Evaluacion de un dolor de cadera

January 1, 2014 ◆ Volume 89, Number 1 www.aafp.org/afp American Family Physician 27

Evaluation of the Patient with Hip PainJOHN J. WILSON, MD, MS, and MASARU FURUKAWA, MD, MS, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

Hip pain is a common presenta-tion in primary care and can affect patients of all ages. In one study, 14.3% of adults 60 years

and older reported significant hip pain on most days over the previous six weeks.1 Hip pain often presents a diagnostic and thera-peutic challenge. The differential diagnosis of hip pain (eTable A) is broad, including both intra-articular and extra-articular pathology, and varies by age. A history and physical examination are essential to accu-rately diagnose the cause of hip pain.

AnatomyThe hip joint is a ball-and-socket synovial joint designed to allow multiaxial motion while transferring loads between the upper and lower body. The acetabular rim is lined by fibrocartilage (labrum), which adds depth and stability to the femoroacetabular joint. The articular surfaces are covered by hya-line cartilage that dissipates shear and com-pressive forces during load bearing and hip motion. The hip’s major innervating nerves originate in the lumbosacral region, which can make it difficult to distinguish between primary hip pain and radicular lumbar pain.

The hip joint’s wide range of motion is sec-ond only to that of the glenohumeral joint

and is enabled by the large number of mus-cle groups that surround the hip. The flexor muscles include the iliopsoas, rectus femoris, pectineus, and sartorius muscles. The glu-teus maximus and hamstring muscle groups allow for hip extension. Smaller muscles, such as gluteus medius and minimus, piriformis, obturator externus and internus, and quadra-tus femoris muscles, insert around the greater trochanter, allowing for abduction, adduc-tion, and internal and external rotation.

In persons who are skeletally immature, there are several growth centers of the pelvis and femur where injuries can occur. Poten-tial sites of apophyseal injury in the hip region include the ischium, anterior superior iliac spine, anterior inferior iliac spine, iliac crest, lesser trochanter, and greater trochan-ter. The apophysis of the superior iliac spine matures last and is susceptible to injury up to 25 years of age.2

Evaluation of Hip PainHISTORY

Age alone can narrow the differential diag-nosis of hip pain. In prepubescent and ado-lescent patients, congenital malformations of the femoroacetabular joint, avulsion frac-tures, and apophyseal or epiphyseal inju-ries should be considered. In those who are

Hip pain is a common and disabling condition that affects patients of all ages. The differential diagnosis of hip pain is broad, presenting a diagnostic challenge. Patients often express that their hip pain is localized to one of three ana-tomic regions: the anterior hip and groin, the posterior hip and buttock, or the lateral hip. Anterior hip and groin pain is commonly associated with intra-articular pathology, such as osteoarthritis and hip labral tears. Posterior hip pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, and less commonly ischiofemoral impingement and vascular claudication. Lateral hip pain occurs with greater trochanteric pain syn-drome. Clinical examination tests, although helpful, are not highly sensitive or specific for most diagnoses; however, a rational approach to the hip examination can be used. Radiography should be performed if acute fracture, disloca-tions, or stress fractures are suspected. Initial plain radiography of the hip should include an anteroposterior view of the pelvis and frog-leg lateral view of the symptomatic hip. Magnetic resonance imaging should be performed if the history and plain radiograph results are not diagnostic. Magnetic resonance imaging is valuable for the detection of occult traumatic fractures, stress fractures, and osteonecrosis of the femoral head. Magnetic resonance arthrography is the diagnostic test of choice for labral tears. (Am Fam Physician. 2014;89(1):27-34. Copyright © 2014 American Academy of Family Physicians.)

▲

Patient information: A handout on this topic, written by the authors of this article, is avail-able at http://www.aafp.org/afp/2014/0101/p27-s1.html. Access to this handout is free and unrestricted.

More online at http://www.aafp.org/afp.

CME This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz questions on page 6.

Author disclosure: No rel-evant financial affiliations.

Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2014 American Academy of Family Physicians. For the private, non-commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.

Hip Pain

28 American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014

skeletally mature, hip pain is often a result of muscu-lotendinous strain, ligamentous sprain, contusion, or bursitis. In older adults, degenerative osteoarthritis and fractures should be considered first.

Patients with hip pain should be asked about ante-cedent trauma or inciting activity, factors that increase or decrease the pain, mechanism of injury, and time of

onset. Questions related to hip function, such as the ease of getting in and out of a car, putting on shoes, running, walking, and going up and down stairs, can be helpful.3 Location of the pain is informative because hip pain often localizes to one of three basic anatomic regions: the anterior hip and groin, posterior hip and buttock, and lateral hip (eFigure A).

Figure 1. Gait testing. (A) C sign. Patients often localize pain by cupping the anterolateral hip with the thumb and fore-finger in the shape of a “C.” (B) Gait analysis. The patient is observed while walking to evaluate for limp or antalgic gait characteristics. (C) Modified Trendelenburg test (single leg stance phase). The patient stands with feet shoulder width apart and lifts one leg. The examiner observes for a drop in the level of the iliac crest on the side of the lifted leg.

A CB

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence rating References

Initial plain radiography of the hip should include an anteroposterior view of the pelvis and a frog-leg lateral view of the symptomatic hip.

C 4

Magnetic resonance imaging should be used for detection of occult hip fractures, stress fractures, and osteonecrosis of the femoral head.

C 23, 30, 33

Magnetic resonance arthrography is the diagnostic test of choice for labral tears. C 6, 19

Ultrasonography is a helpful diagnostic modality for patients with suspected bursitis, joint effusion, or functional causes of hip pain (e.g., snapping hip), and can be employed for therapeutic imaging-guided injections and aspirations around the hip.

