Pain around the hip girdle is a common
complaint in clinical practice. Patients with pain resulting from diseases of
the hip joint usually describe pain in the anterior thigh or inguinal region that
worsens with weight bearing. More commonly, patients with a chief complaint of
hip pain have a problem in one of the nonarticular structures of the hip
girdle, usually located posteriorly or laterally [see Table 1]. A
multitude of bursae have been described in the hip girdle region. Pain in the
upper buttock in and around the gluteal muscles is often referred to as
myofascial hip pain or gluteal bursitis. Pain in this area is often difficult
to differentiate from referred lumbar pain. Local therapy with heat,
stretching, or glucocorticoid injection is usually helpful, but many patients
require long-term therapy.
Trochanteric bursitis is probably the most
common cause of hip girdle pain, although a recent study using MRI suggests
that most patients with this pain syndrome may have tendinitis or a partial
tear of the gluteus medius tendon.[44] Patients typically complain of pain over the
lateral aspect of the hip girdle, sometimes radiating down the thigh, that is
worse at night when they lie on the affected side. Pain is sometimes present
when the patient arises from a chair, but it tends to improve with ambulation.
Point tenderness over the lateral or posterior aspect of the greater trochanter
is usually diagnostic, though some patients with referred lumbar facet or disk
disease may have a similar presentation. Patients with more severe pain may
have a positive Trendelenburg sign on physical examination. Local heat and
NSAIDs may be helpful, and a local glucocorticoid injection is curative in most
patients. In refractory cases, repeated injections, physical therapy, and, in
rare instances, surgical excision of the bursa may be indicated.
Ischiogluteal bursitis results from an
irritation of the bursa in the area of the attachments of the hamstring and
gluteal muscles at the ischial tuberosity. The condition may be brought on by
prolonged sitting or by pressure in the area and usually responds to local
heat, stretching, or glucocorticoid injection.
Iliopectineal bursitis, which is caused by
irritation of the bursa between the iliopsoas muscle and the inguinal ligament,
is an uncommon cause of inguinal pain and may mimic true hip joint disease. The
diagnosis is suggested by the presence of inguinal pain that is aggravated by
extension of the hip (in a patient whose hip x-ray is normal). Confirmation by
ultrasonography or CT scanning may be required. Treatment is usually with local
measures or, in rare cases, by means of surgical excision.
Meralgia paresthetica is characterized by
intermittent paresthesia, hypoesthesia, or hyperesthesia over the upper
anterolateral thigh. The syndrome is caused by an entrapment of the lateral
femoral cutaneous nerve at the level of the anterosuperior iliac spine where
the nerve passes through the lateral end of the inguinal ligament. Causes
include local trauma, rapid weight gain, and the wearing of constrictive
garments around the hips. Useful therapies include avoidance of pressure in the
area, weight loss, and local infiltration of glucocorticoids at the level of
nerve exit.
|
Clinical
Syndrome |
Location of
Pain |
Diagnostic
Features and Comments |
|
Acetabular joint pain |
Anterior hip (inguinal) |
Worse with weight bearing |
|
Ileopectineal bursitis |
Anterior hip (inguinal) |
Pain with extension |
|
Meralgia paresthetica |
Anterior hip (midthigh) |
Numbness and tingling |
|
Trochanteric bursitis |
Lateral hip, posterior hip, or both |
Normal hip movement |
|
Myofascial pain |
Posterior hip |
Localized tenderness |
|
Gluteal bursitis |
Posterior hip |
Localized tenderness |
|
Ischiogluteal bursitis |
Posterior hip |
Normal hip movement |
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