a) spine and sacroiliac joint. b) abdominal and pelvic structures. c) major vessel occlusion.

29. 1) Fractures: * Site: femoral neck, acetabulum and pubic ramus. * Causes: direct trauma, stress # in distance runners and pathological # e.g. OP. * Manifestations: Pain in the hip region, external rotation deformity, shortening of the affected limb, adduction attitude due to pain . * Treatment : it differs according to the site and type of # and the age. 2) Primary and metastatic tumors: * 1ry: the most common is multiple myeloma. * 2ry: from tumors of the breast, lung, prostate, kidney and thyroid gland. * Manifestations: joint pain, pathological #, malaise, weight loss and inguinal lymphadenopathy.

30. Transient synovitis It ’ s a short term affection of the hip, of uncertain cause, characterized clinically by unilateral hip pain, limp & limitation of hip movement. Cause: unknown c/p:<10 y, boys. presenting with pain in groin & thigh, limping, limitation of movement. X-ray: normal. Ultrasonography of the hip may reveal joint effusion. ESR may be slightly elevated. Full recovery within 3-6 wks Treatment: bed rest, analgesics. DD with other hip problems.

31. Pyogenic arthritis Uncommon in hip. Mostly in children, usually secondary to osteomyelitis. Organism: staph/strep (blood born infection) or spread from adjacent OM. Acute inflammation in joint tissues with effusion of pus. Healing with restoration to normal may occur but permanent destruction & damage may occur in older children & adult bony ankylosis may result. c/p: -infants: in 1 st year, present with anxiety, unwellness & pyrexia on examination; restricted hip movement, abscess pointing at skin surface in buttocks or thigh with constitutional manifestations . x-ray; soft tissue shadow, destruction of capital epiphysis of femur, leading to gradual hip dislocation.

32. #in older children & adults: onset is acute or subacute with hip pain, severe limping, joint swelling & restricted painful movement x-ray: widening space between acetabulum & femoral head due to pus, later: narrowing & destruction of articular cartilage and finally bony ankylosis of joint. #-treatment: bed rest and joint rest. antibiotics therapy joint aspiration intra-articular injection of antibiotics

33. Rheumatoid arthritis Hip affection is uncommon in RA ,but occur in severe cases. It may be bilaterally. The main symptoms are pain and limitation of movement aggravated by activity. Swelling can not be detected clinically because it is a deeply seated joint. Fixed flexion or adduction deformity may develop. Gluteal &thigh muscles are wasted. By imaging: narrowing of joint space by destruction of articular cartilage with inward protrusion of softened medial wall of acetabulum Degenerative changes may superimpose on top of inflammation leading to 2ry OA.

34. acetabulae p rotrusio RA of hip joints with p

35. Tuberculous arthritis Hip is most frequently affected by TB. Usually a child 2-5 yrs or a young adult. Main symptoms pain & limp, impaired general condition. Examination: synovial thickening is palpable ,limitation of all hip movement, gluteal &thigh ms are wasted & sometimes cold abscess is palpable in upper thigh or buttock. Imaging: early; bone rarefaction with preserved joint space. later; articular cartilage erosion leading to permanent joint destruction. Diagnosis : history of contact with TB. presence of tuberculous lesion elsewhere. cold abscess. characteristic radiographic changes. +ve synovial membrane biopsy.

36. TB of the left hip

37. Ankylosing spondylitis It is an inflammatory disease and one of the sero – ve spondyloarthropathies. It is primarily a disease of the spine and sacroiliac joint. It affects the proximal joints especially the hips. One or both hips may be affected with pain and stiffness which improve by exercises. Hip involvement may be so severe--------- hip replacement is indicated. Treatment: Medical: NSAIDS, DMARDs and biological therapy. Physical therapy: A corner stone in the management of AS: hydrotherapy, ROM, breathing exercises etc. Surgical treatment: hip replacement.

38. Osteoarthritis OA of hip is one of the causes of severe disablement in elderly. Causes: -disease or damage of joint surface accelerates degeneration (acetabular fracture, Perthes ’ disease, SUFE, osteonecrosis). -2ry to developmental dysplasia or congenital sublaxation. -idiopathic. Pathology: -articular cartilage is worn away at sites where wt. is transmitted -the underlying bone is hard & eburnated. Also osteophytes formation may occur. -diminution of joint space. C/P: The patient is usually elderly pain in groin & front of the thigh and commonly in the knee. Pain is worsened by walking &relieved by rest joint stiffness & limited ROM. fixed deformity (flexion, adduction, lat. Rotation). shortening due to loss of joint space.

39. Imaging: diminution of joint space, subchondral bone sclerosis, osteophyte formation at joint margin. Treatment: #Conservative treatment: -relative rest in early stages. -analgesic, NSAIDS, ABCS. -physiotherapy: local heat, cold therapy, exercise to strengthen ms & preserve ROM. -IA injection: as hyaluronic. #Operative treatment: arthroplasty, osteotomy, arthrodesis

40. Perthes ’ disease IT IS OSTEOCHONDRITIS OF THE EPIPHYSIS OF THE FEMORAL HEAD It is a condition in children characterized by a temporary loss of blood supply to femoral head. Without an adequate blood supply, the rounded head of femur dies. It is temporary softened and may become deformed . -Perthes ’ disease usually is seen in children between 5 -10 yrs of age. It is five times more common in boys than in girls. -Etiology: unknown. most popular theory is temporary interruption of blood supply to femoral head leading to multiple episodes of infarction.