C 8, 9

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Hip Pain


PHYSICAL EXAMINATION

The hip examination should evaluate the hip, back, abdomen, and vascular and neurologic systems. It should start with a gait analysis and stance assessment (Figure 1), followed by evaluation of the patient in seated, supine, lateral, and prone positions (Figures 2 through 6, and eFigure B). Physical examination tests for the evalu-ation of hip pain are summarized in Table 1.

IMAGING

Radiography. Radiography of the hip should be per-formed if there is any suspicion of acute fracture, dislo-cation, or stress fracture. Initial plain radiography of the hip should include an anteroposterior view of the pelvis and a frog-leg lateral view of the symptomatic hip.4

Magnetic Resonance Imaging and Arthrography. Con-ventional magnetic resonance imaging (MRI) of the hip can detect many soft tissue abnormalities, and is the preferred imaging modality if plain radiography does not identify specific pathology in a patient with persis-tent pain.5 Conventional MRI has a sensitivity of 30% and an accuracy of 36% for diagnosing hip labral tears, whereas magnetic resonance arthrography provides added sensitivity of 90% and accuracy of 91% for the detection of labral tears.6,7

Ultrasonography. Ultrasonography is a useful tech-nique for evaluating individual tendons, confirm-ing suspected bursitis, and identifying joint effusions and functional causes of hip pain.8 Ultrasonography is especially useful for safely and accurately performing

Table 1. Physical Examination Tests for the Evaluation of Hip Pain

Test Other names Positioning Positive findings Differential diagnosis

Gait testing (C sign, Figure 1A; gait analysis, Figure 1B)

— Standing Antalgic gait, Trendelenburg gait, pelvic wink (rotation of more than 40 degrees in the axial plane toward the affected hip when terminally extending the hip), excessive pronation or supination of the ankles, and limps caused by differing leg lengths

Hip labral tear, transient synovitis, Legg-Calvé-Perthes disease, SCFE

Modified Trendelenburg test (Figure 1C)

Single leg stance phase

Standing 2-cm drop in the level of the iliac crest, indicating weakness on the contralateral side

Hip labral tear, transient synovitis, Legg-Calvé-Perthes disease, SCFE

ROM testing (Figure 2) — Supine, lateral, or sitting

Pain with passive ROM, limited ROM

Pain with passive ROM: Transient synovitis, septic arthritis

Limited ROM: Loose bodies, chondral lesions, osteoarthritis, Legg-Calvé-Perthes disease, osteonecrosis

FABER test (Figure 3) Patrick test Supine Posterior pain localized to the sacroiliac joint, lumbar spine, or posterior hip; groin pain with the test is sensitive for intra-articular pathology

Hip labral tear, loose bodies, chondral lesions, femoral acetabular impingement, osteoarthritis, sacroiliac joint dysfunction, iliopsoas bursitis

FADIR test (Figure 4) Impingement test

Supine Pain Hip labral tear, loose bodies, chondral lesions, femoral acetabular impingement

Log roll test (Figure 5) Passive supine rotation, Freiberg test

Supine Restricted movement, pain Piriformis syndrome, SCFE

Straight leg raise against resistance test (Figure 6)

Stinchfield test Supine Weakness to resistance, pain Athletic pubalgia (sports hernia), SCFE, femoral acetabular impingement

Ober test (eFigure B) Passive adduction

Lateral Passive adduction past midline cannot be achieved

External snapping hip, greater trochanteric pain syndrome

FABER = flexion, abduction, external rotation; FADIR = flexion, adduction, internal rotation; ROM = range of motion; SCFE = slipped capital femoral epiphysis.

Hip Pain


Figure 2. Hip range-of-motion testing (photos demonstrate normal range of motion). (A) Abduction. (B) Adduction. (C) Extension. (D) Internal and external rotation.

A

C

B D

45°

20-30°

10°

20-35°

30-70°

Hip Pain


Figure 4. FADIR test (flexion, adduction, internal rotation; impingement test). The examiner passively moves the leg into (A) full flexion, then into (B) adduction and internal rotation.

A B

Figure 3. FABER test (flexion, abduction, external rotation; Patrick test). The examiner moves the leg into 45 degrees of flexion, then (A) externally rotates and (B) abducts the leg so that the ankle rests proximal to the knee of the contralateral leg.

A B

Hip Pain


imaging-guided injections and aspirations around the hip.9 It is ideal for an experienced ultrasonographer to perform the diagnostic study; however, emerging evidence suggests that less experienced clinicians with appro-priate training can make diagnoses with reliability similar to that of an experienced musculoskeletal ultrasonographer.10,11

Differential Diagnosis of Anterior Hip Pain Anterior hip or groin pain suggests involve-ment of the hip joint itself. Patients often localize pain by cupping the anterolateral hip with the thumb and forefinger in the shape of a “C.” This is known as the C sign (Figure 1A).

