What red flags did you exclude?
- ? malignancy | No nocturnal pain or weight loss
- ? inflammatory | No morning stiffness, swelling, warmth or redness
- ? neurological | No radiation down the legs, no weakness/numbness
- ? referred | No bowel or bladder symptoms, not related to periods, no discharge, not pregnant
Isn’t hip pain in adults without red flags basically OA or greater trochanteric syndrome?
Those are usually what I think of. However, in younger, more active adults it’s worth thinking about hip impingement (femoroacetabular Impingement). This is caused by extra bony prominences. It is especially common when the developing skeleton has been subjected to stressors, like an athlete or if there has been a SUFE for example.
What helped distinguish FAI from plain OA or GTS?
I did a FADIR test which reproduced the pain. I had not done this before and used reputable online sources to help me do it accurately. Another clue was that specific movements triggered the pain, as opposed to it being a general “background” pain. There was also no tronchanter pain on pressing. That said, it’s still possible there could be a mix of multiple types of hip pain. Clicking/catching/locking can also occur.
Why does it matter to distinguish? Surely at this stage it’s just physio and analgesia anyway?
If suspecting FAI, a pelvic X-ray is recommended, partly to exclude other causes. Many primary care referral pathways also recommend referral to orthopaedics, as there is an increased risk of labral tears with FAI, and surgery may have a role if not improving with 3 months of physio. In this case, we did the X-ray and I also sought advice and guidance from orthopaedics, as they may wish to see her at an earlier stage.
How did seeing a younger adult with atraumatic but subacute hip pain make you feel?
I realise I'm used to hip pain in children and older adults, but younger adults with hip pain is not something I tend to think about much. My mind initially went towards treating it like an unfortunately young person to get older person-type hip pain, but I realise there are some differentials more common at this age. I learnt the importance of specialist examinations like FADIR in these less common presentations, and the importance of not defaulting to what I'm used to, but rather considering the presentation afresh with an open mind and not being afraid to look things up if it does not fit with a classic pattern.
Useful resources
A Patient's Guide to Femoroacetabular Impingement Syndrome (FAI Syndrome)