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.
Differential diagnosis
Common Diagnoses
- Muscular/Ligamentous Strain
- Osteoarthritis
- Trochanteric Bursitis
- Referred from Back
- Meralgia Paraesthetica
Occasional Diagnoses
- Inflammatory Arthritis
- Avascular Necrosis
- Hernia
- Complications of a Total Hip Replacement (e.g. Loosening, Infection)
- Spinal Stenosis
- Iliotibial Band Syndrome
- Acetabular Labral Tear
Rare Diagnoses
- Impacted Fracture
- Dislocation
- Bony Pathology (e.g. Secondaries, Paget’s)
Ready reckoner
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 |
| Leg Numbness | No | No | No | Possible | Yes |
| 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 investigations
Likely: X-ray.
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.
Top Tips
- 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.
Red Flags
- 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.