Evaluation of Hip Pain

Randale Sechrest: Hello, I am Dr. Randale Sechrest your host for eOrthopod.TV. Today I am talking remotely with Dr. William Seeds. Dr. Seeds is an orthopedic surgeon in Ashtabula, Ohio. Thanks for joining us Dr. Seeds.

William Seeds: Randy thanks for having me today.

Randale Sechrest: Dr. Seeds, well, I thought we’d talk about today is a very common problem that any orthopedic surgeon who deals with general orthopedics especially is seeing on a daily basis and that’s hip pain. You know I think that hip and knee pain and possibly shoulder pain are the three biggest things that orthopedic surgeon see in their elective practice when they are trying to take care of people who sort of make an appointment; see I have this pain. So what I thought we would do today is really go through your philosophy and your approach to evaluating the patient that may be is referred to your office or just makes an appointment and comes in and says doc I’ve got this hip pain, what do you think about it? So let’s start by sort of talking with patients about how you do a history, what you’re looking for in terms of information from that patient to help you decide what’s going on that’s causing the hip pain?

William Seeds: Sure Randy, I think, we kind of look at it in subsets of first, you know, the age group we are looking at. We are looking at a kid or we are looking at the young adult or we are looking at the older individual. Those aspects play a part in how you are going to start in reviewing this, you know, their recent problems and how things will they progress. So the history is very important in getting a clear picture of where you think you maybe headed as you start your physical exam. So, of course, this has been something that’s been ongoing, is it something that occurs while weight bearing, is it worse at night? You know the typical questions that we go through with any joint, type of ailment; we want to make sure there is no aspect of infection. We will ask him about fevers, chills, night sweats things like that. We’ll go through any type of trauma history as there had been any trauma, traumatic event in the past or the recent future or recent timeframe. So we’ll kind of go through that process to try to hone in on, what specifically is bringing them in for this process and are there any other related symptoms, is there back pain, is there knee pain associated with this and then we’ll go from there.

Randale Sechrest: Well, what do you find is the most common cause of the pain of patients that come into your office? I mean, what are you seeing as a source of that pain?

William Seeds: I think, I could break that down into probably three parts for you. I think the most common problem I am seeing when they come into the office are at least when they are presenting and/or referred to me, they are referred to me for an arthritic problem of the hip. And the most important thing for me to determine is I certainly have a lot of people that present with X-ray changes that will show an arthritic change in the hip, but they aren’t necessarily presenting those symptoms when they come to my office showing me that it’s really the arthritis that is giving them the problem and that’s where we get into the, I think the two other categories that I see more commonly or just as commonly are trochanteric type of problem like a bursitis or possibly a small tear in the tendon like the gluteus medius where they are having problems around the outside of the hip and it’s perceived to be their arthritic problem or I see sacroiliac problems in the pelvis that may mimic that hip pain where it’s been referred to me and they feel it’s their hip even if the X-ray is showing degenerative changes it is necessarily that problem. So I think they kind of revolve around those three areas.

Randale Sechrest: No, we’re probably out to define what the sacroiliac joint and in some ways what the trochanter is. The areas of the body that we are talking about, can you elaborate on that a little bit in terms of where is the sacroiliac joint and what is the greater trochanter?

William Seeds: The sacroiliac joint is in the – is really the back of the hip joint as patients would refer to it. It’s in the back of the hip. It’s actually the back of the pelvis where the sacrum and the pelvis, the iliac wing come into connection and it’s a joint; it’s a very large joint and that’s an area that we can commonly see, it can be associated with these problems. The greater trochanter is a – if we look at the hip joint it’s more on the outside of the hip joint and it’s where we have a couple of muscle groups the gluteus medius and the minimus, which are two muscles that attach to the trochanter and that kind of access the lever arm for certain movements of the hip and there is also something called the lesser trochanter, which is another part of the hip joint, that is very close to that area too.

Randale Sechrest: Now, what about lumbar spine problems? Where the problem is not in the hip at all, but it actually is coming from a pinched nerve in the low back and the patient may not feel back pain, they may feel some back pain, but what they are really feeling the pain is down in their hip, hip joint or in the thigh area and they are confused as to where the problem is coming. Do you feel like that, that’s a big, a big issue for you in terms of the patients you see trying to distinguish these two processes?

William Seeds: Yes, I would say that I feel, I do see that also, I don’t see it at the, as often as I see the SI joint in the trochanteric problems, but absolutely that’s a patient that we see that will kind of describe a hip pain that migrates down the leg and it’s a little bit more of a different presentation, but it’s something that, it’s another thing that we are looking for at that time of presentation. I feel that my primary care physicians around the area and our pain management physicians have done – are doing a much better job in picking those things up earlier, before I may get to them. But it definitely is another component, and that’s a very good point to bring up.