OSTEOARTHRITIS

Osteoarthritis is the most likely diagnosis in older adults with limited motion and gradual onset of symptoms. Patients have a constant, deep, aching pain and stiffness that are worse with prolonged standing and weight bear-ing. Examination reveals decreased range of motion, and extremes of hip motion often cause pain. Plain radiographs demonstrate the presence of asymmetrical joint-space narrowing, osteophytosis, and subchondral sclerosis and cyst formation.12

FEMOROACETABULAR IMPINGEMENT

Patients with femoroacetabular impinge-ment are often young and physically active. They describe insidious onset of pain that is worse with sitting, rising from a seat, getting in or out of a car, or leaning forward.13 The pain is located primarily in the groin with occasional radiation to the lateral hip and anterior thigh.14 The FABER test (flexion, abduction, external rotation; Figure 3) has a sensitivity of 96% to 99%. The FADIR test (flexion, adduction, internal rota-tion; Figure 4), log roll test (Figure 5), and straight leg raise against resistance test (Figure 6) are also effective, with sensitivities of 88%, 56%, and 30%, respectively.14,15 In addition to the anteroposterior and lateral radiograph views, a Dunn view should be obtained to help detect subtle lesions.16

HIP LABRAL TEAR

Hip labral tears cause dull or sharp groin pain, and one-half of patients with a labral tear have pain that radi-ates to the lateral hip, anterior thigh, and buttock. The

pain usually has an insidious onset, but occasionally begins acutely after a traumatic event. About one-half of patients with this injury also have mechanical symp-toms, such as catching or painful clicking with activity.17 The FADIR and FABER tests are effective for detect-ing intra-articular pathology (the sensitivity is 96% to 75% for the FADIR test and is 88% for the FABER test), although neither test has high specificity.14,15,18 Magnetic resonance arthrography is considered the diagnostic test of choice for labral tears.6,19 However, if a labral tear is not suspected, other less invasive imaging modalities, such as plain radiography and conventional MRI, should be used first to rule out other causes of hip and groin pain.

ILIOPSOAS BURSITIS (INTERNAL SNAPPING HIP)

Patients with this condition have anterior hip pain when extending the hip from a flexed position, often associated

Figure 6. Straight leg raise against resistance test (Stinchfield test). The patient lifts the straight leg to 45 degrees while the examiner applies downward force on the thigh.

Figure 5. Log roll test (passive supine rotation; Freiberg test). Patient’s leg is extended and relaxed on examination table as the examiner internally and externally rotates the leg (log roll).

Hip Pain


with intermittent catching, snapping, or popping of the hip.20 Dynamic real-time ultrasonography is particularly useful in evaluating the various forms of snapping hip.8

OCCULT OR STRESS FRACTURE

Occult or stress fracture of the hip should be consid-ered if trauma or repetitive weight-bearing exercise is involved, even if plain radiograph results are negative.21 Clinically, these injuries cause anterior hip or groin pain that is worse with activity.21 Pain may be present with extremes of motion, active straight leg raise, the log roll test, or hopping.22 MRI is useful for the detection of occult traumatic fractures and stress fractures not seen on plain radiographs.23

TRANSIENT SYNOVITIS AND SEPTIC ARTHRITIS

Acute onset of atraumatic anterior hip pain that results in impaired weight bearing should raise suspicion for transient synovitis and septic arthritis. Risk factors for septic arthritis in adults include age older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint sur-gery, and hip or knee prostheses.24 Fever, complete blood count, erythrocyte sedimentation rate, and C-reactive protein level should be used to evaluate the risk of sep-tic arthritis.25,26 MRI is useful for differentiating septic arthritis from transient synovitis.27,28 However, hip aspi-ration using guided imaging such as fluoroscopy, com-puted tomography, or ultrasonography is recommended if a septic joint is suspected.29

OSTEONECROSIS

Legg-Calvé-Perthes disease is an idiopathic osteone-crosis of the femoral head in children two to 12 years of age, with a male-to-female ratio of 4:1.4 In adults, risk factors for osteonecrosis include systemic lupus erythe-matosus, sickle cell disease, human immunodeficiency virus infection, smoking, alcoholism, and corticosteroid use.30,31 Pain is the presenting symptom and is usually insidious. Range of motion is initially preserved but can become limited and painful as the disease progresses.32 MRI is valuable in the diagnosis and prognostication of osteonecrosis of the femoral head.30,33

Differential Diagnosis of Posterior Hip and Buttock PainPIRIFORMIS SYNDROME AND ISCHIOFEMORAL IMPINGEMENT

Piriformis syndrome causes buttock pain that is aggra-vated by sitting or walking, with or without ipsilateral radiation down the posterior thigh from sciatic nerve compression.34,35 Pain with the log roll test is the most

sensitive test, but tenderness with palpation of the sciatic notch can help with the diagnosis.35

Ischiofemoral impingement is a less well-understood condition that can lead to nonspecific buttock pain with radiation to the posterior thigh.36,37 This condition is thought to be a result of impingement of the quadratus femoris muscle between the lesser trochanter and the ischium.

Unlike sciatica from disc herniation, piriformis syn-drome and ischiofemoral impingement are exacerbated by active external hip rotation. MRI is useful for diagnos-ing these conditions.38

OTHER

Other causes of posterior hip pain include sacroiliac joint dysfunction,39 lumbar radiculopathy,40 and vascular clau-dication.41 The presence of a limp, groin pain, and lim-ited internal rotation of the hip is more predictive of hip disorders than disorders originating from the low back.42

Differential Diagnosis of Lateral Hip PainGREATER TROCHANTERIC PAIN SYNDROME

Lateral hip pain affects 10% to 25% of the general pop-ulation.43 Greater trochanteric pain syndrome refers to pain over the greater trochanter. Several disorders of the lateral hip can lead to this type of pain, including ilio-tibial band thickening, bursitis, and tears of the gluteus medius and minimus muscle attachment.43-45 Patients may have mild morning stiffness and may be unable to sleep on the affected side. Gluteus minimus and medius injuries present with pain in the posterior lateral aspect of the hip as a result of partial or full-thickness tearing at the gluteal insertion. Most patients have an atraumatic, insidious onset of symptoms from repetitive use.43,45,46

