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hip

pain

Case History

Ada would like you to refer her to a chiropodist as she is finding it impossible to bend down and cut her toenails. She sufferers from hip pain which has been getting worse over the years and now at 69 she is finding it difficult to walk more than 100m without pain. You find that she is limping and has now taken to walking with a stick.

Yes, and here's the bad news ­ arthritis accounts for one in five visits to the GP and is the single largest cause of locomotor disability. With an ageing population the problem will inevitably become more prevalent.

Pain occurs in the groin and front of the thigh; the knee can also be affected. Diagnosis can be made difficult as pain from an arthritic hip can also cause back and upper buttock pain. Many patients complain of stiffness. Interference with daily activities is often a problem ­ cutting toenails, putting on socks, climbing in and out of a car. With time these symptoms often worsen.

Most patients are elderly and obese. Look at their gait as they walk into your consulting room. Patients often have a waddling gait with the affected leg held externally rotated. Look for muscle wasting around the affected joint. Joint movements are often impaired and painful ­ especially internal rotation.

Flexion is often well preserved. Try Trendelenburg' signs ­ the test is positive when the pelvis drops as the patient stands on the affected leg.

An X-ray hardly ever changes your management. If a patient insists on one or if the pain has suddenly progressed, or if you and patient are considering hip replacement, X-ray may be justified. Typical X-ray changes include joint space narrowing, presence of osteophytes, subchondral cyst formation, and subchondral sclerosis.

Managing Ada's pain should only be the beginning. Here are a few other options open to you.

·Physiotherapy ­ many patients benefit from improved muscle tone and balance. Propioceptive training, aerobic exercise, stretches, massage and advice on joint protection can help. Application of local heat, cold and hydrotherapy are useful. Walking sticks and walkers can also be provided.

·Podiatry ­ choice of footwear is particularly important and heel cushions can alleviate pain by acting as shock absorbers. Correcting leg-length discrepancies by shoe raises can also make a significant difference.

·Occupational therapy ­ this can assess interference with daily activities and provide aids such as raised toilet seats, dressing sticks for putting on socks and tights, wall bars for getting in and out of the bath and chair lifts to help manage stairs.

·Sexual counselling ­ patients with hip pain may have difficulty with sexual activities. Specific counselling may help.

As always, start with simple paracetamol and work up the ladder to tramadol. Watch for constipation. Joint injections often give good relief, particularly in acute flare-ups, but no more than three injections per year should be given.

Recent studies have found that acupuncture is beneficial in osteoarthritic knee pain. Some patients have also found it useful for hip pain and OA affecting smaller joints.

Glucosamine has been found to be as effective as NSAIDs. It seems to work better when taken in combination with chondroitin sulphate, but this is more expensive.

During surface hip replacement only the damaged joint surfaces from the femoral head are removed to prepare for the metal shell. The femoral neck is left intact. The femoral head is fitted with a spherical metal shell and the acetabulum is lined with a thin spherical metal shell. The hip surface replacement concept remains attractive because the femoral head and neck are preserved, the femur is loaded in a more natural way, and the large femoral shell enhances stability and prevents dislocation.

Preservation of bone is attractive for young, active patients who are likely to outlive their first hip arthroplasty and will need a new hip. There is one complication of surface hip replacement not seen in total hip replacements ­ the fracture of the remaining femoral neck which occurs in up to 1 per cent of patients. Hip resurfacing is contraindicated in:

·very heavy, active patients

·those with osteoporosis

·patients with very small and/or severely deformed hip joints

·previous operation on the hip joint

·patients with bone cysts (voids) in the femoral heads and necks

Filling in disability and orange badge forms is an important way of helping patients. Remain proactive by trying to identify patients with predisposing factors and address known risk factors.

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