Randale Sechrest: Let’s talk a little bit about how you evaluate the patient from a physical exam standpoint and maybe later on a little bit about what test that you began to look at in order to make a diagnosis. But when you are examining the hip and you are examining a patient – go through that process for me a little bit, how do you do that process?

William Seeds: Sure Randy I believe that one of the most important things that I, when I begin a hip exam is, I like to get the patient up and I actually like to watch the patient walk. I like to see the mechanics of their ambulation of their walking and see how that pelvis maybe integrated in that injury or the lower back or the leg. And I think in watching – in just watching a patient walk 25 feet – 50 feet you can appreciate the problem they are having, if it’s you know more of an antalgic problem where they’re swinging their pelvis or is it more related to the knee you know limping type of gait or is it more due to the lumbar spine, which I think you can pick all of those thing up very well in observing their gait pattern. So once I’ve had them do that and we come back I usually sit them down and I’ll initially start to kind of eliminate the low back type of problems where we’ll do some quick exams to verify that there is no radicular or nerve root impingement problems. Then we’ll go on to look at, I’ll go on immediately once they have kind of told me where they feel their pain is then I’ll try to do like a range of motion evaluation, a muscle testing evaluation around the hip joint. And then some rotational type of moves that look for impingement type of symptoms that we can see around the hip and then I think we can get a pretty good idea of where that patient’s pain is coming from, can I reproduce that on my exam – is it a component of that scene with their, when they are walking. And then I’ll correlate that with an X-ray of the lumbar spine and pelvis and hip to go from there.

Randale Sechrest: Now is X-ray pretty much the only radiologic test that you use, do you find that you need any special testing like the MRI scan, CAT scans, bone scans, do you ever use those tests as a part of your diagnosis?

William Seeds: I use it; I use it I would say may be 15% of the time with my hip exams. I feel pretty comfortable with the X-ray findings and the physical exam, if I feel there are, let’s say I feel there are spine problems related with ridiculer symptoms, nerve root impingement, and I am finding a positive neurological exam then I’ll go on to the MRI of the lumbar spine. If on exam of the hip, if I feel there are some intraarticular, some inside the joint type of problems that I can’t pick up on the normal X-ray, that maybe something that where I’ll go on to an MRI, if I am concerned about infection or other issues such as problems where there maybe a breakdown of the structure of the hip itself, where it’s not related to trauma and so forth then I may get an MRI also.

Randale Sechrest: And what about lab test, I mean, just blood test, urinalysis those were to test, you find any of those useful when you are evaluating the hip pain or a hip joint?

William Seeds: Sometimes I will use the blood work as far as looking for more autoimmune type of diseases such as rheumatoid and Sjogren’s and looking for gouty problems and other lupus type of presentations that where you are kind of getting a foggy presentation of that, that hip presentation and more systemic, you know, other systemic problems that may be part of a workup I’ll do a little bit later if I don’t see things that I believe are specifically related to the pathology of that isolated joint.

Randale Sechrest: You know, I guess finally, I think that these days hip arthroscopy actually putting a camera and a small little scope into the hip is becoming more wide spread; do you find that hip arthroscopy helps you in terms of diagnosis; do you use hip arthroscopy as part of your diagnostic process for trying to find out what’s causing pain in the hip?

William Seeds: I do, I’m a hip arthroscopist and I have been actively doing hip arthroscopy in my practice for hip problems. I do feel that the MRI has improved significantly and picking up more of the pathology around the hip joint when we are suspicious for those type of problems such as cartilage injuries, loose bodies, labral tears around the hip and I think that is – become more effective as far as doing a diagnostic hip arthroscopy itself – I feel that that’s probably, you know, down the road as far as if you’ve covered all of the conservative measures you can.

I rarely use it as so to speak a diagnostic hip arthroscopy I usually have, I believe better evidence of going into the hip joint and using that, that maybe more play, more of a role here in the future. I have gone in and found labral tears that weren’t present on the MRI or I found articular injuries that have not been present on the MRI. So I feel a little bit better about my physical exam, if it’s pushing me that way towards when I feel there is a labral tear or a cartilage injury.

Randale Sechrest: You know, one question that sort of brings up and that is the notion of putting dye in the hip when you do the MRI scan, I know different surgeons, different radiologist have different ideas about how well you can see those labral tears the tears in the soft tissue inside the hip with and without dye; What’s your thoughts on that, do you try to put dye in the hip when you do the MRI scan or do you feel like you get just as good a picture without the dye?

William Seeds: I initially did do – I did a lot of my hip MRIs with the dye and felt that at that time we were getting a pretty reliable report and I think it just depends on the institution that you are working with or the radiologist that you are working with, I do think that there has been somewhat of a change of hip MRIs without dye where the MRI radiologist specific for hip joints have been getting better and feel more comfortable without the dye. And I think if you have access to that process of where you can utilize those, what I would call them hip specialist with the MRI that they can certainly help you in discerning those problems. And we have been very fortunate actually in doing that where now, you can send your images, you know, within a couple of minutes anywhere in the world to have those radiologists involved in reading those images.

