Review Question - QID 219753

Hip Osteoarthritis QID: 219753 (SBQ24HK.5)

QID 219753 (Type "219753" in App Search)

A 65-year-old female presents to establish care after recently moving from another state. She reports a long history of right-sided back pain that was initially treated with physical therapy. After minimal improvement, another physician obtained X-rays (shown in Figure A) and opted to perform an intra-articular right hip injection. The patient reports she had 1 week of symptom relief before once again becoming symptomatic and is currently very painful. On physical exam, the patient has a positive straight leg raise and pain with resisted hip flexion. When asked to demonstrate her pain she grips her inguinal crease between thumb and index finger at the level of her hip. Given the patient’s treatment course to this point, what is the next best step in her treatment?

Type & Select Correct Answer

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Repeat intra-articular corticosteroid injection of the hip

12/684

Additional physical therapy

23/684

Recommend total hip arthroplasty

86%

586/684

Lumbar Fusion

14/684

Referral to hip specialist for consideration of femoral osteochondroplasty

43/684

Select Answer to see Preferred Response

The patient has physical examination and radiographic findings suggestive of intra-articular hip pathology. They have failed conservative management with an intraarticular steroid injection and should be offered hip replacement.

Patients with hip spine syndrome require a systematic approach to elicit their underlying diagnosis. A detailed medical history and accompanying physical exam should be performed on every patient. A positive Stinchfield test (pain with resisted hip flexion) and C-sign (groin cupping) are suggestive of intra-articular pathology. Diagnostic tests beyond plain radiography are often required to narrow the differential as hip osteoarthritis and degenerative spine changes are not conclusive when considered in isolation. Hip injections can help determine the primary pain generator but should be reserved for patients with evidence of hip osteoarthritis. Once the diagnostic evaluation is complete patients should be offered the most appropriate management based on their symptoms.

Suarez et al performed a comprehensive review of the evaluation of groin pain. They report a diverse differential diagnosis and present a stepwise assessment that factors in radiation pattern, location, associated symptoms, and pertinent physical exam maneuvers. They recommend a comprehensive medical history and tailored physical exam to select additional diagnostic modalities or referrals.

Gonzalez-Lomas et al reviewed the often-difficult nature of the diagnosis of deep gluteal pain and presented a wide differential based on anatomic considerations. They provide a systematic approach to diagnosis and treatment options based on history, physical exam including special maneuvers, and imaging. They conclude that gluteal pain is a challenging problem secondary to complex anatomy and the overlap of several related conditions.

Figure A demonstrates bilateral hip osteoarthritis with evidence of subchondral sclerosis.

Incorrect Answers:
Answer 1: Although the patient had improvement in her symptoms, they were short-lived which portends to similar results with repeat attempts.
Answer 2: An earlier attempt at PT was attempted without significant relief
Answers 4: The patient is not displaying any neurological symptoms that would warrant further evaluation of spinal pathology
Answer 5: This patient's radiograph demonstrates osteoarthritis without evidence of CAM or pincer deformities.