Hip and Pelvis Injuries

Hip and pelvis injuries can occur through acute and chronic mechanisms.  

As with other injuries, determining the mechanism of injury and the amount of functional impairment provides a basis for further evaluation and treatment.  

• Sudden onset of pain with an inability to weight bear is an obvious worrisome presentation.  

• Stress fractures may appear in any bone including the femoral neck.  

• The need for further studies such as x-rays and bone scans depends on findings in the history and physical exam.

Differential diagnosis of hip/pelvis pain

Acute:

• Fractures

• Muscle strains

• Trauma causing soft tissue and nerve damage

• Infection (rare)

Chronic

• Stress fractures

• Bursitis

• Labral tears  (rare)

• Snapping hip syndrome

• Osteitis pubis

• Pyriformis syndrome

History

• Determine the location of the pain.  Often a muscle strain will have fairly localized pain whereas a stress fracture of the femur may have poorly localized or even referred pain into the knee. 

• How did the pain occur- was there a fall or some other trauma? Or was there a gradual worsening of the pain over the past few weeks?

• Can the patient walk?  Do they have an antalgic gait or limp?

• Are there systemic signs or symptoms?

• After determining the likely mechanism  and extent of injury, the hip and pelvis are examined to further narrow the diagnosis and determine if further tests are needed.

Physical 

• Inspect the hip and look for obvious deformity.  Look at the toes and not if they are pointing symmetrically and if the leg lengths are nearly equal.  A rotated shortened leg implies a fracture, often of the femur

• Palpate gently over the anatomic landmarks to elicit any tenderness.  Start at the Anterior Superior Iliac Spine (ASIS), work down  to the Anterior Inferior Iliac Spine (AIIS), and then laterally to the Greater Trochanter of the femur.  Tenderness at the ASIS and/or AIIS suggests a hip flexor strain.  Tenderness under the greater trochanter suggests either bursitis or fracture. 

• Check range of motion.  Have the patient attempt active flexion of the hip.   Passively range the hip through internal and external rotation.  Pain on extremes of passive range of motion of the hip is the most sensitive sign of a femoral neck stress fracture.  Extremely painful range of motion suggests fracture or infection.

• Continue palpation.  While the hip is externally rotated, palpate along the anterior hip to the superior and then inferior pubic ramus to feel for tenderness on the bones, as in a stress fracture, or in the muscles as in a strain.

• Labral (cartilage) tears of the hip are extremely difficult to diagnose.  Consider them the equivalent of a meniscus tear in the knee or a labral tear in the shoulder.  The patient will complain of a deep painful click in the hip.   Axially load the hip and rotate it internally and externally.  A painful click suggests a labral tear.

Tests

• X-rays.  Inability to bear weight, point tenderness, significant trauma, and pain on range of motion of the hip.  If a stress fracture is strongly suspected and initial x-rays are negative, re x-ray in 2 weeks at which time 80-90 % will be apparent , or consider a bone scan.

• Bone scan.  X-rays commonly miss stress fractures of the femoral neck.  If you suspect a femoral neck stress fracture, the patient should be on crutches non-weight bearing until a bone scan can be obtained. 

• MRI may be necessary to stage the extent of a femoral neck stress fracture.  MRI with contrast has a poor sensitivity but may show  a labral tear

• If infection is suspected, get a CBC, ESR, and consider US vs. MRI

Treatment

• If unable to ambulate, the patient should be given crutches. 

• Suspected infected joints should be emergently referred for antibiotics and surgical drainage.  If unable to Medevac, give an antibiotic that covers gonorrhea, such as Ceftriaxone.

• Suspected femoral neck stress fracture patients should be non weight bearing on the affected leg until a definitive diagnosis can be made through bone scan or MRI.  If the fracture were to complete, there is a chance that there will be long term sequalae even  with surgical fixation including avascular necrosis (AVN).  AVN may lead to the need for a hip replacement in a young, otherwise very healthy and active person.

• Muscle strains should be treated acutely using PRICEMM:

  • Protect from further injury

  • Relative rest

  • Ice 20 minutes t.i.d.

  • Compression (difficult if not impossible in this case)

  • Elevate

  • Medication – NSAIDs for pain

  • Modalities – such as e-stim and US

• Begin long term treatment following the usual progression:

• Range of Motion

• Strength

• Endurance

• Agility/Balance/Proprioception

• Bursitis is treated with stretches to the Iliotibial band, NSAIDs, and perhaps modalities like phonophoresis

Quick review of some of the causes of hip and groin pain:

a) Femoral neck stress fracture

• primarily in endurance athletes, overuse injury

• presence with groin or anterior thigh pain, often a deep ache relived with cessation of activity.

• antalgic gait, painful ROM, especially with internal and external rotation

• Plain radiographs taken early may be negative- Further imaging may be required- (i.e.) MRI/ Bone Scan.  If suspected, keep on crutches nonweight bearing until diagnosis confirmed

• Treatment -

  • nondisplaced fracture on the compression (inferior) side consists of non-weightbearing/modified bed rest until the patient is completely pain free

  • displaced fractures and nondisplaced tension  side fractures - ORIF

b) Acetabular Labral Tears-

• patient may experience a feeling of giving way or deep sharp catching pain in the groin which radiates into the anterior thigh, especially with hip rotation,

• MRI with contrast or arthroscopy can confirm diagnosis.

• Treatment-NSAIDS, physical therapy, surgical may be necessary     

c)  Snapping Hip Syndrome 

• patient notes audible or palpable snapping.

• most common cause involves the snapping of the iliotibial band or the tensor fascia lata over the greater trochanter, less commonly, the iliopsoas tendon may snap as it slides over the iliopectineal eminence.

• patient may note pain, crepitation and local warmth, performance rarely impaired

• physical exam focuses on source of the click. 

• Treatment-modified activity, muscle stretching, NSAIDS, occasionally corticosteriod injections.

d)  Pubic ramus stress fracture, inferior and/or superior

• mostly occurs in distance runners and joggers.

• pain in the inguinal, perineal, or adductor region.

• exquisite tenderness over pubic ramus

• plain radiographs may initially be negative, bone scan may be necessary

• Treatment-cessation of running activity, when pain free gradual return to activity.

e)  Osteitis pubis

• inflammatory lesion of the cartilage and bone adjacent to the symphysis pubis.

• pubic symphysis is usually tender to palpation, pain reproduced by passive abduction and active resisted adduction of the thigh.

• Treatment-relative rest, icing, NSAIDS, stretching and strengthening exercises of the adductors.  Rarely needs injection.

f)  Greater trochanteric bursitis

• bursa  inflamed as iliotibial band rides over greater trochanter

• pain superficial and localized to just over greater trochanter

• Treatment – Ice massage, NSAIDs, ITB stretches

• phonophoresis/ injection sometimes necessary

g)  Pyriformis syndrome

• pain deep in hip from Pyriformis muscle compressing sciatic nerve

• on exam, will get increased pain with hip passive internal rotation, active external rotation

• Treat with Pyriformis stretches, hip range of motion

This section provided by Fred Schmidt, PA-C and Scott D. Flinn, MD

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