Hip problems can cause back pain
When to wait, when to transfer?
Patients with functional disorders of the musculoskeletal system often go to the family doctor in the first instance and receive initial treatment from them. This article provides an overview of two symptoms that general practitioners are confronted with on a regular basis: pain in the lumbar spine and hip pain. Important examination techniques are summarized and indicators are presented which should lead to a referral to a specialist.
Pain and dysfunction of the musculoskeletal system are common, increase with age and are usually harmless. The context in which these complaints occur provides important information as to whether it is more of a harmless or a more serious clinical picture. Pain after unfamiliar physical activity without adequate trauma can usually be interpreted as an overload reaction and is harmless. Very painful and pressure-sensitive tendon attachments, so-called trigger points, are often found in the stressed body region. The surrounding musculature can show pronounced induration (muscle tension) with considerable tenderness. Generalized pain in the musculoskeletal system can also be of parainfectious or rheumatic origin. In the following, the procedure for pain in the lumbar spine and hip pain is explained as an example.
Back pain is the most common type of pain in women and men of all ages . In Germany they cause direct costs of 8.4 billion euros per year , 4% of the total workforce in Germany is lost due to inability to work due to back pain . Low back pain is the fourth most common cause of a doctor's visit  and the most common reason for inability to work and early retirement .
Specific or Non-Specific Low Back Pain?
The distinction between the generally harmless non-specific low back pain and the specific low back pain is central to any general practitioner therapy. The rarer specific low back pain has a defined anatomical / neurophysiological cause. In this case, the targeted and early specialist diagnosis and treatment must be initiated promptly .
To identify the urgency of a specialist outpatient or even emergency inpatient treatment, a so-called “diagnostic triage” based on warning signals (“red flags”) should be carried out. These are pre-existing conditions and symptoms that indicate a specific cause that needs urgent treatment. The areas of fracture, tumor and infection must be clarified based on anamnestic. An orienting neurological examination can rule out the presence of nerve damage (Table 1).
Non-specific low back pain is pain that is triggered without identifiable anatomical and neurophysiological causes. They are usually harmless and make up the largest proportion of patients with low back pain.
- Lack of the "red flags" typical anamnesis (pain after special or unusual stress without significant trauma, e.g. heavy lifting, longer forced postures)
- Pain is often localized in the lower lumbar spine (lumbar spine) or in the lumbosacral junction
- no pounding pain over the spine
- painful restriction of movement of the spine (inclination and reclination pain)
- Paravertebral muscle tension
- negative Lasègue test
- no radicular dermatome-related pain radiation
- no neurological failures
Radicular or pseudoradicular?
Leg pain may also be present if there is pain in the lower lumbar spine and in the lumbosacral junction. Here, the differentiation between radicular pain radiation, as found in a herniated disc with compression of a nerve root, and the rather harmless pseudoradicular pain radiation is crucial. The latter is characterized by a diffuse radiation of pain that does not follow a dermatome pattern, mostly limited to the pelvis and thighs, without sensorimotor deficits.
If there is leg pain, an orienting neurological examination, especially of the dermatomes and key muscles L4 - S1, has to rule out acute radiculopathy as well as severe arterial circulatory disorders, a thrombosis and a coxal cause.
Early diagnostic imaging does not improve the quality of treatment per se  and is therefore primarily not indicated for non-specific low back pain. The chronification of low back pain, on the other hand, can be aggravated by overestimating the disease and the detailed interpretation of imaging findings and lead to stigmatization of those affected. It is helpful to convey the good prognosis and harmlessness of the disease to the patient. Long-term sick leave should be avoided if possible because of the secondary gain in illness, the economic damage and the stigmatization of the patient mentioned.
Therapy of non-specific low back pain
Non-specific low back pain can usually be adequately treated at the general practitioner level:
- Early pain-adapted mobilization, no immobilizing bed rest
- Adequate pain medication according to the WHO scheme: NSAIDs can primarily be used effectively, taking the contraindications into account
- Warmth in the area of the paravertebral muscles
- if necessary physiotherapy, but not in the acute, painful phase
In contrast to older adults, in whom coxarthrosis dominates as the cause of pain, hip pain in children can indicate a more serious illness (see Table 2) and therefore always requires (children) an orthopedic specialist clarification.
