Examination of a painful hip is fairly succinct. Much of the examination focuses on assessing for extraarticular sources of hip pain. In fact, in the author's center, only approximately 20% of all patients who present with a chief complaint of hip problems actually have an intraarticular source of their symptoms, with the most common being degenerative arthritis. Also, for those who do genuinely have an intraarticular source of their symptoms, only a small percentage are candidates for any type of ar-throscopic intervention.
Common extraarticular sources of hip-related symptoms begin remote from the joint itself. These complaints include symptoms referred from the lumbar spine, sacroiliac joint, and sciatic nerve. Hamstring and ischial symptoms are usually readily differentiated. However, hip flexor or adductor muscle strains may closely mimic hip joint symptoms. Lateral symptoms such as trochanteric bursitis or hip abductor muscle injury are usually characteristic. Deep tendinous involvement such as the piriformis or iliopsoas tendon may be difficult to differentiate from mechanical hip symptoms and may also occur in conjunction with intraarticular pathology.
An occult femoral hernia produces groin symptoms. Pain localization suggests hip pathology, but symptoms are not generated by examination of the hip. Nor do symptoms correlate with weight bearing or walking as much as with Valsalva-type maneuvers.
Consequently, it is often a challenge to differentiate musculoskeletal problems from visceral or nervous system disorders. After determining that the problem is musculoskeletal, the next step is to differentiate intraarticular (or intracapsular) sources from extraarticular disorders. Even then, many intraarticu-lar sources of hip pain are not amenable to arthro-scopic intervention. Examples include femoral neck stress fracture seen in active individuals, early-stage avascular necrosis frequently plaguing the younger population, and advanced arthritic disorders that are usually apparent radiographically. Thus, various imaging studies are often important in ruling out some of these disease states as much as in confirming a diagnosis (see Chapter 4).
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