Posterior Hip Pain/Hip pain or hip joint pain is an acute, chronic, pain felt in or around the hip joint due to causes of sudden fracture, osteoarthritis, osteonecrosis, muscle, tendon, ligament injury. The pain may be felt sudden, intense pain associate with paresthesia, tingling, numbness, and chronic life-threatening condition. It isn’t always felt in the hip itself but may instead be felt in the groin or thigh.
Types of Hip Joint Pain
Anterior Hip Pain
Problems within the hip joint pain, such as inflammation, infection, or a bone fracture, may result in anterior hip pain—pain felt on the inside of your hip and/or within your groin area.
- Osteoarthritis – Osteoarthritis of the hip occurs when the cartilage in the hip joint gradually wears away over time. As the cartilage frays and degenerates over time—often with increasing age or as a result of a prior hip injury—the joint space between the bones of the hip joint narrows, so bone may eventually rub on bone. Depending on the degree of osteoarthritis, pain may be dull, aching, or sharp; although, in nearly all cases, the pain and stiffness of hip osteoarthritis worsen with activity and improve with rest.
- Inflammatory Arthritis – Various types of inflammatory arthritis may affect the hip, resulting in dull, aching pain, such as rheumatoid arthritis, ankylosing spondylitis, and systemic lupus erythematosus. Unlike the pain of osteoarthritis, which is worsened with activity, hip pain from inflammatory arthritis is often eased with activity.
- Fracture – A hip fracture, or a break in the upper quarter of the thigh bone, causes a deep, boring pain felt in the outer-upper thigh or groin area. A hip fracture may occur after a fall or direct blow to the hip. It may also occur as a result of a stress injury. Stress fractures of the hip are most common in female athletes who have an eating disorder, menstrual irregularities, and bone weakening (conditions that, together, are known as the female athlete triad). Steroid use, a history of smoking, and medical conditions that weaken the bone (e.g., cancer or osteoporosis) are additional risk factors. With a stress fracture, as opposed to a complete break from a fall, a person may experience more of a gradual onset of pain that worsens with weight-bearing.
- Iliopsoas Bursitis – Bursitis simply translates to irritation or inflammation of a bursa, which is a small, fluid-filled sac that serves as a cushion between joints, muscles, and tendons. One bursa, located on the inner or groin side of your hip—called the iliopsoas bursa—causes anterior hip pain if inflamed. Iliopsoas bursitis, which is most common in runners or soccer players, causes anterior hip pain that may radiate to the front of the thigh area or into the buttock area. Sometimes, a snapping, catching, or popping sensation is felt in the hip with this type of bursitis.
- Hip Flexor Strain – A hip strain refers to a stretching or tearing of a muscle or its associated tendon (or both). Hip flexor muscles, like the iliopsoas muscle or rectus femoris muscle, are often involved in a hip strain. A person may develop a hip flexor strain from overuse (e.g., cyclists, martial artists, or soccer players), or from some sort of trauma, such as a direct hit during a contact sport. In addition to anterior hip pain, hip flexor strains may result in swelling, restricted movement, and muscle weakness.
- Osteonecrosis of the Hip – Osteonecrosis of the hip occurs when the hip bone does not receive a sufficient blood supply, which leads to the death of the bone cells and the destruction of the hip joint. The vast majority of cases are due to corticosteroid use and excessive alcohol intake. Besides anterior hip pain and groin pain that worsens with walking, a person may experience pain in the thighs, buttocks, and/or knees.
- Hip Labrum Tear – Your hip labrum is a band of cartilage-like tissue that courses around the outer rim of your hip socket. This labrum helps to support the joint and deepen the socket. Sometimes overuse or an injury to your hip can cause a tear in your labrum, prompting dull or sharp anterior hip pain that worsens with weight-bearing.
- Femoroacetabular Impingement (FAI) –In femoroacetabular impingement (FAI), bony growths develop around the hip joint. These growths can restrict movement and eventually cause tears of the labrum and hip osteoarthritis. The symptoms of femoroacetabular impingement include an aching or sharp pain in the groin area that moves toward the outside of the hip. The pain is often felt once standing after sitting for a prolonged period of time. Stiffness and limping are also common.
- Infected Hip Joint – Uncommonly, the hip joint may become infected (called a septic joint). In addition to severe anterior hip and/or groin pain, swelling, warmth, and restricted hip movement are typically present. Fever often also occurs, but may not be present in older individuals.
- Bone Cancer – Rarely, bone cancer (either primary or metastatic) may cause hip pain. Usually, the pain starts off being worse at night, but as the bone tumor progresses, the pain often becomes constant. Swelling around the hip area may also occur along with weight loss and unusual fatigue. Due to bone weakening from cancer, a hip fracture may occur.
Lateral Hip Pain
Lateral hip pain refers to pain on the side of the hip, as opposed to the front or back of the hip.
- Trochanteric Bursitis – Trochanteric bursitis causes sharp lateral hip pain that often spreads down into the thigh and knee. The pain is usually worse at night when sleeping on the affected hip and when engaging in physical activities like walking or running. Over time, the pain may evolve into a deep aching pain that spreads over a larger area of the hip. Swelling and limping may also occur.
- Snapping Hip Syndrome – Snapping hip syndrome causes a snapping or popping sensation and possibly lateral hip pain with walking or other movements, like getting up from a chair. The actual “snapping” is due to one or more tight muscles, tendons, or other soft tissue moving over a bony structure within your hip. One commonly affected “tight” or irritated tissue is the iliotibial band (IT band)—a thick collection of connective tissue that starts at the hip and runs along the outer thigh The snapping sound results from the area where the IT band passes over the greater trochanter (the upper portion of the thigh bone). This condition is most common in people who engage in sports or activities that cause them to frequently bend at the hip (one reason why it’s also referred to as “dancer’s hip.”)