Randale Sechrest: You know, this injecting dye in the hip joint brings up another point I think that, you know, in lots of joints we do diagnostic test that involve injection. So we may inject either lidocaine, some type of an anesthetic into a joint or into an area of the body and the whole goal is really to try to numb up that area to make the pain go away and what we think is that actually proves that that structure whatever structure we healed, we numbed up when we did the injection is the source of the pain if it goes away. Sometimes we will also add a little cortisone into that to try to treat the problem and give some symptom relief. How much do you use in diagnostic injections and sometimes even therapeutic injections, you know, trying to make the problem better in the hip joint? What’s your thoughts on that?

William Seeds: Randy, I utilize that the hip injection diagnostically and therapeutically quite often in my practice I feel that it’s quite an advantage especially with the hip joint to help in confirming a diagnosis and to also give some therapeutic relief for that problem in treating that patient with hip problems and I found it to be an effective way of really being one of my first initial steps in that process of treatment of where I think you where you, if you’re not getting a clear picture on the process if it is truly hip pain versus SI joint pain or lower back pain or more of an extraarticular on the hip, it’s an excellent way to get a clear and concise, I think initial evaluation of that hip is that can you knock that pain off for that patient and on top of that if you can add a steroid to that regime in that treatment, you’re, I think the patients are even more happier for a period of time if you can help relieve that pain.

Randale Sechrest: Yeah, I found that to be the case as well and I think injections, you know, diagnostic injections are great help in terms of trying to identify what’s going with that patient’s hip pain and what structure is causing the pain. And that brings up another point and, you know, for years, I think a lot of people had the notion that, you know, if you’ve got hip pain that is probably wear and tear in the hip I think over the last decade, we’ve really teased out different types of problems that affect the hip so that not everything is seeing is just a degenerative hip problem. We’ve labral tears, we’ve greater trochanteric bursitis, we now have tears in the tendons that attach to the greater trochanter area we are starting to recognize the fact that this SI joint can actually mimic hip pain and as you mentioned even lumbar spine pain, I think that’s combined with several processes that we see going on in the hip with people’s hip joints that are just a little different than normal and they may not have problems initially as, in childhood or in early adulthood like some of the abnormalities that we’re born with, but some of these problems begin to appear in the 40’s and in the 50’s and accelerate the problem.

So I think our ability to really sort of isolate what’s really going on in the hip has changed drastically over the last 20 years as the MRI scan has become more accurate and it’s our sort of understanding with things like arthroscopy and that sort of stuff, what’s really going on in the hip joint. So I definitely think patients should leave this discussion understanding that even though you think that maybe what you’re dealing with is wear and tear on the hip osteoarthritis or the hip is just wearing out, it’s far more complex than that and there are far more things going on in the hip at times then that’s simple sort of concept would suggest. So I guess that’s a long way of asking the question and that is, as we close this discussion, do you have any thing that you think patients sort of know that we haven’t discussed about hip pain and how to go about trying to evaluate hip.

William Seeds: Yeah absolutely Randy, I think that the most information or best information I can give at this point is I don’t want those patients to be discouraged when they feel that it maybe an arthritic problem of the hip joint or they’re told that by their primary care physician because of some X-ray findings where a lot of times we find that yes, sure there are some changes on X-ray, but it’s not specifically the problem they’re dealing with. And I could tell you in a fourth, probably one quarter of the patients present with hip pain in my office, there is some other factor that’s related to that problem that’s easily treatable and it’s not related to those X-ray findings or those initial indications where somebody gave him the idea that it’s the arthritis that’s producing this, it’s a bad problem and you maybe headed for surgery.

Randale Sechrest: Yeah, I think that’s an excellent advice, I think that a lot of patients when they’re start having hip pain, you know, and they see someone and they’re told they have arthritis of the hip. I mean, in the past the only real treatment we had for those patients was replace the hip, a big operation that required replacement of the entire hip, I think things are much different today and I think that we have treatments that are much more directed at the absolute problem and trying to postpone the need for that artificial hip replacement, because some of these conditions that we’re talking about can accelerate that wear and tear on the hip and lead to an artificial hip.

So I am glad you mention that, I think that the take home message for patients to this should be, hip pain is more than just osteoarthritis, more than just wear and tear or it could be and you probably ought to get in and get a good evaluation with a good hip surgeon, a good orthopedic surgeon who understands the hip, which most orthopedic surgeons that do general orthopedics have a pretty good understanding of the hip joint. And I think that patients would be well served to get that pain evaluated earlier rather than later. So I want to thank you for joining us today, any other comments as we close this discussion.

William Seeds: No Randy, I think this has been a very insightful segment and I look forward to doing more work with you.

Randale Sechrest: Okay. Well, thank you very much for joining us today.

William Seeds: Thanks Randy.