**Hip- Differential Diagnosis**

**July 2006 OIG**

**LT David Honaberger**

A couple words of wisdom from a few predecessors:

"If it's funky check the hip!" -- COL Cindy Benson, MPT, OCS

"Assume it's a horse but be on the lookout for the occasional zebra."

\- COL Cindy Benson, MPT, OCS

"Clear joints above and below." - COL Gaile Deyle PT, DPT, OCS, FAAOMPT

**Slipped Capital Femoral Epiphysis (SCFE):** A posterior and inferior
slippage of the proximal femoral epiphysis on the femoral neck,
occurring through the physeal plate during adolescent growth spurts. The
most common hip abnormality that presents in adolescence as well as a
primary cause of early osteoarthritis. Most recently classified
according to stability rather than onset and duration: Stable SCFE is
one in which ambulation is possible with or eithout crutches, with
unstable SCFE ambulation is not possible with or without crutches.

[Etiology:]{.underline} Associated with endocrine disorders such as
hypothyroidism or growth hormone administration, renal osteodystrophy,
but most often idiopathic.

[Demographics:]{.underline} Associated c obesity, more common in black
or Polynesian children, boys more than girls (60% to 40%). Average age:
12 in girls, 13.5 in boys, bilateral in 25-40% of children. Frequent in
overweight, skeletally immature boys.

[Presentation:]{.underline} Intermittent limp and pain for weeks or
months in thigh, groin and knee, progressive decrease of ROM: IR, Flex,
ABD. The hip is typically held in Flex, Abd and ER position.

[Diagnosis:]{.underline} Primarily through imaging. radiographs with AP
and frog-leg views, MRI is more sensitive to detect early marrow edema
and slippage.

[Treatment]{.underline}: Immediate alleviation of wt. bearing, referral
to orthopedic surgeon. The most widely accepted treatment for stable
SCFE is in situ fixation with a single central screw. Spica casting not
done as much due to difficulty for pt. & physician but primarily due to
\>15% chondrolysis rate often resulting in poor outcome. Prognosis is
good for most pt.s but will develop degenerative arthritis after several
decades.

**Legg-Calve-Perthes Disease:** Self-limiting hip disorder caused by
avascular necrosis of the femoral head.

[Etiology (remains unclear):]{.underline} Supply to capital femoral
epiphysis interrupted, bone infarction occurs c femoral head collapse or
flattening, revascularization occurs after several months and new bone
ossification starts with completion after 2-3 years. Occurs in four
phases: Avascular (stage I), Revascularization (stage II), Reparative
(stage III), Regenerative (stage IV).

[Demographics:]{.underline} Usually seen 4 to 8 y.o. boys with delayed
skeletal maturity. Affects boys more than girls 4-5:1, rare in African
Americans. 15-20% are bilaterally affected though usually at different
stages. Age is key to diagnosis, after 8 years of age has poor prognosis
c gradual development of osteoarthritis.

[Presentation:]{.underline} Persistent pn in hip, thigh, and/or knee c
limp (can be painless), stiffness, limited ROM in all ranges due to
joint inflammation but particularly in IR and ABD, mm atrophy.

[Diagnosis:]{.underline} Radiographic imaging ( AP & frog-leg views),
MRI (imaging method of choice), bone scan, limp, loss of hip ROM,
typically insidious onset.

[Treatment:]{.underline} Rx goal is containment (keeping femoral head
inside socket) achieved through maintaining ROM, NSAID's, decreasing wt.
bearing, traction, avoidance of vigorous activity, surgical intervention
which varies greatly depending on severity.

**Meralgia Paresthetica:** Entrapment of the superior branch of the
lateral femoral cutaneous nerve, which is purely sensory. It can be
compressed as it courses from the lumbosacral plexus, abdominal cavity,
under the inguinal ligament and as it exits through the femoral canal in
the groin or next to the ASIS where it emerges from the pelvis.

[Etiology:]{.underline} Most often entrapped under the ilioinguinal
ligament. Common causes: obesity c overlying panniculus, tight garments
around waist, scar tissue, pregnancy and DM are contributing factors,
seat belt injuries s/p MVA, long-distance walking or cycling.