Posterior Hip Pain
Posterior hip pain, which is pain felt on the outside of the hip or buttock area, is usually due to a problem with the muscles, tendons, or ligaments that surround the hip joint, as opposed to the actual joint itself.
- Hamstring Muscle Strain – Muscle strains result from small micro-tears in muscles caused by a quick twist or pull to the muscle. When this occurs to the hamstring muscles located around the hip joint, buttock pain and/or pain in the back of your hip occurs.
- Sacroiliac Joint Problem – The sacroiliac (SI) joint connects the lower spine to the pelvis. You have one located on both sides of your body. Various problems with the SI joint, including arthritis of the joint, infection of the joint, and injury to the joint ligaments, may result in posterior hip pain. The sharp and/or burning pain is often worse with standing and walking, and may radiate from the hip down the back of the leg.
- Piriformis Syndrome – Piriformis syndrome—also called deep gluteal syndrome—occurs when the sciatic nerve (a large nerve that branches off from your lower back into your hip, buttock, and leg) becomes irritated or compressed by the piriformis muscle, which is located deep within the buttock, near the top of the hip joint. The burning or aching pain of piriformis syndrome typically begins in the posterior hip and buttock region and moves down the back of the thigh.
Causes of Posterior Hip Pain
These are some of the conditions that commonly cause hip pain
- Arthritis – Osteoarthritis and rheumatoid arthritis are among the most common causes of hip pain, especially in older adults. Arthritis leads to inflammation of the hip joint and the breakdown of the cartilage that cushions your hip bones. The pain gradually gets worse. People with arthritis also feel stiffness and have a reduced range of motion in the hip. Learn more about hip osteoarthritis.
- Hip fractures. With age, the bones can become weak and brittle. Weakened bones are more likely to break during a fall. Learn more about hip fracture symptoms.
- Bursitis – Bursae are sacs of liquid found between tissues such as bone, muscles, and tendons. They ease the friction from these tissues rubbing together. When bursae get inflamed, they can cause pain. Inflammation of the bursae is usually due to repetitive activities that overwork or irritate the hip joint. Learn more about bursitis of the hip.
- Tendinitis – Tendons are the thick bands of tissue that attach bones to muscles. Tendinitis is inflammation or irritation of the tendons. It’s usually caused by repetitive stress from overuse. Learn more about tendinitis symptoms.
- Muscle or tendon strain – Repeated activities can put a strain on the muscles, tendons, and ligaments that support the hips. When they become inflamed due to overuse, they can cause pain and prevent the hip from working normally. Learn about the best stretches for tight hip muscles.
- Hip labral tear – This is a rip in the ring of cartilage (called the labrum) that follows the outside rim of the socket of your hip joint. Along with cushioning your hip joint, your labrum acts like a rubber seal or gasket to help hold the ball at the top of your thighbone securely within your hip socket. Athletes and people who perform repetitive twisting movements are at higher risk of developing this problem. Learn more about hip labral tears.
- Cancers – Tumors that start in the bone or that spread to the bone can cause pain in the hips, as well as in other bones of the body. Learn more about bone tumors.
- Avascular necrosis (also called osteonecrosis) – This condition happens when blood flow to the hip bone slows and the bone tissue dies. Although it can affect other bones, avascular necrosis most often happens in the hip. It can be caused by a hip fracture or dislocation, or from the long-term use of high-dose steroids (such as prednisone), among other causes.
- Ache – A persistent, dull aching is commonly felt in the groin and front of the thigh. Some people may experience a dull ache in the buttock, outside of the hip, and/or in the lower back. People with hip arthritis use words like dull, aching, nagging, sore, and throbbing to describe this type of pain.
- Prolonged inactivity – People with hip arthritis often complain of pain in the morning when getting out of bed. The pain will often dissipate within 30 minutes of getting out of bed or from a seated position.
- Abduction, external and internal rotation – Spreading the legs or rotating the toes inward or outward can cause hip pain. Lying on the back causes a natural outward rotation of the toes and legs, so sleeping on the back can be uncomfortable. Sexual intercourse can be painful, also.
- Bending over – Deep bending can be difficult to impossible for patients with hip arthritis. Many complain that bending over to put on socks and shoes is challenging.
- Difficulty getting in or out of a car – People suffering from hip joint pain will often complain of difficulty with driving and need the assistance of their arms to lift the leg and thigh both into and out of the car.
- Intermittent Sharp Pain – Intense, stabbing pain episodes due to hip arthritis are sudden and brief. People describe this hip pain using words such as sharp, stabbing, ice pick, spike, or paralyzing.
- Prolonged physical activity – Participating in weight-bearing physical activity, including sports, can result in stabbing pain or be followed by an aching pain.
Symptoms of Posterior Hip Pain
- aching pain in the groin area, outer thigh, and buttocks
- joint stiffness
- reduced range of motion (for example, difficulty putting on shoes and socks)
- Popping or Clicking
- Pain in the groin, on the side, or in the buttock region
- Pain with sitting or steps
- pain in your groin
- pain also in your buttocks, thigh, or knee
- the pain made worse during rainy weather, in the morning, or after resting or sitting for a while
- hip pain that keeps you from sleeping
- pain when bending over, getting up from a chair, or taking a short walk
- grinding sound with movement (called crepitus), or your hip locking or sticking
Diagnosis of Posterior Hip Pain
Examination steps
The hip examination, like all examinations of the joints, is typically divided into the following sections
- Position/lighting/draping
- Inspection
- Palpation
- Motion
- Special maneuvers
The middle three steps are often remembered with the saying look, feel, move.
