Understanding Your Symptoms

Pain originating from any cause within or around the hip joint will be felt in the groin, the front of the thigh, the inner thigh, the knee, the knobbly bone felt on the side of the hip or the deep/lower buttock area.  The pain may begin in any area mentioned above or any combination of these.

Mechanical back pain which comes from the spine will usually be felt in the midline or across the lower back and upper buttock zones.  This pain will not usually cause a limp, but may, and can often be influenced by body position.

Neurogenic back pain (nerve irritation in the back) can be felt anywhere that a particular nerve provides sensory input from or sends impulses too.  So, any of the nerve roots originating from the lower back (lumbar spine) being impinged upon or irritated may result in pain anywhere in the lower leg without any pain being felt in the back itself.

A clinician’s job is to tease out the source of the pain and define the pathological cause before recommending any form of targeted treatment.

Again, the hip joint as a source of pathology will give passive stiffness or restricted range of motion, start-up discomfort (getting out of a chair to stand for example) can be noted to improve subsequently with motion then become painful again if too much is done.  Usually muscle and tendon pain will not improve and be there from the start.  Direct pressure on a muscle and/or tendon will give pain as opposed to the hip joint which is difficult to palpate and/or localise as it is a deep structure.  Unfortunately, tendinitis and/or joint pathology may coincide and make matters more complicated with respect to a diagnosis.

The groin is a large anatomical area and a point of referral from many sources.  From the hip joint perspective pain is felt in the groin crease, middle to outside, or mid-groin crease to front of thigh or the inner thigh.  Generally pain from the hip that is felt in the groin will also cause a painful limp as opposed to other causes.  Other sources of groin pain also usually do not cause restricted passive range of motion for the hip, i.e., no stiffness.  Orthopaedically speaking, the groin does not equate to the hip joint and in fact consists of the attachment points for the adductor muscles onto the symphysis pubis or pubic bone as well as the attachment of the lower abdominal muscles to the pubic bone and this also includes the structures that exit the inguinal canal and femoral canal.  Any one of these structures can be a source of pain.

Generally, this pain is indistinguishable as the referral pattern is the same, however bone pain will be more intense and not allow any weight-bearing.  Bone is very sensitive to pressure change, so banging on the rest of the leg will cause pain in the hip if there is bone pathology. Also bone pain can persist even when at rest.

Examples are:

Stress fractures of the femoral neck

Bone lesions (tumours, benign or malignant)

Problems with bone metabolism or turnover (Paget’s disease)

Bone infection

Bone-on-bone joint destruction (cartilage wear and tear or osteoarthritis)

The hip joint is intrinsically a stable and constrained joint which acts as a base of operations for the rest of the leg and specifically the knee.  The knee is very dependent upon its ligamentous structures and joint capsule as well as the muscles and tendons around it for stability.  The hip can however become unstable with injury to its labrum and/or capsule or because there is a form of dysplasia where the socket is shallow or mal-orientated.  Patients may often present with knee pain while the knee is actually normal and the culprit is the hip joint which can often refer pain exclusively to the knee.

Pain is a part of life.  As we age there will be more and more potential sources of pain in the body.  It is important to recognise when to pay attention to any pain felt.  Any pain which persists and/or recurs with similar and/or worsening intensity over a 4 to 6 week period should not be ignored but rather looked into in more detail.  Any pain which is persistent at rest and/or even into the evenings disrupting one’s sleep should be taken seriously.  Any pain associated with systemic symptoms of feeling ill or poorly should likewise be taken seriously.

For example:

You see a physiotherapist and and/or take medications for groin pain which helps but the pain keeps recurring over a six-week period. Do not ignore this and stick your head in the sand, rather consult a specialist and be investigated.  A simple x-ray can often reveal diagnoses such as stress fractures and/or bone lesions which you may put down to just a groin strain, but in fact is a more serious condition.

In systemic disease a patient may often present with joint pain.  This can take the form of many joints involved or a single joint, however, the joint is an innocent bystander or part of a symptom complex relating to a generalised systemic disease.

Examples would include:

All the immune related disorders and/or rheumatological diseases. A common one you may have heard of is gout, which will negatively affect the joint but is in actual fact related to poor renal excretion of urate.

Joint pain secondary to systemic disease is centred on inflammation of the synovial membrane which produces joint lubrication (synovial) fluid. An inflamed synovium, otherwise known as “synovitis” is the reason for the joint pain and stiffness.  These pathologies are treated by specialist physicians known as rheumatologists.  This is not surgical treatment but medical treatment.  The medical treatment is aimed at preventing the long-term consequences of chronic synovitis i.e. cartilage destruction.  The end stage of this process will result in the need for joint replacement surgery.  Sometimes one could consider arthroscopic or keyhole surgery to perform a synovial biopsy to aid in diagnosis and/or indeed removal of the synovial lining (synovectomy), as much as possible to minimise the inflammation while gaining medical control of the inflammatory process.