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Hip girdle pain is defined as pain in the buttock that radiates into the thigh.  It is a common problem, particularly in the older person. Although there are many possible causes of this condition, most are found to be  degenerative disease of the hip joint (osteoarthritis), the lumbar spine (facet arthritis, lumbar stenosis) or the buttock tendons (tendinopathy, “trochanteric bursitis”) at their attachment to the greater trochanter, the bony bump just forward of one`s pants pocket.

The history given by the patient is often similar in the three conditions:  pain in the buttock radiating into the thigh and sometimes into the outer leg below the knee. This pain typically worsens with activity and improves with rest. The physical exam, though occasionally diagnostic, more often is non-specific, failing to implicate one specific area of pain generation more than another.

X-ray and MRI are often employed in the diagnostic testing and are excellent at showing degenerative disease of the hip and spine and, to a lesser extent, the tendons.  Positive findings on the films, however, do not provide a definitive diagnosis, as those degenerative changes may be simply age related and not causing any of the symptoms experienced by the patient.

At this point in the systematic search for a diagnosis, the orthopedist must answer several questions:

• Do the arthritic changes seen on x-ray and MRI play any role in the patient’s symptom production?
• Is there one site that is the primary pain generator and are the other pain producing sites merely secondary (“compensatory”*) or are there two or more sites equally responsible for producing the pain?
• What additional diagnostic testing would provide the most information with the least risk?  

To answer these questions we often turn to steroid/anesthetic injections in our quest for a specific diagnosis.  The three sites of injection are the hip joint (osteoarthritis), the lumbar spine (facet arthritis, lumbar stenosis) and the greater trochanter (tendinopathy, trochanteric bursitis).   We begin our injection sequence at the site that is the prime suspect and wait for several days to properly gauge a response.  If the response is a 50% reduction in pain then injecting the other two sites is unnecessary, as the prime pain generator has been identified. If the injection response is equivocal we move on to the second site, and if that too is indecisive, on to the third. In the rare event that all three are non-diagnostic, we expand our search to include uncommon causes of hip girdle pain.

Once we have our diagnosis, the treatment is focused on that condition. Effective treatment for the primary condition often markedly diminishes the symptoms from the secondary sites.

Treatment for all three conditions initially involves physical therapy, each program tailored to the specific pathology or abnormality.  In many cases, the injection used for diagnosis is therapeutic as well as diagnostic, with pain relief lasting months.  

Sometimes conservative treatment yields only short-term relief. In these situations, depending on the diagnosis, total hip replacement for osteoarthritis or decompression of the lumbar spine for lumbar stenosis yields very good to excellent results. Surgery for trochanteric bursitis is less common, but would involve repair of a tear, if present, of the buttock tendons attachment to the greater trochanter.

“Pain in the butt” is a popular cliché with good reason, for the complaint is common and the symptoms annoying. The list of possible causes of hip girdle pain is long and complex, and making the diagnosis can be both challenging for the orthopedist and frustrating for the patient. Fortunately, most hip girdle pain is due to common degenerative changes about the hip and low back, conditions for which treatment is available and rewarding.

* This term refers to the overuse of a muscle that is compensating for the underuse of the injured area. 

SHOULDER PAIN – The Big Three

“My shoulder hurts, Doc”.  This is a common complaint heard by the orthopedist. The history is remarkably consistent:  gradual onset of increasing shoulder and upper arm pain, with or without a preceding, usually minor, injury.

The diagnosis is most often one of three conditions we`ll call “the Big Three”:  Rotator Cuff Tedinopathy, Adhesive Capsulitis, and Osteoarthritis of the Shoulder. Though similar in presentation, these conditions differ markedly in pathology (what is wrong anatomically and microscopically) and etiology or cause.