Position/lighting/draping
- Position – for most of the exam the patient should be supine and the bed or examination table should be flat. The patient’s hands should remain at their sides with the head resting on a pillow. The knees and hips should be in the anatomical position (knee extended, hip neither flexed nor extended).
- Lighting – adjusted so that it is ideal.
- Draping – both of the patient’s hips should be exposed so that the quadriceps muscles and greater trochanter can be assessed.
1. Inspection
- Inspection is done while the patient is standing
Look
Front and back of pelvis/hips and legs and comment on
- Ischaemic or trophic changes·
- Level of ASIS (anterior superior iliac spine)
- Swelling (soft tissue, bony swellings)
- Scars (old injuries, previous surgery)
- Sinuses (infection, neuropathic ulcers)
- Wasting (old polio, Charcot-Marie-Tooth) or hypertrophy (e.g. calf pseudo-hypertrophy in muscular dystrophy)
- Deformity (leg length discrepancy, pes cavus, scoliosis, lordosis, kyphosis)
Feel
- Any swellings·Anteriorly in Scarpa’s triangle, Trochanteric region, or gluteal region
- Pelvic tilt by palpating level of ASIS (anterior superior iliac spine)
Move
Gait Observe
- Smooth and progression of phases of the gait cycle
- Comment on stance, toe-off, swing heel strike, stride, and step length
- Sufficient flexion/extension at hip/knee ankle and foot:
- Any fixed contractures?
- Arm-swing and balance on turning around·
Abnormal Gait Patterns
- Trendelenburg (pelvic sway/tilt, aka waddling gait if bilateral)
- Broad-based (ataxia)
- High-stepping (loss of proprioception/drop foot)
- Antalgic (mention “with reduced stance phase on left/right side”)
- In-toeing (persistent femoral anteversion)
Inspection is done while supine
The hip should be examined for:
- Masses
- Scars
- Lesions
- Signs of trauma/previous surgery
- Bony alignment (rotation, leg length)
- Muscle bulk and symmetry at the hip and knee
Measures
- True leg length – Greater Trochanter of the femur or Anterior Superior Iliac Spine of the pelvis to medial malleolus of ipsilateral leg.
- Apparent leg length – umbilicus or xiphisternum (noting which is used) to the medial malleolus of ipsilateral leg. In hip fractures, the affected leg is often shortened and externally rotated.
2. Palpation
The hip joint lies deep inside the body and cannot normally be directly palpated. To assess for pelvic fracture one should palpate the:
- Iliac spines
- Superior and inferior pubic rami
3. Movement
- Internal rotation – with knee and hip both flexed at 90 degrees the ankle is abducted.
- External rotation – with knee and hip both flexed at 90 degrees the ankle is adducted. (also done with Patrick’s test / FABER test)
- Flexion (also known as the Gaenslen’s test)
- Extension – done with the patient on their side. Alignment should be assessed by palpation of the ASIS, PSIS, and greater trochanter.
- Abduction – assessed whilst palpating the contralateral ASIS.
- Adduction – assessed whilst palpating the ipsilateral ASIS.
- Assessment for hidden flexion contracture of the hip – hip flexion contractures may be occult, due to compensation by the back. They are assessed by:
- Placing a hand behind the lumbar region of the back
- Getting the patient to fully flex the contralateral hip.
- The hand in the lumbar region is used to confirm the back is straightened (flexed relative to the anatomic position). If there is a flexion contracture in the ipsilateral hip it should be evident, as the hip will appear flexed.
Normal range of motion
- Internal rotation – 40°
- External rotation – 45°
- Flexion – 125°
- Extension – 10-40°
- Abduction – 45°
- Adduction – 30°
Special maneuvers
- Trendelenburg test/sign – The Trendelenburg test is used to assess hip stability. The patient is asked to stand unassisted on each leg in turn, whilst the examiner’s fingers are placed on the anterior superior iliac spines. The foot on the contralateral side is elevated from the floor by bending at the knee. An alternative approach is to have the patient undertake this maneuver facing the examiner and supported only by the index fingers of the outstretched hands; this accentuates any instability of balance shown during a positive test. In normal function, the hip is held stable by the gluteus medius acting as an abductor in the supporting leg. If the pelvis drops on the unsupported side – positive Trendelenburg sign – the hip on which the patient is standing is painful or has a weak or mechanically disadvantaged gluteus medius.
- A positive Trendelenburg test is found in
- any condition that brings the origin and insertion of gluteus medius together
- subluxation or dislocation of the hip
- coxa vara
- greater trochanter fractures
- slipped upper femoral epiphysis
- abductor paralysis or weakness e.g.:
- polio
- root-lesion
- post-operative nerve damage
- muscle-wasting disease
- Make sure the pelvis is horizontal by palpating ASIS.
- Ask the patient to stand on one leg and then on the other.
- Assess any pelvic tilt by keeping an index finger on each ASIS.
- Normal (Trendelenburg negative) – In the one-legged stance, the unsupported side of the pelvis remains at the same level as the side the patient is standing or even rises a little, because of the powerful contraction of hip abductors on the stance leg.
- Abnormal (Trendelenburg positive) – In the one-legged stance, the unsupported side of the pelvis drops below the level as the side the patient is standing on. This is because of the (abnormal) weakness of hip abductors on the stance leg. The latter hip joint may therefore be abnormal.
