Clinical examination of the hip and buttock

Introduction

Pain felt in the hip and buttock does not necessarily originate from a lesion in these areas. Cyriax stated that most pain in the buttock derived from the lumbar spine (reference from L1 and S2), whereas pain in the thigh is referred from the lumbar spine and hip region as often as it has a local origin. When dealing with pain in this area, it is often not easy at first to determine if there is a problem in the lower back, the sacroiliac joint or the hip. Therefore, a detailed and chronologically ordered history is first taken, as described for the lumbar spine (see Ch. 36). Past and present symptoms are noted and the examiner is informed about the exact site and nature of the pain. Next, a preliminary examination must be performed that includes the whole lower quadrant: from the lumbar spine, over the sacroiliac and hip joints to the upper leg. Once it is clear that the symptoms do not arise from the lumbar spine or sacroiliac joint, the structures of the hip are examined more intensively.

If the diagnosis is still obscure after taking the history and carrying out a physical examination, the focus should turn to disorders outside orthopaedics that could be responsible for the symptoms – usually intra-abdominal lesions. In such conditions the pain is usually unrelated to movements that have been undertaken during the examination. Another cause of pain in the buttock of non-orthopaedic origin is occlusion of the common iliac artery with intermittent claudication. Finally, it must be remembered that hip complaints may be claimed but can have a non-physical basis in the psyche.

Referred pain

Pain referred to the buttock and hip region

Most pain in the buttock and hip results from a lumbar lesion with a segmental (L1–S2) or multisegmental (dural) reference of pain. Knowledge of the dermatomes that meet in the buttock and hip is therefore essential.

The first lumbar dermatome is represented by an area of skin at the outer and upper buttock which is partly overlapped by the second and third lumbar dermatomes (Fig. 45.1).

Fig 45.1 Dermatomes at the hip and buttock.

The skin of the lower part of the buttock is derived from the first and second sacral segments. The fourth and fifth lumbar segments are not present in the buttock. In spite of this, fourth and fifth lumbar disc protrusions are the commonest cause of pain in the buttock,¹ and are an expression of dural pain.

It is worth remembering that the first lumbar dermatome also covers the lower abdomen and the groin. The second lumbar dermatome is from the front of the thigh to the patella. The third lumbar dermatome is positioned over the inner aspect and the front of the thigh, then down the leg to just above the ankle. The first and second sacral dermatomes cover the gluteal area, the back of the thigh, the posterior aspect of the leg and the sole.

Multisegmental dural pain in the buttock is broad and may spread diffusely to both legs, excluding the feet.

Pain in the groin may also result from intra-abdominal pathological conditions: appendicitis, gynaecological disorders or inguinal or femoral hernia.

Pain referred from the buttock and hip region

Box 45.1 Summary of referred pain

History taking is largely the same as in lumbar spine disorders (see Ch. 36) because it is not always clear from the onset if the patient has a lumbar, sacroiliac or hip problem. However, once it has become more or less apparent that the complaints are the outcome of a hip lesion, some particular questions should be asked.

After the usual questions on the patient’s age, sex, occupation and hobbies, the examiner tries to find out what the actual problem is: pain, functional disability or instability? The problem should then be worked out systematically via a chronological approach: when and how did the problem start, what was its evolution and what are the current symptoms (Box 45.2)?

Box 45.2 Summary of symptoms