Data Sources: We searched articles on hip pathology in American Fam-ily Physician, along with their references. We also searched the Agency for Healthcare Research and Quality Evidence Reports, Clinical Evidence, Institute for Clinical Systems Improvement, the U.S. Preventive Services Task Force guidelines, the National Guideline Clearinghouse, and UpTo-Date. We performed a PubMed search using the keywords greater tro-chanteric pain syndrome, hip pain physical examination, imaging femoral hip stress fractures, imaging hip labral tear, imaging osteomyelitis, ischiofemoral impingement syndrome, meralgia paresthetica review, MRI arthrogram hip labrum, septic arthritis systematic review, and ultrasound hip pain. Search dates: March and April 2011, and August 15, 2013.

The authors thank Kristen Prewitt, DO, (model examiner in the figures) and Grace Trabulsi (model patient) for their assistance.

The AuthorsJOHN J. WILSON, MD, MS, is an assistant professor in the Department of Family Medicine at the University of Wisconsin School of Medicine and Public Health in Madison. He is also a team physician for the University of Wisconsin Intercollegiate Athletics.

Hip Pain


MASARU FURUKAWA, MD, MS, is a postgraduate trainee in the Depart-ment of Family Medicine at the University of Wisconsin School of Medicine and Public Health.

Address correspondence to John J. Wilson, MD, MS, University of Wisconsin–Madison, 1685 Highland Ave., Madison, WI 53705 (e-mail: [email protected]). Reprints are not available from the authors.

REFERENCES

1. Christmas C, Crespo CJ, Franckowiak SC, et al. How common is hip pain among older adults? Results from the Third National Health and Nutri-tion Examination Survey. J Fam Pract. 2002;51(4):345-348.

2. Rossi F, Dragoni S. Acute avulsion fractures of the pelvis in adolescent competitive athletes. Skeletal Radiol. 2001;30(3):127-131.

3. Martin HD, Shears SA, Palmer IJ. Evaluation of the hip. Sports Med Arthrosc. 2010;18(2):63-75.

4. Gough-Palmer A, McHugh K. Investigating hip pain in a well child. BMJ. 2007;334(7605):1216-1217.

5. Bencardino JT, Palmer WE. Imaging of hip disorders in athletes. Radiol Clin North Am. 2002;40(2):267-287.

6. Czerny C, Hofmann S, Neuhold A, et al. Lesions of the acetabular labrum: accuracy of MR imaging and MR arthrography in detection and staging. Radiology. 1996;200(1):225-230.

7. Czerny C, Hofmann S, Urban M, et al. MR arthrography of the adult acetabular capsular-labral complex. AJR Am J Roentgenol. 1999;173(2): 345-349.

8. Deslandes M, Guillin R, Cardinal E, et al. The snapping iliopsoas tendon: new mechanisms using dynamic sonography. AJR Am J Roentgenol. 2008;190(3):576-581.

9. Blankenbaker DG, De Smet AA. Hip injuries in athletes. Radiol Clin North Am. 2010;48(6):1155-1178.

10. Balint PV, Sturrock RD. Intraobserver repeatability and interobserver reproducibility in musculoskeletal ultrasound imaging measurements. Clin Exp Rheumatol. 2001;19(1):89-92.

11. Ramwadhdoebe S, Sakkers RJ, Uiterwaal CS, et al. Evaluation of a training program for general ultrasound screening for developmen-tal dysplasia of the hip in preventive child health care. Pediatr Radiol. 2010;40(10):1634-1639.

12. Altman R, Alarcón G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoar-thritis of the hip. Arthritis Rheum. 1991;34(5):505-514.

13. Banerjee P, McLean CR. Femoroacetabular impingement. Curr Rev Mus-culoskelet Med. 2011;4(1):23-32.

14. Clohisy JC, Knaus ER, Hunt DM, et al. Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res. 2009;467(3):638-644.

15. Ito K, Leunig M, Ganz R. Histopathologic features of the acetabular labrum in femoroacetabular impingement. Clin Orthop Relat Res. 2004;(429):262-271.

16. Beall DP, Sweet CF, Martin HD, et al. Imaging findings of femoroac-etabular impingement syndrome. Skeletal Radiol. 2005;34(11):691-701.

17. Burnett RS, Della Rocca GJ, Prather H, et al. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am. 2006;88(7):1448-1457.

18. Leunig M, Werlen S, Ungersböck A, et al. Evaluation of the acetabular labrum by MR arthrography [published correction appears in J Bone Joint Surg Br. 1997;79(4):693]. J Bone Joint Surg Br. 1997;79(2):230-234.

19. Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2(2):105-117.

20. Blankenbaker DG, De Smet AA, Keene JS. Sonography of the iliopsoas tendon and injection of the iliopsoas bursa for diagnosis and manage-ment of the painful snapping hip. Skeletal Radiol. 2006;35(8):565-571.

21. Egol KA, Koval KJ, Kummer F, et al. Stress fractures of the femoral neck. Clin Orthop Relat Res. 1998;(348):72-78.

22. Fullerton LR Jr, Snowdy HA. Femoral neck stress fractures. Am J Sports Med. 1988;16(4):365-377.

23. Newberg AH, Newman JS. Imaging the painful hip. Clin Orthop Relat Res. 2003;(406):19-28.

24. Margaretten ME, Kohlwes J, Moore D, et al. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478-1488.

25. Eich GF, Superti-Furga A, Umbricht FS, et al. The painful hip: evalua-tion of criteria for clinical decision-making. Eur J Pediatr. 1999;158(11): 923-928.

26. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. 1999;81(12):1662-1670.

27. Learch TJ, Farooki S. Magnetic resonance imaging of septic arthritis. Clin Imaging. 2000;24(4):236-242.

28. Lee SK, Suh KJ, Kim YW, et al. Septic arthritis versus transient synovitis at MR imaging. Radiology. 1999;211(2):459-465.

29. Leopold SS, Battista V, Oliverio JA. Safety and efficacy of intraarticular hip injection using anatomic landmarks. Clin Orthop Relat Res. 2001; (391):192-197.

30. Mitchell DG, Rao VM, Dalinka MK, et al. Femoral head avascular necro-sis: correlation of MR imaging, radiographic staging, radionuclide imag-ing, and clinical findings. Radiology. 1987;162(3):709-715.

31. Mont MA, Zywiel MG, Marker DR, et al. The natural history of untreated asymptomatic osteonecrosis of the femoral head. J Bone Joint Surg Am. 2010;92(12):2165-2170.

32. Assouline-Dayan Y, Chang C, Greenspan A, et al. Pathogenesis and natu-ral history of osteonecrosis. Semin Arthritis Rheum. 2002;32(2):94-124.

33. Totty WG, Murphy WA, Ganz WI, et al. Magnetic resonance imag-ing of the normal and ischemic femoral head. AJR Am J Roentgenol. 1984;143(6):1273-1280.

34. Kirschner JS, Foye PM, Cole JL. Piriformis syndrome, diagnosis and treat-ment. Muscle Nerve. 2009;40(1):10-18.

35. Hopayian K, Song F, Riera R, et al. The clinical features of the piriformis syndrome. Eur Spine J. 2010;19(12):2095-2109.

36. Torriani M, Souto SC, Thomas BJ, et al. Ischiofemoral impingement syn-drome. AJR Am J Roentgenol. 2009;193(1):186-190.

37. Ali AM, Whitwell D, Ostlere SJ. Case report: imaging and surgical treat-ment of a snapping hip due to ischiofemoral impingement. Skeletal Radiol. 2011;40(5):653-656.

38. Lee EY, Margherita AJ, Gierada DS, et al. MRI of piriformis syndrome. AJR Am J Roentgenol. 2004;183(1):63-64.

39. Slipman CW, Jackson HB, Lipetz JS, et al. Sacroiliac joint pain referral zones. Arch Phys Med Rehabil. 2000;81(3):334-338.

40. Moore KL, Dalley AF, Agur AM. Clinically Oriented Anatomy. 6th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2010.

41. Adlakha S, Burket M, Cooper C. Percutaneous intervention for chronic total occlusion of the internal iliac artery for unrelenting buttock claudi-cation. Catheter Cardiovasc Interv. 2009;74(2):257-259.

42. Brown MD, Gomez-Marin O, Brookfield KF, et al. Differential diagno-sis of hip disease versus spine disease. Clin Orthop Relat Res. 2004; (419):280-284.

43. Segal NA, Felson DT, Torner JC, et al.; Multicenter Osteoarthritis Study Group. Greater trochanteric pain syndrome. Arch Phys Med Rehabil. 2007;88(8):988-992.

44. Strauss EJ, Nho SJ, Kelly BT. Greater trochanteric pain syndrome. Sports Med Arthrosc. 2010;18(2):113-119.

45. Williams BS, Cohen SP. Greater trochanteric pain syndrome. Anesth Analg. 2009;108(5):1662-1670.

46. Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy. 2008;24(12):1407-1421.

eTab

le A

. Dif

fere

nti

al D

iag

no

sis

of

Hip

Pai

n

Dia

gnos

isPa

in c

hara

cter

istic

sH

isto

ry/r

isk

fact

ors

Exam

inat

ion

findi

ngs

Add

ition

al t

estin

g

An

teri

or

thig

h p

ain

Mer

algi

a pa

rest

hetic

aPa

rest

hesi

a, h

ypes

thes

iaO

besi

ty, p

regn

ancy

, tig

ht p

ants

or

belt,

co

nditi

ons

with

incr

ease

d in

tra-

abdo

min

al p

ress

ure

Ant

erio

r th

igh

hype

sthe

sia,

dys

esth

esia

N

one

An

teri

or

gro

in p

ain

Ath

letic

pub

algi

a (s

port

s he

rnia

)D

ull,

diff

use

pain

rad

iatin

g to

in

ner

thig

h; p

ain

with

dire

ct

pres

sure

, sne

ezin

g, s

it-up

s,

kick

ing,

Val

salv

a m

aneu

ver

Socc

er, r

ugby

, foo

tbal

l, ho

ckey

pla

yers

No

hern

ia, t

ende

rnes

s of

the

ingu

inal

ca

nal o

r pu

bic

tube

rcle

, add

ucto

r or

igin

, pai

n w

ith r

esis

ted

sit-

up o

r hi

p fle

xion

Radi

ogra

phy:

No

bony

invo

lvem

ent

MRI

: Can

sho

w t

ear

or d

etac

hmen

t of

the

rec

tus

abdo

min

is o

r ad

duct

or lo

ngus

An

tero

late

ral h

ip a

nd

gro

in p

ain

(C

sig

n)

Fem

oral

nec

k fr

actu

re/s

tres

s fr

actu

re

Dee

p, r

efer

red

pain

; pai

n w

ith

wei

ght

bear

ing

Fem

ales

(es

peci

ally

with

fem

ale

athl

ete

tria

d),

end

uran

ce a

thle

tes,

low

ae

robi

c fit

ness

, ste

roid

use

, sm

oker

s

Pain

ful R

OM

, pai

n on

pal

patio

n of

gr

eate

r tr

ocha

nter

Radi

ogra

phy:

Cor

tical

dis

rupt

ion

MRI

: Ear

ly b

ony

edem

a

Fem

oroa

ceta

bula

r im

ping

emen

t D

eep,

ref

erre

d pa

in; p

ain

with

st

andi

ng a

fter

pro

long

ed

sitt

ing

Pain

with

get

ting

in a

nd o

ut o

f a

car

FAD

IR a

nd F

ABE

R te

sts

are

sens

itive

Ra

diog

raph

y: C

am o

r pi

ncer

def

orm

ity,

ace

tabu

lar

retr

over

sion

, cox

a pr

ofun

da

Hip

labr

al t

ear

Dul

l or

shar

p, r

efer

red

pain

; pa

in w

ith w

eigh

t be

arin

gM

echa

nica

l sym

ptom

s, s

uch

as

catc

hing

or

pain

ful c

licki

ng; h

isto

ry

of h

ip d

islo

catio

n

Tren

dele

nbur

g or

ant

algi

c ga

it, lo

ss o

f in

tern

al r

otat

ion,

pos

itive

FA

DIR

and

FA

BER

test

s

MRI

: Can

sho

w a

labr

al t

ear

Mag

netic

res

onan

ce a

rthr

ogra

phy:

off

ers

adde

d se

nsiti

vity

and

spe

cific

ity

Iliop

soas

bur

sitis

(in

tern

al s

napp

ing

hip

)

Dee

p, r

efer

red

pain

; in

term

itte

nt c

atch

ing,

sn

appi

ng, o

r po

ppin

g

Balle

t da

ncer

s, r

unne

rsSn

ap w

ith F

ABE

R to

ext

ensi

on,

addu

ctio

n, a

nd in

tern

al r

otat

ion

; re

prod

uctio

n of

sna

ppin

g w

ith

exte

nsio

n of

hip

fro

m fl

exed

pos

ition

Radi

ogra

phy:

No

bony

invo

lvem

ent

MRI

: Bur

sitis

and

ede

ma

of t

he il

iotib

ial b

and

Ultr

ason

ogra

phy:

Ten

dino

path

y, b

ursi

tis, fl

uid

arou

nd

tend

on

Dyn

amic

ultr

ason

ogra

phy:

Sna

ppin

g of

ilio

psoa

s or

ili

otib

ial b

and

over

gre

ater

tro

chan

ter

Legg

-Cal

vé-P

erth

es

dise

ase

Dee

p, r

efer

red

pain

; pai

n w

ith

wei

ght

bear

ing

2 to

12

year

s of

age

, mal

e pr

edom

inan

ceA

ntal

gic

gait,

lim

ited

ROM

or

stif

fnes

sRa

diog

raph

y: E

arly

sm

all f

emor

al e

piph

ysis

, scl

eros

is

and

flatt

enin

g of

the

fem

oral

hea

d

Loos

e bo

dies

and

ch

ondr

al le

sion

sD

eep,

ref

erre

d pa

in; p

ainf

ul

clic

king

Mec

hani

cal s

ympt

oms,

his

tory

of

hip

disl

ocat

ion

or lo

w-e

nerg

y tr

aum

a,

hist

ory

of L

egg-

Cal

vé-P

erth

es d

isea

se

Lim

ited

ROM

, cat

chin

g an

d gr

indi

ng

with

pro

voca

tive

man

euve

rs, p

ositi

ve

FAD

IR a

nd F

ABE

R te

sts

Radi

ogra

phy:

Can

sho

w o

ssifi

ed o

r os

teoc

hond

ral

loos

e bo

dies

MRI

: Can

det

ect

chon

dral

and

fibr

ous

loos

e bo

dies

Ost

eoar

thrit

is

of t

he h

ip

Dee

p, a

chin

g pa

in a

nd

stif

fnes

s; p

ain

with

wei

ght

bear

ing

Old

er t

han

50 y

ears

, pai

n w

ith a

ctiv

ity

that

is r

elie

ved

with

res

tIn

tern

al r

otat

ion

< 1

5 de

gree

s, fl

exio

n

< 1

15 d

egre

esRa

diog

raph

y: P

rese

nce

of o

steo

phyt

es a

t th

e ac

etab

ular

join

t m

argi

n, a

sym

met

rical

join

t-sp

ace

narr

owin

g, s

ubch

ondr

al s

cler

osis

and

cys

t fo

rmat

ion

cont

inue

d

FABE

R =

flex

ion,

abd

uctio

n, e

xter

nal r

otat

ion;

FA

DIR

= fl

exio

n, a

dduc

tion,

inte

rnal

rot

atio

n; M

RI =

mag

netic

res

onan

ce im

agin

g; R

OM

= r

ange

of

mot

ion.


eTab

le A

. Dif

fere

nti

al D

iag

no

sis

of

Hip

Pai

n (c

on

tin

ued

)

Dia

gnos

isPa

in c

hara

cter

istic

sH

isto

ry/r

isk

fact

ors

Exam

inat

ion

findi

ngs

Add

ition

al t

estin

g

An

tero

late

ral h

ip a

nd

gro

in p

ain

(C

sig

n)

(con

tinue

d)

Ost

eone

cros

is

of t

he h

ipD

eep,

ref

erre

d pa

in; p

ain

with

w

eigh

t be

arin

g A

dults

: Lup

us, s

ickl

e ce

ll di

seas

e,

hum

an im

mun

odefi

cien

cy v

irus

infe

ctio

n, c

ortic

oste

roid

use

, sm

okin

g,

and

alco

hol u

se; i

nsid

ious

ons

et, b

ut

can

be a

cute

with

his

tory

of

trau

ma

Pain

on

ambu

latio

n, p

ositi

ve lo

g ro

ll te

st,

grad

ual l

imit

atio

n of

RO

MRa

diog

raph

y: F

emor

al h

ead

luce

ncy

and

subc

hond

ral

scle

rosi

s, s

ubch

ondr

al c

olla

pse

(i.e.