- Assisted Trendelenburg test – If the balance is a problem, face the patient and ask them to place their hands on yours to support him/her as he/she does alternate one-legged stance. Increased asymmetrical pressure, on one hand, indicates a positive Trendelenburg test, on the side of the abnormal hip
- A ‘delayed’ Trendelenburg – has also been described, where the pelvic tilt appears after a minute or so: this indicates abnormal fatiguability of the hip abductors.
- Romberg’s test – This assesses proprioception/balance (dorsal columns of spinal cord/spinocerebellar pathways). Ask the patient to stand with heels together and hands by the side. Ask the patient to close his/her eyes and observe for swaying for about 10seconds.
- Manual Romberg’s test – Most people sway a bit but then quickly decrease the amplitude of swaying. If however, the swaying is not corrected, or the patient opens the eyes or takes a step to regain balance, Romberg’s test is positive.
- When doing this test – stand facing the patient with your arms outstretched and hands are at the level of the patient’s shoulders to catch or stabilize him/her in case of a positive Romberg test.
- Ober’s test – for tight ITB (Iliotibial Band, also called IlioTibial Tract) performed with patient side-lying on the unaffected side and the provider extending the affected hip. Stabilize the pelvis and let the affected leg drop. A positive test is indicated if the leg does not adduct to the table.[rx]
- Thomas test – for tight hip flexors both performed by the provider holding the unaffected leg to the chest and leaving the affected leg on the table. If the affected leg cannot lie flat on the table it is a positive test.[rx] the Kendall test is similar, but the patient holds the unaffected leg to their chest.[rx]
- Rectus Femoris Contracture test – for tight rectus femoris performed like Thomas test, but with the affected leg bent off the end of a table. a positive test is indicated if the thigh is not parallel with the table.[rx]
- Kaltenborn test or Hip Lag Sign test – for hip abductor function. To perform the Kaltenborn test, the patient has to lie in a lateral, neutral position with the affected leg being on top. The examiner then positions one arm under this leg to have good hold and control over the relaxed extremity, whereas the other hand stabilizes the pelvis. The next step is to passively extend to 10° in the hip, abduct to 20° and rotate internally as far as possible, while the knee remains in a flexed position of 45°. After the patient is asked to hold the leg actively in this position, the examiner releases the leg. The Hip Lag Sign is considered positive if the patient is not able to keep the leg in the aforementioned abducted, internally rotated position and the foot drops more than 10 cm. To ensure an accurate result, the test should be repeated three times.[rx]
ACTIVITY LIMITATION AND PARTICIPATION RESTRICTION MEASURES
| 6-Minute Walk Test | |
|---|---|
| ICF category | Measurement of activity limitation: walking long distances |
| Description | A physical performance measure that assesses how far a person can walk in 6 minutes[rx] |
| Measurement method | During the performance of the 6-minute walk test (6MWT), patients are instructed to cover as much distance as possible during the 6-minute time frame, with the opportunity to stop and rest if required. The test is conducted on an unobstructed level surface. The course is marked off in meters, and the distance traveled by each subject is measured to the nearest meter. Standardized verbal encouragement, “You are doing well, keep up the good work” is provided at 60-second intervals. Patients are permitted to use their regular walking aids if needed.[rx] |
| Nature of variable | Continuous |
| Units of measurement | Meters |
| Measurement properties | The 6MWT showed high test-retest reliability (ICC2,1 of 0.95–0.97).[rx] Kennedy et al]rx] also showed high test-retest reliability for the 6MWT with ICC2,1 of 0.94 (95% CI: 0.88–0.98). The MDC90 for the 6MWT determined from a sample of 150 subjects with hip and knee OA, of which 69 underwent total hip arthroplasty (THA) was 61.34 m.[rx] |
| Self-Paced Walk Test | |
|---|---|
| ICF category | Measurement of activity limitation: walking short distances |
| Description | A physical performance measure which assesses how fast a person can walk for 4 m and for 40 m |
| Measurement method | During the performance of the self-paced walk test (SPWT), patients are instructed to walk as quickly as you can without overexerting yourself” and timed with a stopwatch while they walk 2 lengths (turn excluded) of a 20-m indoor course[rx] |
| Nature of variable | Continuous |
| Units of measurement | Seconds |
| Measurement properties | The test-retest reliability of the SPWT for 40 m has been examined by Kennedy et al.[rx] They found an ICC of 0.91 (95% CI: 0.81–0.97). Kennedy et al[rx] also showed the SPWT was responsive in detecting deterioration and improvement in the early postoperative period following arthroplasty. The MDC90 for the 40-m SPWT determined from a sample of 150 subjects with hip and knee OA of which 69 underwent THA was 4.04 seconds.[rx] In a cohort of 492 older adults the recommended criterion for substantial meaningful change for gait speed at 10 ft, 4 m, and 10 m was 0.1 m/s.[rx] |
| Stair Measure | |
|---|---|
| ICF category | Measurement of activity limitation: climbing |
| Description | A physical performance measure, which assesses how well a person, can ascend and descend a flight of stairs |
| Measurement method | During the performance of the stair measure (SM) patients are instructed to ascend and descend 9 steps (step height, 20 cm) in their usual manner, and at a safe and comfortable pace[rx] |
| Nature of variable | Continuous |
| Units of measurement | Seconds |
| Measurement properties | The test-retest reliability of the SM has been examined by Kennedy et al.[rx] They found an ICC of 0.90 (95% CI: 0.79–0.96).[rx] Kennedy et al[rx] also showed the SM to be responsive in detecting deterioration and improvement in the early postoperative period following arthroplasty. The MDC90 for the SM, determined from a sample of 150 subjects with hip and knee OA, of which 69 underwent THA, was 5.5 seconds.[rx] |
| Timed Up-and-Go Test | |
|---|---|
| ICF category | Measurement of activity limitations: getting in and out of a seated position, walking short distances |