41. stages (2-3 years): Ingrowth of new blood vessels and removal of dead bone by steoclasts. New bone is laid down on the dead trabeculae with gradual constitution of the bone nucleus. Remodeling --- but bone necrosis and replacement is not uniform ---- so the nucleus appears fragmented on X-ray. Net result is deformation of the epiphysis and flattening of the femoral head.

42. Four Stages of Perthes ’ disease: Femoral head becomes more dense with possible fracture of supporting bone. Fragmentation and reabsorption of bone. Reossification when new bone has regrown. Healing, when new bone reshapes. Phase I takes about 2-6 months, Phase 2 takes one year or more, and Phase 3 and 4 may go on for many years.

43. C/P: limping with antalgic gait. mild pain at hip area in the groin (usually unilateral) or thigh with insidious onset. Moderate limitation of all hip movement with pain and spasm if movement is forced. N.B: no impact on general health but secondary OA of the hip develops later on. Diagnosis: by x-rays and MRI ( early diagnosis)

44. Treatment: Nonsurgical treatment: - anti-inflamatory medication. -Crutches are used for non-weight bearing treatment for pain. -Range of motion exercises may be given at home. - abduction splint (leg in abduction, int. rotation or abd., flexion by plaster cast or braces to keep femoral head in acetabulum). Surgical treatment: -varus femoral osteotomy to redirect femoral head in acetabulum -pelvic osteomy to redirect acetabulum over femoral head.

45. Osteonecrosis( avascular necrosis) Necrosis of bone of femoral head may be a complication of trauma, fracture of femoral neck , but may be a non-traumatic or idiopathic osteonecrosis is thought to be result of an ischemic episode affecting the bone and marrow tissue and may cause progressive collapse of femoral head in young adults. Cause: unknown . Fat embolism, intravascular coagulation. history of steroid therapy or alcohol addiction. patients receiving immuno-suppressive therapy following organ transplantation. Pathology: the bone necrosis does not involve the entire femoral head, but commonly occupies a wedge shaped segment beneath the superior weight baring surface. This may result in subchondral fracture with subsequent collapse of articular surface and a progression to secondary OA.

46. C/P: The patient is usually young or middle aged, will present with increasing pain in the hip or thigh during standing or walking (limping). When bony collapse has occurred, there may be marked restriction of hip movement with secondary contractures and limb shortening. Diagnosis: MRI in early stage show low intensity focus in the affected femoral head. x-ray: narrowing of joint space with flattening of weight bearing surface of head and underlying area of sclerosis in the bone. Treatment: surgical.

47. Slipped upper femoral epiphysis This is affection of late childhood in which the upper femoral epiphysis is displaced from its normal position upon the femoral neck. The displacement occurs at the growth plate( epiphysial line) and in both sides. Cause: Unknown. The condition is often associated with overweight from endocrine dysfunction, but in other cases the pt is of normal build. Pathology: The junction between the capital epiphysis and the neck of femur loosens. With the downward pressure of wt bearing and the upward pull of muscles on the femur the epiphysis displaced from its normal position. Displaced is always backward & downward , so that the epiphysis comes to lie at the back of femoral neck. C/P: The patient is between 10 and 20 years of age. gradual onset of pain in the hip with limp. Pain is felt mainly in the knee on examination: limitation of certain hip movement (flexion, abduction &medial rotation).

48. Diagnosis : x-ray shows slight displacement of the epiphysis in lateral radiograph. Complication: -osteonecrosis. -OA in severe displacement. Treatment: surgical.

49. Periarticular structures: Trochanteric bursitis: inflammation of the bursa between the greater trochanter and the tendon of gluteus maximus and medius. It is common in elderly. Or in young individuals who perform activities as walking, running and biking. Manifestations: pain over the greater trochanter which may radiate down the outer aspect of the thigh. In severe cases there is limping and stiffness of the hip. Diagnosis: imaging to exclude other causes. Treatment: NSAIDS, physical therapy, local steroid injection and rarely surgical removal of the inflamed bursa. b) Iliopsoas tendinitis: Inflammation and irritation of the iliopsoas tendon due to overuse of repititive microtruamata in sport activities. c) Iliopsoas bursitis: Inflammation of the bursa underneath the tendon.

50. Extrinsic causes of hip pain: Features of referred pain: pain is felt at the hip region but local hip examination is completely free i.e. no local tenderness, no limited ROM, imaging study is free as well. Abnormalities can be detected in the original site of pain e.g. spine, SIJ etc. Disorders of the spine: Discogenic pain may refer to the gluteal region and the lateral aspect of the thigh. b) Disorders of sacroiliac joint: They include: TB, pyogenic arthritis and AS. Pain is diffuse and felt over the gluteal area and may extend to the posterior aspect of the thigh ( sciatica-like pain).

51. c) Disorders of the abdomen and pelvis: Examples: deep peri appendicular abscess------ irritation of the obturator nerve and irritative spasm of the hip muscles which originate from the abdomen and pelvis as psoas major, iliacus, pyriformis and obturator internus. Pain may be associated with limited ROM due to muscle spasm. Careful history taking, examination and investigation reveal the proper diagnosis. d) Occlusive vascular disease: Examples: thrombosis of the abdominal aorta or main branches. Pain is elicited by activity and relieved by rest. The femoral pulse is weak or absent. Other lower limb arteries may be strong.

52. Thank you