23 Lower limb

Daniel Porter

Cases relevant to this chapter

15, 23, 76

Essential facts

1. In hip osteoarthritis, early features are exercise-induced groin or anterior thigh pain.

2. About 90% of patients get a pain-free hip once recovery from a hip replacement is complete; risks of surgery are: death (1%), infection (1–2%), dislocation (1–2%) and loosening (1% per annum).

3. Spinal pathology from low lumbar spondylosis, nerve roots, sacroiliac disease and spinal stenosis can all radiate to the hip.

4. Meniscal tears result in pain, locking and inability to extend the knee; McMurray’s test is positive and magnetic resonance imaging can confirm the diagnosis.

5. Osteoarthritis of the knee may affect any of the three compartments, but the medial compartment in most frequently affected and leads to a varus deformity.

Hip

Common pathologies around the adult hip are listed below:

• Hip osteoarthritis

• Trochanteric bursitis

• Rectus femoris sprain/avulsion

• Psoas bursitis

• Meralgia paraesthetica

• Labral injury

• Avascular necrosis

• Other musculoskeletal pathology

• Non-musculoskeletal pathology.

Hip osteoarthritis

This is detailed in Chapter 15.

Trochanteric bursitis

A bursa is found deep to the fascia lata tendon sheet over the greater trochanter of the femur. This can become inflamed and produce hip pain on lying and walking. Point tenderness over the greater trochanter is evident, but there is a relatively normal range of hip movement. Ultrasonography or magnetic resonance imaging (MRI) can often confirm the diagnosis. Although the condition is self-limiting, it may recur. Steroid injection into the bursa can be targeted under ultrasound control. Surgery to lengthen the fascia lata or remove a trochanteric spur may be necessary in intractable pain. A common differential diagnosis, increasingly diagnosed on MRI, is gluteus medius tendinopathy, which may respond to local injections of steroid into the muscle insertion points onto the ilium, followed by muscle-strengthening exercises.

Rectus femoris sprain/avulsion

Young men may present with pain in the groin after sport, frequently first felt when kicking or twisting against resistance. Local tenderness just inferior to the anterior pelvic brim indicates a possible sprain of the rectus femoris origin. Complete avulsion may result in a ‘bunching’ of the muscle in the upper thigh. Sometimes the avulsed anterior inferior iliac spine is seen on radiographs. In an elite sportsperson the fragment and the associated attachment of the short head of rectus may need to be fixed back to the ilium. Other avulsions are the hamstrings from the ischium and the sartorius/tensor fascia lata from the anterior superior iliac spine.

Psoas bursa

Sometimes deep hip pain may be associated with swelling. Hip movement may be almost full, but an ultrasound or MRI scan may identify a bursa deep to the psoas over the anterior hip joint or a ganglion emanating from the psoas tendon sheath. Symptoms may improve spontaneously or require surgical decompression.

Meralgia paraesthetica

The lateral cutaneous nerve of the thigh may be compressed as it perforates the inguinal ligament 1–1.5 cm medial to the anterior superior iliac crest. Symptoms are of pain or dysaesthesia in its distribution. This is most frequent in younger women who are often overweight. Steroid injection or surgical decompression can be considered in intractable discomfort.

Acetabular labral injury

The acetabular labrum can be torn in early degenerative hip osteoarthritis (OA) and more rarely in sportsmen and women. Pain is elicited with the hip in flexion, adduction and internal rotation. Diagnosis in confirmed on MRI arthrography. In some centres hip arthroscopy and repair is advocated.

Avascular necrosis

The hip is at high risk of an avascular insult because of its vulnerable blood supply. Segmental or total collapse is seen as a consequence of OA. It also occurs after systemic steroid use, alcohol abuse, fractures, dislocations, in childhood hip disorders, Caisson’s (decompression) disease, Gaucher’s disease (an inborn error of metabolism) and blood dyscrasias. During the revascularization phase, bone is resorbed and the articular surface collapses resulting in acute pain, effusion and eventual risk of secondary OA. In the earliest phase, a surgical core decompression of the avascular segment may provide relief and improve the outcome. Rotational osteotomies of the femoral head are undertaken in Japan, but have not gained favour in Europe.

Referred pain

Pain from spinal pathology such as low lumbar spondylosis, nerve roots, sacroiliac disease and spinal stenosis can all radiate to the hip. Apart from a high lumbar disc prolapse, these give symptoms felt more posteriorly.

< div class='tao-gold-member'>

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Epidemiology and genetics of rheumatic diseases Sport and exercise associated problems in children and adolescents Normal variants in children Bone disorders Systemic diseases Clinical History and Examination

Stay updated, free articles. Join our Telegram channel

Join

Full access? Get Clinical Tree