| Description | A physical performance measure which assesses how well a person can get up from a chair with armrests, walk a short distance (3 m), turn around, return, and then sit down again[rx] |
| Measurement method | During the performance of the timed up-and-go test (TUG), the patient sits in a chair with armrests and is asked to stand up from the chair and walk as quickly and safely as possible to a cone 3 m away, turn, walk back to the chair, and sit down again. The performance of this test is timed. |
| Nature of variable | Continuous |
| Units of measurement | Seconds |
| Measurement properties | There was good agreement among observers on the subjective scoring of the TUG, and good correlation with the Berg balance scale, gait speed, Barthel’s Index of activities of daily living, and predicted patient’s ability to walk outside safely.[rx] Podsiadlo[rx] showed that the TUG had good intertester and intratester reliability (ICC = 0.99). Steffen et al[rx] also showed the TUG had high test-retest reliability (ICC2,1 = .95–.97). Podsiadlo[rx] provided evidence for the criterion-related validity of the TUG by showing it correlates well with other functional scales. Kennedy et al[rx] showed the TUG was responsive in detecting deterioration and improvement in the postoperative time period following arthroplasty. The MDC90 for the TUG, determined from a sample of 150 subjects with hip and knee OA, of which 69 underwent THA, was 2.5 seconds.[rx] |
PHYSICAL IMPAIRMENT MEASURES
| Passive Hip Internal and External Rotation and Hip Flexion | |
|---|---|
| ICF category | Measurement of impairment of body function: mobility of a single joint |
| Description | The amount of passive hip rotation and passive hip flexion measured prone and supine, respectively. Although assessing the range in all 6 directions (3 planes) of hip motion is important in patients with hip OA, for brevity, we included the 3 most commonly limited hip motions. The patient is also asked to rate the amount of pain experienced during the movement on a 0-to-10 numerical pain rating scale (NPRS). |
| Measurement method | Hip Internal and External Rotation: The patient is positioned prone with feet over the edge of the treatment table. The hip measured is placed in 0° of abduction, and the contralateral hip is placed in about 30° of abduction. The reference knee is flexed to 90°, and the lower extremity is passively moved to produce hip rotation. The movement arm of the goniometer is aligned vertically along the shaft of the tibia while the stationary arm is aligned along an imaginary vertical line. Manual stabilization is applied to the pelvis to prevent pelvic movement and also at the tibiofemoral joint to prevent motion (rotation or abduction/adduction), which could be construed as hip rotation.[rx] The tibia is then moved in the frontal plane to produce hip internal and external rotation. The motion is stopped and measurements are taken when the extremity achieves its end range of passive hip rotation or when pelvic movement is necessary for additional movement of the lower extremity. An inclinometer may also be used to measure hip rotation. The inclinometer is first “calibrated” by placing it along the distal shaft of the vertically aligned tibia, just proximal to the medial malleolus, and then setting the inclinometer dial to zero. Then, the extremity is passively moved to produce hip rotation and an inclinometer measure is taken when the hip achieves its end range of passive internal and external rotation.[rx] Hip Flexion: With the patient in the supine position, the hip is passively flexed with the movement arm of the goniometer along the long axis of the femur and the stationary arm of the goniometer along the long axis of the trunk, while stabilizing the lumbar spine to avoid any posterior pelvic tilt.[rx] |
| Nature of variable | Continuous (ROM) and ordinal (pain) |
| Units of measurement | Degrees and 0-to-10 NPRS |
| Measurement properties | Limited ROM is associated with high levels of disability in patients with hip OA.[rx] The reliability for hip rotation and hip flexion ROM measurements has been shown to be excellent, ICC of 0.95 to 0.97[rx] for rotation and ICC of 0.94 (95% CI: 0.89–0.97)[rx] for flexion. ROM measurements in 22 individuals with hip OA demonstrated excellent interrater test-retest reliability (ICC = .97) for hip flexion.[rx] Croft et al[rx] showed good agreement among 6 testers when assessing for hip rotation and hip flexion in patients with hip OA. Steultjens et al[rx] also showed good reliability when assessing the hip joint in patients with OA. The MDC95 for hip flexion, determined using 22 patients with knee OA and 17 subjects without lower extremity symptoms or known pathology, is 5°, meaning any change more than 5° is considered to be changed beyond measurement error.[rx] The MDC95 for pain with hip flexion is 1.2 on the 0–10 NPRS.[rx] The clinically important difference for the NPRS, derived from patients with low back pain, has been shown to be a reduction of 2 points.[rx,rx] |
| Hip Abductor Muscles Strength Test | |
|---|---|
| ICF category | Measurement of impairment of body function: the power of isolated muscles and muscle groups |
| Description | A test to determine the strength of the hip abductor muscles |
| Measurement method | The hip abductor muscles strength test is performed with the subject in the supine position and the hip in a neutral position of flexion/extension, abduction/adduction, and external/internal rotation. A “make” test using a handheld dynamometer is used by asking the subject to push the most they can against the handheld dynamometer applied on the lateral aspect of the distal thigh, just above the knee. The hip abductor muscles may also be tested in the side-lying position with the hip in the abduction and slight extension. A “break” test is performed by the tester applying force via the handheld dynamometer applied on the lateral aspect of the distal thigh just above the knee. The direction of force application is toward adduction and slight flexion while the pelvis is stabilized with the other hand.[rx] |
| Nature of variable | Continuous |
| Units of measurement | Force in Newtons |
