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CLINICAL DEVELOPMENTS: A PHYSICAL THERAPY RESOURCE FOR PHYSICIANS

Volume 1, No.2:
LOWER EXTREMITY
HIP JOINT PAIN REFERRAL PATTERNS: A DESCRIPTIVE STUDY


Lesher JM, Dreyfuss P, Hager N, et al. Pain Medicine. 2008; 9(1):22-25.
Abstracted by Gina Fick, PT, ScD, COMT from Highlands Ranch, CO.
Reprinted by permission: IAOM-US Quarterly Review, Volume 63, 3rd Quarter 2008
http://www.iaom-us.com

Accurate diagnosis of pain originating from the hip joint can be clinically challenging. The purpose of this study was to determine hip joint pain referral patterns based on pre-injection pain diagrams completed by patients who had a positive response to a fluoroscopically guided intra-articular anesthetic (FGIA) hip injection. Fifty-one consecutive patients (28 female and 23 male) with a mean age of 60.6 years and a history of hip pain and pathology were selected from 4 different physiatrist practices for this study. The study’s inclusion criteria were evidence of hip pathology on plain radiographs or magnetic resonance imaging studies and > 90% pain reduction 30 minutes after the FGIA hip injection.

Prior to the injection patients completed an anatomical pain drawing and pre-procedure visual analog scale. For the injection procedure, patients were placed supine, and a local anesthesia was used. Patients did not receive oral or intravenous sedation. Under fluoroscopic guidance, a 22-, 25-, or 26-guage needle was inserted from a skin position just lateral and superior to the mid-position of the intertrochanteric line. The needle was guided medial and slightly inferior to the mid-portion of the femur’s anatomical neck under the joint capsule. Intra-articular flow within the hip joint was verified by a contrast medium injection, and then 4 cc of 0.5% bupivicaine and 2 cc of triamcinoline 40mg/cc were injected.

Thirty minutes following the injection, each patient completed a post-procedure visual analog scale. Data analysis was performed by an investigator who was not involved in the injection procedure. The pain diagram was analyzed to determine pain referral patterns. Pain referral patterns were delineated to the regions of the buttock, groin, thigh, knee, leg, and foot. The buttock was defined as the area inferior to the iliac crests, lateral to the posterior superior iliac spines, and superior to the posterior thigh. The groin area was defined as a the area superior to the greaster trochanter and inferior to the lower abdomen. The thigh and leg were further anatomically divided into anterior, posterior, medial, and lateral divisions.

The results of the data analysis on the pre- and post-procedure anatomical pain map and visual analog scale demonstrated that the hip joint referred to the groin and thigh in 55% and 57% of patients, respectively. However, pain was also seen in the buttock and lower extremity distal to the knee in 71% and 22% respectively. Foot and knee pain were seen in only 6% and 2% of patients, respectively, while lower lumbar spine referral did not occur. In all, fourteen pain referral patterns were observed.

In summary, the authors of this study determined that buttock pain was the most common referral area from symptomatic hip joint, while the traditionally accepted groin and thigh referral areas were less common. Futhermore, they found that hip joint pain referral to the foot did occur in limited cases. This study’s referral patterns can be a useful tool in the differential diagnosis of hip joint related pain.

IAOM-US Comment
Differential diagnosis of hip pain can be challenging due to the broad spectrum of pain referral patterns associated with the hip joint. Previous studies addressing hip joint pain referral patterns have relied upon anatomical studies, regional hip blockade, and analysis of pain patterns in patients awaiting primary or revision total hip arthroplasty.1,2,3,4 Unlike previous studies, this is the first published study to our knowledge that has assessed hip joint referral patterns based on a diagnostic FGIA hip injection. FGIA injections have been the gold standard for diagnosing sacroiliac (SI) and lumbar zygapophyseal joint pain, yet previous studies addressing hip hoint pain referral have not utilized this approach.5,6,7 In this study it is important to note that false positive responses were minimized by avoiding pre-procedural sedation and high-grade pain relief.

The authors found that referred pain to the buttock was most common with an incidence of 71%, while thigh and groin referral were almost equal in occurance at 57% and 55% respectively. Only 16% of patients descibed lower leg pain. The most referral combination was buttock pain with thigh referral (20%). Though most of the thigh pain was located anterior (27%) and lateral (27%), some individuals experienced pain that was posterior (24%) or medial (16%).

What these findings seem to illustrate most clearly is the importance of a thorough history and complete basic functional examination and local examination of the hip joint, as well as the importance of screening the lumbar spine and SI joint for potential involvement as these structures can be responsible for similar pain referral patterns. Futhermore, pain diagrams can be useful as an adjunct to such examination when evaluating a patient with potential hip pathology.

References
1. Khan A, McLoughlin E, Giannakas K, et al. Hip osteoarthritis: Where is the pain?
Ann Coll Surg Engl. 2004; 86:119-121.
2. Khan N, Woolson S. Referral patterns of hip pain in patients undergoing total hip replacement. Orthopedics. 1998; 21:123-126.
3. James C, Little T. Regional hip blockade. Anesthesia. 1976; 31:1060-1067.
4. Gardner E. The innervation of the hip joint. Anat Rec. 1948; 101:353-371.
5. Fortin J., Dwyer A, West S, Pier J. Sacroiliac joint: Pain referral maps upon applying a new injection/arthrography technique. Part I: Asymptomatic vaolunteers. Spine. 1994; 10:1475-1482.
6. Schwarzer A, Aprill C, Derby R, et al. Clinical features of patients with pain stemming from the lumbar zygapophyseal joints. Spine. 1994; 10:1132-1137.
7. Slipman C, Jackson H, Lipetz J, et al. Sacroiliac joint pain referral zones. Arch Phys Med Rehabil. 2000; 81:334-338.

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