Acute hip pain in young and middle adulthood can be caused by femoral head necrosis. Particularly affected are patients with nicotine and alcohol abuse as well as patients under chemotherapy or steroid therapy. Likewise, a lesion of the acetabular labrum or synovitis can cause hip pain in this age group. A swift orthopedic clarification should take place here.
The hip joint is the joint most commonly affected by osteoarthritis. Coxarthrosis is particularly common in advanced age. The prevalence of symptomatic coxarthrosis in people over 60 years of age in Germany is given as 5–6% . In 2011, the disease led to the implantation of around 210,000 artificial hip joints in Germany alone .
If coxarthrosis occurs at an advanced age, it is most likely to be primary, i.e. fatal, coxarthrosis. On the other hand, if the disease occurs earlier, secondary coxarthrosis is likely (see Table 2).
Symptoms of hip joint affection
In the case of hip joint affection, the inguinal pain is the most prominent, as the hip joint is located centrally under the inguinal ligament. The patients usually complain of drawing to stabbing inguinally accentuated pain that can radiate into the greater trochanter region. Typical of coxarthrosis are pain during and after physical exertion with provocation, especially when walking and standing for long periods, as well as starting pain. Sporty patients often experience the first symptoms of stress while jogging. Coxarthrosis can hide behind a supposed hernia! Inguinal or femoral hernias, insertion tendons, adductor strains, bursitides and meralgia paraesthetica nocturna are to be included in the differential diagnosis.
As the osteoarthritis progresses, there is an increasing painful restriction of movement. Patients often report that they are no longer able to put on stockings and shoes themselves because of the hindrance to their terminal flexion and rotation. Later on, there are pains at rest, sometimes with considerable sleep disturbance. If left untreated, the range of motion continues to decrease.
Examination findings with hip joint affection
Basically, a typical pathological gait pattern, the Duchenne limp, is noticeable in painful hip joint affections. In the stance phase, the upper body is bent over the affected hip joint. This means that the hip abductors do not have to be tensed as much, and the femoral head is pressed less forcefully into the socket. When standing on one leg, the contralateral pelvis sinks (positive Trendelenburg sign, Fig. 1).
During the movement test using the neutral-zero method, a painful restriction in flexion and internal rotation is particularly noticeable. A hip flexion contracture is often concealed by anterior tilting of the pelvis and hollow back and can be objectified using the Thomas handle (Figs. 2 and 3).
Diagnostics and therapy
To confirm the diagnosis of coxarthrosis, a conventional X-ray image in two planes is sufficient (anterior-posterior beam path and Lauenstein image). Further imaging examinations, especially MRI, are only indicated for specific questions and should be arranged by the orthopedic surgeon.
Hip pain in older patients without risk factors can initially be treated symptomatically under the responsibility of a general practitioner:
- Physical conservation
- Short-term administration of NSAIDs under stomach protection in the absence of contraindications in acute phases
- Mobilizing and joint-centering KG with traction treatment of the hip
- Soft, sturdy footwear
If there is no improvement in the symptoms, a specialist orthopedic assessment should be carried out.
Hip pain that occurs in younger patients, especially in children, should be immediately referred to a specialist orthopedic or, if possible, pediatric orthopedic assessment, as the cause may be relevant diseases that require urgent treatment. Likewise, patients with immobilizing hip pain should be referred directly to a specialist.
If the diagnosis of primary coxarthrosis has been confirmed, artificial joint replacement (total endoprosthesis) represents the last stage of therapy if, despite symptomatic conservative therapy, quality of life and mobility are significantly impaired. The choice of implant depends on the individual's biological age, any existing comorbidities, bone quality and anatomy, and the patient's expectations.
Reliable prognoses on the progression of osteoarthritis are difficult in individual cases. In contrast to "rapid coxarthrosis", there can be years between the onset of symptoms and the indication for surgery. After the radiological confirmation of the diagnosis and advice from the orthopedic surgeon, the functional and drug therapy can also be carried out responsibly by the family doctor, whereby regular (annual) follow-up checks by the specialist are recommended. The orthopedic surgeon should also be consulted in the event of acute deterioration.
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