| Measurement properties | Interrater and intrarater reliability of force measurements obtained from college-age women were excellent using a handheld dynamometer for the abductor’s muscles (interrater ICC, .88–.96; interrater ICC, .90–.95).[rx] Force measurements of hip abductors in 22 individuals with hip OA demonstrated good interrater test-retest reliability (ICC of .84). The MDC95, determined from a sample of 90 subjects (age range, 22–70 years) without any previous musculoskeletal problems, was 5.4% of body weight for males and 5.3% of body weight for females.[rx] |
| The FABER (Patrick’s) Test | |
|---|---|
| ICF category | Measurement of impairment of body function: pain in joints |
| Description | A test to determine the irritability of the hip joint |
| Measurement method | The FABER test is administered with the subject in supine, the heel of the lower extremity to be tested placed over the opposite knee. The hip joint is passively externally rotated and abducted by the examiner applying manual pressure over the ipsilateral knee while stabilizing the contralateral innominate with the opposite hand. After being zeroed against a wall, the inclinometer is placed on the medial aspect of the tibia of the tested lower extremity, just distal to the medial tibial condyle. ROM measurement is taken at the point of maximal passive resistance or at the point where the patient stops the test secondary to pain.[rx] The patient is also asked to rate the location of the pain as well as the amount of pain experienced during the movement on a 0-to-10 NPRS. |
| Nature of variable | Continuous (ROM) and ordinal (pain) |
| Units of measurement | 0-to-10 NPRS |
| Measurement properties | Interrater reliability of ROM (ICC = 0.96; 95% CI: 0.92–0.98) and pain (ICC = 0.87; 95% CI: 0.78–0.94) measurements was excellent for the FABER test.[rx] Cibulka[rx] found the FABER test was responsive in detecting improvement in ROM and in the report of pain in patients with hip pain. The MDC95, determined from a sample of 22 patients with knee OA and 17 subjects without lower extremity symptoms or known pathology, was 8° for ROM and 1.6 points on the NPRS.[rx] The clinically important difference for the NPRS, derived from patients with low back pain, has been shown to be a reduction of 2 points.[rx] |
| The Scour Test | |
|---|---|
| ICF category | Measurement of impairment of body function: pain in joints |
| Description | A test to determine the irritability of the hip joint |
| Measurement method | The hip Scour test is performed with the patient lying in the supine position while the clinician flexes and adducts the hip until resistance to movement is detected. The clinician then maintains flexion into resistance and gently moves the hip into abduction, then bringing the hip through 2 full arcs of motion. If the patient reports no pain, then the examiner repeats the test while applying long-axis compression through the femur. This test must be administered with some caution so as to not irritate the hip joint. The patient is asked to rate the pain experienced during the movement on a 0-to-10 NPRS.[rx] |
| Nature of variable | Ordinal |
| Units of measurement | 0-to-10 NPRS |
| Measurement properties | The intratester reliability of the Scour test is good (ICC = 0.87; 95%CI: 0.76–0.93) for a rating of hip pain.[rx] The MCID for the NPRS has been shown to be a reduction of 2 points.[rx,rx] The MDC95 for the Scour test was determined from a sample of 22 patients with knee OA and 17 subjects without lower extremity symptoms or known pathology. The MDC95 for pain was a change of more than 1.6 points on the 0-to-10 NPRS.[rx] |
Lab Tests
- Laboratory tests – Leukocytosis is one of the most important tests for hip joint pain that supports the possibility of infection and bone-related disease in the thigh. Blood cultures, urine examination, stool examination, or other possible primary sites of foot bone infection that obligatory when a septic infectious joint is being considered for examination. The elevated inflammatory condition markers like ESR or CRP include suggesting an infectious or inflammatory disease condition may involve hip joints pain.
- A serum uric acid level – It is often considered by clinicians and doctors when a kidney or other abnormality is suspected, but it is not a reliable and dangerous condition as it may be spuriously elevated or high in acute inflammatory conditions or acutely during a or not.
- Ultrasound – It is basically done to investigate the thickness of the fascia, tendon, nerve, ligament injury in the spine with hip joints pain or arthritis, and hip joints pain, or osteoarthritis.[rx]
- Musculoskeletal ultrasound – It can further visualize the tendon and bony attachment of the lumbar spine, muscles, ligaments, and nerves. Ultrasound can also be used to identify the area and extent, nature of the injury and used to evaluate periodically during the recovery phase pain.
Imaging
- Radiographs – Conventional X-ray and radiography is the most widely used imaging system and allows for the detection of bone fractures, osteoporosis, and abnormal pathologies condition like fracture, osteoporosis, erosions, osteonecrosis, osteoarthritis, or a juxta-articular bone tumor, neoplasm, and hip joints pain or arthritis. Characteristic features of sciatica in the hip joints pain or arthritis include marginal osteophytes formation, joint space gradually narrowing, subchondral sclerosis formation in the thigh front side, and backside pain.
- CT Scan – High contrast CT scan is more effective to diagnose hip joints pain or arthritis pain. Abnormal tendons, ligaments, cartilage, muscles and osteophytes, synovial fluid. It also helps to identify the bone tumor, necrosis, abnormal joint condition, etc.
- MRI – It is called magnetic radical imaging is also helpful to find the bone conditions, abnormal tendon, ligament, cartilage, muscle and osteophyte, synovial fluid. It also helps to identify the bone tumor, necrosis, abnormal joint condition, etc. It is the final stage test to confirm that all hip joints pain or arthritis or any other abnormality. suspected others condition heel pain, such as soft tissue injury and bone tumors, osteonecrosis, osteomyelitis, and stress fracture.[rx,rx]
- Nerve Conduction velocity test – It a special test for leg pain on both sides or right and left side leg associate with sciatica. It is the procedure where test the sensation of the peripheral nerve stimuli to send the central nervous system means brain. It helps to identify the nervous system sensory and motor problem from the central to the peripheral cell.
