Addie Brooks: A 52-Year-Old Woman With Right Hip and Groin Pain

Learning Objectives

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Learn the common causes of hip pain.
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Develop an understanding of the unique anatomy of the hip joint.
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Develop an understanding of the causes of hip joint arthritis.
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Learn the clinical presentation of osteoarthritis of the hip joint.
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Learn how to use physical examination to identify pathology of the hip joint.
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Develop an understanding of the treatment options for osteoarthritis of the hip joint.
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Learn the appropriate testing options to help diagnose osteoarthritis of the hip joint.
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Learn to identify red flags waving in patients who present with hip pain.
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Develop an understanding of the role in interventional pain management in the treatment of hip pain.

Addie Brooks

Addie Brooks is a 52-year-old rancher with the chief complaint of, “I’ve got a hitch in my git-along.” Addie went on to say that she wouldn’t have bothered coming in, but “it is coming up on calving season and those cows gotta eat.” I asked Addie if anything like this has happened before. She shook her head and said, “You can’t run cattle and not have something aching or paining. But this hitch is really wearing me out, and the old heating pad and aspirin just aren’t cutting the mustard. Doc, I wouldn’t complain, but I can barely get moving in the morning because my sleep is all jacked up. It hurts every time I roll over on that damn right hip. Hell, some mornings I just want to sit down and cry. Doc, can you just give me a quick shot or something to get me through calving season? You know as well as anybody if I don’t get those calves to market, my kids and I don’t eat.”

I asked Addie about any antecedent trauma to the right hip. She thought about it for a minute and said that she got thrown from her horse onto her right hip when she was a teenager. She went on to say that Old Doc Jones “thought I just sprained my hip and I would be fine, and until the last few weeks when I was unloading bales of hay, he was right. He was a real crackerjack—Old Doc Jones. He delivered my mom and he delivered me. We put a lot of stock in whatever Doc Jones told us and always did what he said.”

I asked Addie to point with one finger to show me where it hurts the most. She pointed to the front of her right groin and said, “Doc, I got a hitch right here, especially when I first get up in the morning. The crazy thing is, sometimes I feel like the hip is popping or catching.” I asked if she had any fever or chills and she shook her head no. “What about steroids? Did you ever take any cortisone or drugs like that?” Addie again shook her head no and said, “Doc, you know me. I am healthy as a horse. I love working the ranch, but this hitch has really got me down for the count.” Addie denied any other gynecologic symptoms or blood in her urine.

On physical examination, Addie was afebrile. Her respirations were 18 and her pulse was 74 and regular. Her blood pressure (BP) was normal at 122/74. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. I did a rectal exam and pelvic, which were both normal. Visual inspection of the right groin and hip revealed no cutaneous lesions or obvious hernia or other abnormal mass. The area overlying the right hip was cool to touch. Palpation of the right hip revealed mild diffuse tenderness, with no obvious effusion or point tenderness. There was mild crepitus, but I did not appreciate any popping or catching. Range of motion was decreased, with pain exacerbated with active and passive range of motion. When I performed the Patrick (FABER: flexion, abduction, external rotation) test on the right hip, Addie cried out in pain and said, “Doc, that’s the hitch in my git-along!” ( Fig. 1.1 ). The left hip examination was normal, as was examination of her other major joints, other than some mild osteoarthritis in the right hand. A careful neurologic examination of the upper and lower extremities revealed that there was no evidence of peripheral or entrapment neuropathy and the deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

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A distant history of acute trauma to the right hip secondary to falling from a horse
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No history of previous significant hip pain other than the short-term pain secondary to the acute hip trauma
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No fever or chills
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Gradual onset of right groin and hip pain over the last several weeks with exacerbation of pain with hip use
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Popping sensation in the right hip
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Sleep disturbance
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Difficulty walking secondary to pain upon first arising from the supine or recumbent position

The Physical Examination

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The patient is afebrile
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Normal visual inspection of hip
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Palpation of right hip reveals diffuse tenderness
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No point tenderness
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No increased temperature of right hip
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Crepitus to palpation
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Positive Patrick (FABER) test on the right (see Fig. 1.1 )

Other Findings of Note

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Normal BP
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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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No groin mass or inguinal hernia
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No CVA tenderness
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Normal pelvic exam
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Normal rectal exam
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Normal upper extremity neurologic examination, motor and sensory examination
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Examination of joints other than the right hip were normal

What Tests Would You Like to Order?

The following tests were ordered:

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Plain radiographs of the right hip

Test Results

The plain radiographs of the right hip revealed significant joint space narrowing and osteophyte formation consistent with severe osteoarthritis ( Fig. 1.2 ).