[Presentation:]{.underline} Symptoms include paresthesia and dysesthesia
along the anterolateral thigh. Discomfort increases with valsalva
maneuvers.

[Diagnosis:]{.underline} Based mainly on pn description and location,
with characteristic sensory abnormalities.

[Treatment:]{.underline} NSAID's, rest, therapeutic ultrasound,
avoidance of tight fitting clothes, wt. loss, local injection,
anticonvulsants c persistent sxs.

**Snapping Hip Syndrome:** A syndrome characterized by an audible snap
or click around the area of the hip that can be painful. Multiple causes
possible.

[Demographics:]{.underline} Most often in pt.s 15-40 y.o., affects
females slightly more than males, increased incidence in female ballet
dancers (\~ 40% in one clinic c hip complaints in ballet dancers).

[Etiology:]{.underline} External cause: snapping of IT-band or gluteus
max. over greater trochanter, which can be reproduced c sudden hip
loading (landing after a jump). Internal cause: snapping of iliopsoas
tendon over iliopectineal eminence, acetabular labral tear,
intra-articular loose body, rarely: long head of biceps femoris over
ischial tuberosity. Multiple biomechanical contributing factors/causes:
repetitive stress, mm length and strength imbalances, excessive
foot/ankle pronation, coxa varus.

[Presentation:]{.underline} Audible snap or click in the hip which may
be painful, location usually in lateral hip or groin, sensation of hip
subluxing, duration usually months or years.

[Diagnosis]{.underline}: US useful, MRI not as useful but may r/o labral
tear or systemic problems, magnetic resonance arthrogram (MRA) more
sensitive to labral tears than MRI, hip arthroscopy when dx remains
unclear.

[Treatment:]{.underline} Address inflammation: NSAIDs, corticosteroid
injection, rest, ice. Biomechanical issues: (pelvic alignment, mm
length, strength, leg-length, etc...), manual therapy, stretching,
orthotics. Surgical intervention: Z-plasty, resections of tendons and/or
lesser trochanter.

**Hip Pointer:** Contusion of the iliac crest, surrounding soft tissue
or greater trochanter. Usually from a direct blow or fall to the side of
the hip and pelvis. Common in contact sports.

[Etiology:]{.underline} contusion in hip or iliac crest from direct blow
or fall c pain & inflammation of surrounding soft tissue c potential to
develop into a hematoma in some cases.

Presentation: Sudden pain onset following trauma to hip region. Pain
exacerbation c running, jumping, twisting, bending. Pain limited ROM in
hip, and trunk, as well as hip abduction strength. Contusion or
swelling, tender to palpation over local area, antalgic gait in some
cases.

[Diagnosis:]{.underline} Imaging c plain films to rule out myositis
ossificans or fx, CT scans for dx of hematoma. Clinical musculoskeletal
exam c sxs consistent c mechanism of injury.

[Treatment:]{.underline} Rest, ice, US, iontophoresis, corticosteroids,
NSAIDs, stretching.

**Osteitis Pubis:** Inflammation of the pubic symphysis & surrounding
muscle insertions.

[Demographics:]{.underline} More prevalent in sports involving running,
kicking or rapid lateral movements such as: soccer, sprinting, ice
hockey, American football. Several small studies report incidence \~5
times greater in males than in females.

[Etiology:]{.underline} Exact etiology is unknown, most likely caused by
repetitive microtrauma and/or shearing forces to pubic symphysis.

[Presentation:]{.underline} Typically athletes c pain in hip, groin,
perineum, testicles, adductors. Pain aggravated c running, kicking,
quick directional changes, lower abdominal pain, tenderness over pubic
ramus.

\*\*[Caution]{.underline} c sxs of fever, chills, may need to rule out
systemic problems such as prostatitis, pelvic inflammatory disease,
osteomyelitis\*\* Also check for inguinal hernia in pt.s c groin pain.