Treatment of Posterior Hip Pain
Nonpharmacologic Treatments
- Rest – The surrounding muscles, tendons, cartilage, and ligaments that support the hip joint can tire, placing more pressure on the joint. Resting the hip joint can ease this type of pain.
- Gentle moderate activity – Gentle activity can relieve the pain and stiffness that are caused by prolonged rest. When the hip joint is used, synovial fluid is secreted, lubricating and delivering nutrients to the joint properly.
- Exercise – An exercise program that does not involve high-impact activities usually is advocated and is associated with pain reduction.[rx] Aquatic exercises also improve function.[rx,rx] Exercises that strengthen and stretch the muscles around the hip can support the hip joint and ease the hip strain pain. Certain activities and exercises that can aggravate hip joint pain should be recognized and avoided. Activities that necessitate twisting at the hip such as golf or are high impact such as jogging should be replaced with activities that exert less stress on the hip joint such as gentle yoga, cycling, or swimming. Manipulation and stretching should be considered as adjuncts to core treatments, particularly for hip pain and osteoarthritis.[rx]
- Physical Therapy – Physical therapy is the main and helpful for treatment in mild and early hip pain and osteoarthritis and is aimed at strengthening hip muscles and maintaining joint mobility. Physical therapy that is provided during the later stages of hip osteoarthritis may provide little or no benefit.[rx]
- Weight Reduction – It is a helpful treatment plan for pressure upon a hip with each step.[rx] Unloading the joint through weight loss can slow cartilage loss, degeneration, and decrease the joint impact. Weight recommendations that address hip osteoarthritis are based upon findings from many cohort studies.[rx–rx] An individualized exercise program combined with effective behavioral strategies aimed at weight loss may be most beneficial in reducing pain for overweight patients
- Transcutaneous Electrical Nerve Stimulation – your doctor may advise transcutaneous electrical nerve stimulation should be considered as an adjunct to core treatments for pain relief for patients with hip joints pain.[rx]
- Temperature Extremes – your doctor may advise hot bath and cold compression as the immediate treatments in accidental hip joint pain, sometimes are effective pain relief modalities. Heat treatments enhance the circulation of blood and soothe stiff joints and tired muscles easily. Cold treatments slow the circulation of blood, reduce swelling and alleviate acute pain. A patient may need to experiment and/or alternate the use of heat and cold therapies to determine which is most effective.
- Proper Footwear and Bracing/Joint Supports/Insoles – your doctor may advise patients should be educated about appropriate footwear that features shock-absorbing properties to address lower limbs.[rx] Patients with OA who have biomechanical joint pain or instability may be considered for assessment of bracing/joint supports/insoles as an adjunct treatment.[rx] Bracing may have a role in modifying biomechanics to treat hip osteoarthritis, although more research in this area is necessary.[rx]
- Assistive Devices – Walking sticks, tap turners, canes, and other devices should be considered as adjuncts to core treatments for people with osteoarthritis of the hip who have specific problems with activities of daily living. If needed, patients can be referred for further evaluation and treatment from occupational and physical therapists and/or specialized disability device and equipment companies.[rx]
- Acupuncture – It is not recommended as osteoarthritis treatment of hip joint, but in some cases of rehabilitation it is needed. Patient education can help to incorporate multiple approaches into hip osteoarthritis treatment and minimize risk factors.
Medications
- Non-steroidal anti-inflammatory drugs (NSAIDs) – your doctor may advise drugs like naproxen and ibuprofen two times daily, may relieve pain and help reduce inflammation. NSAIDs are available in both over-the-counter and prescription forms.
- Corticosteroids – your doctor may advise medications like prednisone, two times daily, minimum 7 days are potent anti-inflammatories. They can be taken by mouth, by injection, or used as creams that are applied directly to the skin.
- Disease-modifying antirheumatic drugs (DMARDs). These drugs act on the immune system to help slow the progression of the disease. Methotrexate and sulfasalazine are commonly prescribed DMARDs.
- Acetaminophen and Nonsteroidal Anti-Inflammatory Drugs – Acetaminophen typically is recommended as a first-line medication for hip joint pain.[rx] However, the role of acetaminophen for short-term relief of hip osteoarthritis pain remains equivocal.[rx] Topical Nonsteroidal anti-inflammatory drugs (NSAIDs) (such as capsaicin) may be considered as an adjunct therapy for pain in addition to core treatments. Acetaminophen and topical NSAIDs your doctor may advise for oral NSAIDs, cyclooxygenase 2 inhibitors, or opioids.[rx]
- Rubefacients – Topical rubefacients should be used to treat osteoarthritis of hip pain.[rx] Rubefacients are drugs that cause irritation and reddening of the skin due to increased blood flow. They are believed to relieve pain in various musculoskeletal conditions and are available on prescription and over-the-counter remedies. Salicylate is a commonly used rubefacient.
- Glucosamine/Chondroitin – Use of glucosamine or chondroitin products for OA treatment is not recommended.[rx] Glucosamine is an amino sugar and a prominent precursor in the biochemical synthesis of glycosylated proteins and lipids. Glucosamine is part of the structure of two polysaccharides, chitosan, and chitin. Glucosamine is one of the most abundant monosaccharides
- Duloxetine – It is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) posited to inhibit pain via mechanisms acting on the central nervous system. Although some scientists refer to hip OA, phase III clinical trials have reported reduced pain and improved function associated with duloxetine use in knee OA [rx, rx].
