Coxalgia

Definition

Coxalgia is hip pain originating in the constituent structures of the hip joint.

Aetiology

There are many causes for coxalgia, the most common being osteoarthritis and bursitis of the hip.

Osteoarthritis of the hip is strongly related to age (> 50 year); other factors such as congenital diseases, certain sports, and accidents involving the hip, may also play a role in the development of osteoarthritis of the hip. Obesity does not play a role in the development of hip osteoarthritis, but does aggravate pre-existing hip osteoarthritis. The development of bursitis of the hip is clearly associated with pre-existing osteoarthritis of the knee or hip, and with pre-existing back problems. The prevalence of hip osteoarthritis varies from 0.4 to 27%.

Trochanteric bursitis is also seen in patients with no hip osteoarthritis and has a unilateral prevalence of 15% (females) and 6.0% (males) and a bilateral prevalence of 8.5% (females) and 1.9% (males). Already existing osteoarthritis of the knee and hip, and low back pain have a clear relationship with trochanteric bursitis.

Signs and symptoms

The patient may feel pain radiating in the front and outer side of the thigh down to the knee, accompanied by pain in the groin. Patients also complain of morning stiffness that disappears within an hour of rising.

In hip bursitis, the pain is felt above the hip joint and on the side of the upper leg, radiating to the knee and sometimes down to the ankle. Patients mainly complain of pain at night when lying on the affected hip.

Diagnostics

Physical Examination

In coxalgia, examination of the lower back, pelvis and knee is mandatory. Since patients mainly complain of pain in the groin, it is also important to examine this. Neurological examination can exclude radiculopathy of L2 and L3.

In coxalgia, active and passive flexion, internal rotation, external rotation and extension are evaluated. Passive flexion of the hip < 115o and passive internal rotation <15o, together with typical anamnesis, point in the direction of hip osteoarthritis.

In addition, a number of SI tests, such as the SI compression test, SI distraction test, Patrick test, Gaenslen test, Thigh Thrust test, Fortin finger test and Gillet test must be performed in order to exclude SI pathology, since this pathology can also give rise to groin pain.

Furthermore, 'red flags' such as tumours, fractures, femur head necrosis, and infections must be excluded.

In hip bursitis, it is important to put local pressure on the greater trochanter in order to demonstrate painful bursitis of the hip.

Additional Somatic Diagnostics

  • X-rays hips.
  • Ultrasound when there is suspicion of trochanteric bursitis.
  • RAND-36 (quality of life)
  • VAS Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Additional Psycho-cognitive Diagnostics

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis.  Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment comprising various non-somatic treatments may be necessary.

Non-somatic Treatment

Somatic Treatment

Pharmacological treatment:

  • NSAIDs
  • Cox-2 remmers

Other Treatments

Interventional Pain Treatment

Invasive Treatment

  • In serious and therapy-resistant osteoarthritis of the hip with major functional restrictions, referral to an orthopaedic surgeon is indicated.