[Diagnosis:]{.underline} Clinical exam, gynecological exam to rule out
PID, CBC erythrocyte sedimentation rate (ESR), urinalysis, radiographs
are (-) early in the disease but will show some widening of the pubic
symphysis after several wks., Bone scans are hot (show increased
uptake), MRI c fat suppression views useful.

[Treatment:]{.underline} NSAID's, corticosteroid injection, manual
therapy (manipulation, mm energies, soft tissue mobilization),
stretching, ultrasound, iontophoresis, electrical stimulation, core
strength/stability exercises.

[**Trochanteric Bursitis**:]{.underline} An anatomical diagnosis for
inflammation of the trochanteric bursae c associated hip pain. There are
three trochanteric bursae: the first between the gluteus maximus and
greater trochanter, second between gluteus maximus and gluteus medius
tendon, third between gluteus medius and the greater trochanter.

[Etiology]{.underline}: Caused by exaggerated movement of gluteus medius
tendon and tensor fascia over the outer femur. Aggravated with
repetitive hip flexion and direct pressure. Gait disturbances cause the
majorit of cases. Untreated, the bursal wall thickens, fibroses and
gradually loses ability to lubricate the out hip.

[Presentation:]{.underline} Local tenderness c bursal inflammation,
outer thigh pain, difficulty walking, aggravated c direct pressure.

[Diagnosis:]{.underline} Clinical findings: outer thigh pain, local
tenderness, pain/stiffness at end range hip IR/ER, pain relief with
regional anesthetic block to rule out referred pain from lumbosacral
pain or meralgia paresthetica. X-rays recommended in suspected
trochanteric bursitis to rule out calcification in areas of bursal
inflammation.

[Treatment:]{.underline} *Goals*: reduce bursal inflammation, correct
any gait disturbance (leg-length, SI dysfunction), prevention with hip
and back stretches. Moist heat, and stretching: (IT-band, cross-leg
pulls, iliopsoas, HS, gluteals), ultrasound, iontophoresis, restrict wt.
bearing, strenuous activity and direct pressure on the bursae,
corticosteroid injection, surgery: rarely, IT-band longitudinal release.

REFERENCES

1\. Adler B: Slipped capital femoral epiphysis:

[www.emedicine.com/radio/topic641.htm](http://www.emedicine.com/radio/topic641.htm),
2006: 1-8.

2\. Anderson BC: Meralgia paresthetica:
[*www.uptodate.com/utd/content/topic.do*](http://www.uptodate.com/utd/content/topic.do)

version 14.2, 2006: 1-5.

3\. Disabella VN: Osteitis Pubis:
[www.emedicine.com/sports/topic90.htm](http://www.emedicine.com/sports/topic90.htm),
2006: 1-15

4\. Garry JP: Snapping Hip Syndrome:
[www.emedicine.com/sports/topic123.htm](http://www.emedicine.com/sports/topic123.htm),
2006:

1-17.

5\. Goodman CC, Fuller KS, Boissonnault WG: *Pathology implications for
the physical*

*therapist* ed 2, Philadelphia, 2003, Saunders, 938-9.

6\. Legg-Calve-Perthes:
[www.nlm.nih.gov/medlineplus/ency/article/001264.htm](http://www.nlm.nih.gov/medlineplus/ency/article/001264.htm),
2006:

1-3.

7\. Loder RL: Slipped capital femoral epiphysis:

[www.aafp.org/afp/980501ap/loder.html](http://www.aafp.org/afp/980501ap/loder.html),
2006: 1-10.

8\. Martinez JM: Hip Pointer:
[www.emedicine.com/sports/topic50.htm](http://www.emedicine.com/sports/topic50.htm),
2006: 1-12.

9\. Nochimson G: Legg-Calve-Perthes Disease:

[www.emedicine.com/emerg](http://www.emedicine.com/emerg)[/topic294.htm]{.underline},
2006: 1-8.

10\. Placzek JD, Boyce DA: Orthopaedic physical therapy secrets, Hanley
& Belfus,

Inc., Philadelphia 2001, 395.