- Intra-articular injection therapies/triamcinolone injection – It is the tertiary stage treatment for hip osteoarthritis and hip joint pain are an area of increasing interest. The available evidence suggests that intra-articular corticosteroid injections (IASI) offer symptomatic relief in hip OA.[rx]. With regards to pain reduction, it reported a large effect size 1-week post-injection and a moderate effect size after 8 weeks, although treatment effect declined thereafter. [rx, rx].
- Hyaluronic acid (HA) – It is a glycosaminoglycan normally constituent in synovial fluid but present in decreased concentrations in osteoarthritis of the hip, hip joint pain, is a compound used in clinical practice for its possible anti-inflammatory and analgesic properties. [rx–rx].
- Platelet-rich plasma (PRP) – There have been relatively few studies investigating the use of platelet-rich plasma (PRP) as an intra-articular injection therapy in hip osteoarthritis [rx], and hence it is too early to comment on its efficacy [rx]. Two small clinical trials have investigated PRP injections for hip OA, in both cases comparing to HA; one reported no difference between the two treatments [rx], while the other found PRP to be more efficacious at 2- and 6-month follow-up [rx].
Surgical Treatments
- Hip Arthroscopy – Studies on the use of arthroscopy in hip OA are not high quality. Arthroscopy, which primarily is performed during early OA stages, provides temporary relief and is associated with a high conversion rate to THA .[rx]
- Total Hip Arthroplasty – THA is today’s surgical modality for patients with intractable pain, for those who have failed nonsurgical treatment, and for those with severe functional impairment. Approximately 1 million THA procedures are performed globally each year for patients with advanced hip OA.rx][rx]
- Hip preservation surgeries: These are operations that prevent damaged cartilage from wearing down further. They include:
- Hip osteotomy – Cutting the femur or pelvic bone to realign its angle in the joint to prevent cartilage. An osteotomy may be appropriate if the patient is young and the arthritis is limited to a small area of the hip joint. It allows the surgeon to rotate the arthritic bone away from the hip joint, placing weight-bearing on relatively uninvolved portions of the ball and socket. The advantage of this type of surgery is that the patient’s own hip joint is retained and could potentially provide many years of pain relief without the disadvantages of a prosthetic hip. The disadvantages include a longer course of rehabilitation and the possibility that arthritis could develop in the newly aligned hip.
- Hip arthrotomy – This is where the joint is opened up to clean out loose pieces of cartilage, remove bone spurs or tumors, or repair fractures.
- Hip arthroscopy – In this minimally invasive surgery, arthroscopies used to clean out loose bodies in the joint or to remove bone spurs.
- Joint fusion (arthrodesis) – In this treatment, the pelvis and femur are surgically connected with pins or rods to immobilize the joint. This relieves pain but makes the hip permanently stiff, which makes it more difficult to walk.
Total or partial joint replacement surgery
- Total hip replacement – Also known as total hip arthroplasty, this is the removal of the ball and socket of the hip, which is replaced with artificial implants.
- Partial hip replacement – Also called hemiarthroplasty, this involves replacing only one side of the hip joint – the femoral head – instead of both sides as in total hip replacement. This procedure is most commonly done in older patients who have had a hip fracture.
- Hip resurfacing – In this alternative to total hip replacement (appropriate for some patients), the arthritic cartilage and acetabulum (socket) are replaced, but the person’s natural femoral head is preserved.
Low-impact exercise
- Low-impact exercise, such as swimming, water exercise, or walking, may help reduce your pain and improve sleep. You may also want to try tai chi or yoga.
- You should avoid sitting for long periods of time throughout the day, as well.
Stretching for Hip joint Pain
In addition to low-impact exercise during the day, you can try stretching your hip. You can stretch throughout the day or at night if the pain is keeping you awake.
- Stand up and hold on to something for balance if you need to.
- Cross your legs, and reach to touch your toes.
- Hold for 20 to 30 seconds.
- Cross your legs the other way and repeat.
You can also try these exercises to help relieve hip bursitis pain or these exercises to strengthen your hip flexor.
Sleep Hygiene Hip joint Pain
Practicing good sleep hygiene can help you fall and stay asleep. Here are some helpful tips:
- Go to bed and get up at the same time every day.
- Have a relaxation routine before bedtime.
- Consider taking a warm bath one to two hours before bedtime to release your body’s natural pain fighters, called endorphins. A warm bath also relaxes muscles around the sciatic nerve. Don’t make the water too hot, though, because it’ll raise your temperature and make it hard to fall asleep.
- Make your room dark and quiet, and keep the temperature cool to avoid waking up from being too hot.
- Avoid using electronics close to bedtime, including televisions, computers, and smartphones.
- Avoid consuming caffeine 5 or fewer hours from your bedtime.
You should also avoid using alcohol to help you fall asleep. It may make you drowsy, but you’ll likely wake after just a few hours of restless sleep.
Prevention
While you may not be able to prevent all causes of hip pain, there are several things you can do to be proactive in this regard
- Lose weight if you are overweight or obese
- Eat a balanced, nutritious diet that contains sufficient vitamin D and calcium to maintain bone health.
- Opt for low-impact activities like swimming or biking
- Stretch before and cool down after exercising
- Obtain a special shoe insert if you have leg-length inequality.
- Wear properly cushioned, fitted shoes and avoid or limit running on hard surfaces like asphalt
- Discuss a daily exercise routine for maintaining muscle and bone strength with your doctor
- Considering yoga or tai chi to help prevent falls, one of the most common causes of hip fractures.
References