, cre

scen

t si

gn),

fla

tten

ing

of t

he f

emor

al h

ead

MRI

: Bon

y ed

ema,

sub

chon

dral

col

laps

e

Slip

ped

capi

tal

fem

oral

epi

phys

is

Dee

p, r

efer

red

pain

; pai

n w

ith

wei

ght

bear

ing

11 t

o 14

yea

rs o

f ag

e, o

verw

eigh

t (8

0th

to

100

th p

erce

ntile

)A

ntal

gic

gait

with

foo

t ex

tern

ally

rot

ated

on

occ

asio

n, p

ositi

ve lo

g ro

ll an

d st

raig

ht le

g ra

ise

agai

nst

resi

stan

ce

test

s, p

ain

with

hip

inte

rnal

rot

atio

n re

lieve

d w

ith e

xter

nal r

otat

ion

Radi

ogra

phy:

Wid

ened

epi

phys

is e

arly

, slip

page

of

fem

ur u

nder

epi

phys

is la

ter

Sept

ic a

rthr

itis

Refu

sal t

o be

ar w

eigh

t, p

ain

with

leg

mov

emen

t C

hild

ren

: 3 t

o 8

year

s of

age

, fev

er, i

ll ap

pear

ance

Adu

lts:

Old

er t

han

80

year

s, d

iabe

tes

mel

litus

, rhe

umat

oid

arth

ritis

, rec

ent

join

t su

rger

y, h

ip o

r kn

ee p

rost

hese

s

Gua

rdin

g ag

ains

t an

y RO

M; p

ain

with

pa

ssiv

e RO

MH

ip a

spira

tion

guid

ed b

y flu

oros

copy

, com

pute

d to

mog

raph

y, o

r ul

tras

onog

raph

y; G

ram

sta

in a

nd

cultu

re o

f jo

int

aspi

rate

MRI

: Use

ful f

or d

iffe

rent

iatin

g se

ptic

art

hriti

s fr

om

tran

sien

t sy

novi

tis

Tran

sien

t sy

novi

tisRe

fusa

l to

bear

wei

ght

Chi

ldre

n: 3

to

8 ye

ars

of a

ge,

som

etim

es f

ever

and

ill a

ppea

ranc

ePa

in w

ith e

xtre

mes

of

ROM

Late

ral p

ain

Exte

rnal

sna

ppin

g hi

p*Pa

in w

ith d

irect

pre

ssur

e,

radi

atio

n do

wn

late

ral

thig

h, s

napp

ing

or p

oppi

ng

All

age

grou

ps, a

udib

le s

nap

with

am

bula

tion

Posi

tive

Obe

r te

st, s

nap

with

Obe

r te

st,

pain

ove

r gr

eate

r tr

ocha

nter

Radi

ogra

phy:

No

bony

invo

lvem

ent

MRI

: Bur

sitis

and

ede

ma

of t

he il

iotib

ial b

and

Ultr

ason

ogra

phy:

Ten

dino

path

y, b

ursi

tis, fl

uid

arou

nd

tend

on

Dyn

amic

ultr

ason

ogra

phy:

Sna

ppin

g of

ilio

psoa

s or

ili

otib

ial b

and

over

gre

ater

tro

chan

ter

Gre

ater

tro

chan

teric

bu

rsiti

s*Pa

in w

ith d

irect

pre

ssur

e,

radi

atio

n do

wn

late

ral t

high

Runn

ers,

mid

dle-

aged

wom

enPa

in o

ver

grea

ter

troc

hant

er

Gre

ater

tro

chan

teric

pa

in s

yndr

ome

Pain

with

dire

ct p

ress

ure,

ra

diat

ion

dow

n la

tera

l thi

ghA

ssoc

iate

d w

ith k

nee

oste

oart

hriti

s,

incr

ease

d bo

dy m

ass

inde

x, lo

w b

ack

pain

; fem

ale

pred

omin

ance

Prox

imal

ilio

tibia

l ban

d te

nder

ness

, Tr

ende

lenb

urg

gait

is s

ensi

tive

and

spec

ific

Post

ero

late

ral p

ain

Glu

teal

mus

cle

tear

or

avu

lsio

n*Pa

in w

ith d

irect

pre

ssur

e,

radi

atio

n do

wn

late

ral t

high

an

d bu

ttoc

k

Mid

dle-

aged

wom

enW

eak

hip

abdu

ctio

n, p

ain

with

res

iste

d ex

tern

al r

otat

ion,

Tre

ndel

enbu

rg g

ait

is

sens

itive

and

spe

cific

MRI

: Glu

teal

mus

cle

edem

a or

tea

rs

Iliac

cre

st a

poph

ysis

av

ulsi

onTe

nder

ness

to

dire

ct

palp

atio

nH

isto

ry o

f di

rect

tra

uma,

ske

leta

l im

mat

urit

y (y

oung

er t

han

25 y

ears

)Ili

ac c

rest

ten

dern

ess

and

/or

ecch

ymos

isRa

diog

raph

y: A

poph

ysis

wid

enin

g, s

oft

tissu

e sw

ellin

g ar

ound

ilia

c cr

est

cont

inue

d

FABE

R =

flex

ion,

abd

uctio

n, e

xter

nal r

otat

ion;

FA

DIR

= fl

exio

n, a

dduc

tion,

inte

rnal

rot

atio

n; M

RI =

mag

netic

res

onan

ce im

agin

g; R

OM

= r

ange

of

mot

ion.

*—C

ondi

tions

ass

ocia

ted

with

gre

ater

tro

chan

teric

pai

n sy

ndro

me.

34B American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2013 American Academy of Family Physicians. For the private, non-commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.

Hip Pain

eTab

le A

. Dif

fere

nti

al D

iag

no

sis

of

Hip

Pai

n (c

on

tin

ued

)

Dia

gnos

isPa

in c

hara

cter

istic

sH

isto

ry/r

isk

fact

ors

Exam

inat

ion

findi

ngs

Add

ition

al t

estin

g

Post

erio

r p

ain

Ham

strin

g m

uscl

e

stra

in o

r av

ulsi

onBu

ttoc

k pa

in, p

ain

with

dire

ct

pres

sure

Ecce

ntric

mus

cle

cont

ract

ion

whi

le h

ip

flexe

d an

d le

g ex

tend

edIs

chia

l tub

eros

ity

tend

erne

ss,

ecch

ymos

is, w

eakn

ess

to le

g fle

xion

, pa

lpab

le g

ap in

ham

strin

g

Radi

ogra

phy:

Avu

lsio

n or

str

ain

of h

amst

ring

atta

chm

ent

to is

chiu

m

MRI

: Ham

strin

g ed

ema

and

retr

actio

nIs

chia

l apo

phys

is

avul

sion

Butt

ock

pain

, pai

n w

ith d

irect

pr

essu

reSk

elet

al im

mat

urit

y, e

ccen

tric

mus

cle

cont

ract

ion

(cut

ting,

kic

king

, ju

mpi

ng)

Isch

iofe

mor

al

impi

ngem

ent

Butt

ock

or b

ack

pain

with

po

ster

ior

thig

h ra

diat

ion,

sc

iatic

a sy

mpt

oms

Gro

in a

nd/o

r bu

ttoc

k pa

in t

hat

may

ra

diat

e di

stal

lyN

one

esta

blis

hed

MRI

: Sof

t tis

sue

edem

a ar

ound

qua

drat

us f

emor

is

mus

cle

Pirif

orm

is s

yndr

ome

Butt

ock

pain

with

pos

terio

r th

igh

radi

atio

n, s

ciat

ica

sym

ptom

s

His

tory

of

dire

ct t

raum

a to

but

tock

or

pai

n w

ith s

ittin

g, w

eakn

ess

and

num

bnes

s ar

e ra

re c

ompa

red

with

lu

mba

r ra

dicu

lar

sym

ptom

s

Posi

tive

log

roll

test

, ten

dern

ess

over

the

sc

iatic

not

chM

RI: L

umba

r sp

ine

has

no d

isk

hern

iatio

n, p

irifo

rmis

m

uscl

e at

roph

y or

hyp

ertr

ophy

, ede

ma

surr

ound

ing

the

scia

tic n

erve

Sacr

oilia

c jo

int

dysf

unct

ion

Pain

rad

iate

s to

lum

bar

back

, bu

ttoc

k, a

nd g

roin

Fe

mal

e pr

edom

inan

ce, c

omm

on in

pr

egna

ncy,

his

tory

of

min

or t

raum

aFA

BER

test

elic

its

post

erio

r pa

in lo

caliz

ed

to t

he s

acro

iliac

join

t, s

acro

iliac

join

t lin

e te

nder

ness

Radi

ogra

phy:

Pos

sibl

y no

find

ings

, nar

row

ing

and

scle

rotic

cha

nges

of

the

sacr

oilia

c jo

int

spac

e

FABE

R =

flex

ion,

abd

uctio

n, e

xter

nal r

otat

ion;

FA

DIR

= fl

exio

n, a

dduc

tion,

inte

rnal

rot

atio

n; M

RI =

mag

netic

res

onan

ce im

agin

g; R

OM

= r

ange

of

mot

ion.

*—C

ondi

tions

ass

ocia

ted

with

gre

ater

tro

chan

teric

pai

n sy

ndro

me.

January 1, 2014 ◆ Volume 89, Number 1 www.aafp.org/afp American Family Physician 34CDownloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2013 American Academy of Family Physicians. For the private, non-commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.

Hip Pain

34D American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014

eFigure A. Localization of hip pain. (A) Posterior view. (B) Anterior view.

eFigure B. Ober test (passive adduction). The patient is positioned on his or her side, with the unaffected hip on the examination table. The examiner stands behind the patient with one hand on the patient’s hip, and the other hand supporting the lower leg. (A) To evaluate the tensor fasciae latae: The hip and knee are held at 0 degrees of extension and allowed to passively adduct with gravity. (B) The gluteus medius: The hip is held at 0 degrees of extension and 45 to 90 degrees of knee flexion. (C) The gluteus maximus: The shoulders are rotated back toward the table, with the hip in flexion and knee in extension.

A B C

The rights holder did not grant the American Academy of Family Physicians the right to sublicense this material to a third party. For the missing item, see the original print version of this publication.


Evaluacion de un dolor de cadera

Health & Medicine

Transcript of Evaluacion de un dolor de cadera