• Rotator cuff tendinopathy is a common problem in which shoulder motion, though full, is painful. This pain is worsened when the arm is used away from the body, as in throwing a ball.  The underlying cause of this condition is degenerative: fraying of the cuff’s attachment to bone. This wear and tear phenomenon is not surprising given the stress these short muscle undergo counterbalancing their long lever, the arm.
• Adhesive capsulitis or “frozen shoulder” is characterized by stiffness with marked pain at the extremes of motion. These people cannot reach around to scratch their backs, and throwing off the bed covers in the morning causes severe pain.  The pathology in this entity consists of an inflamed capsule that thickens and undergoes contracture, all of which lead to pain and loss of motion.  The etiology is unknown, but autoimmunity is believed to play a role.
• Osteoarthritis of the shoulder joint is characterized by gradual onset of pain and stiffness with the pain being less intense than the previous two conditions.  Here, the joint surface becomes rough and worn, reducing motion and inducing a dull low grade pain. The origin of osteoarthritis is multifactorial and may include prior trauma or a genetic propensity.

Initial treatment for each of the Big Three is conservative, consisting of physical therapy (stretching, strengthening, education on care of the shoulder for the particular diagnosis), a steroid injection and a measure of time, the latter based on knowledge of the natural history of the particular condition.  In rotator cuff tendinopathy, surgery is considered if conservative therapy fails to bring relief after a few months or initially if there is suspicion that the cuff had been torn by a precipitating injury.  An MRI is almost always used in the surgical decision making.  Frozen shoulder is a self limiting disease, though its protracted course of 6-18 months can try the patience of both doctor and patient.   Steroids injected into the shoulder joint within the first few months of onset can sometimes dramatically reduce pain and shorten the natural course. The shoulder joint afflicted with osteoarthritis often tolerates its burden surprisingly well. A regular program of stretching and strengthening is often all that is needed to maintain reasonable function and a pain level that is tolerable.  For those patients with recalcitrant pain and stiffness, shoulder replacement offers an excellent alternative.

With the possible exception of low back pain, shoulder pain is the most common complaint heard in a general orthopedic practice. Although there are many causes, the vast majority are one of the Big Three, with rotator cuff dysfunction being by far the most common.  Fortunately, in most cases, proper education and rehabilitation can return this complex but fascinating structure we call the shoulder to a high level of function.

This is an update on Osteoporosis (OP) and Fragility Fractures (FFs), conditions initially introduced in our October and December 2010 columns.  I recommend a review of those earlier columns. A brief summary is as follows:     

• OP is defined as “thin bones “and is due to inadequate calcification of the skeleton
• FFs are fractures through these weakened bones and occur following minor trauma
• Bisphosphonates (BPs) are a class of drugs proven to reduce the risk of FFs and improve skeletal calcification
• Post menopausal women are at high risk for developing OP

 OP and its sequelae, FFs, are increasing at an alarming rate in the United States. There are more FFs each year than heart attacks, strokes and new cases of breast cancer combined.

A program of exercise, adequate calcium/Vitamin D intake (especially during the prime growth years of 8-18) and, when indicated, BPs, has been proven to reduce significantly the risk of OP and its complications. Despite this evidence, misconceptions and distrust abound, keeping compliance and participation low.

Let us review some fears, facts, and current thinking on OP.

         Fear: “Bisphosphonates cause femur (thigh bone) fractures rather than prevent them.”

Fact:  BPs can cause femur fractures, but it’s rare. Actually, BPs prevent as many as 100 femur fractures to every one they may cause.  This rare event, moreover, seems to occur in persons taking BPs for longer than 5 years, the point at which many patients can safely stop the drug as their bone mass may well have stabilized.

         Fear:  “Calcium supplements can cause heart attacks”

Fact:  This causal relationship, though implied in recent studies, has not been proven.  Because of this possible connection, however, the recommendation is to obtain most of one’s daily calcium requirement through dietary means.  Dietary calcium has not been linked to heart attacks.

         Fear:  “OP is the accepted cost of aging and FFs are relatively uncommon, especially if one is careful”

Fact:  Fifty per cent of women over age 50 will have a FF in their lifetime. This serious complication of OP is largely a preventable condition if prophylactic recommendations are followed.  Being careful is not enough.

Here are the current OP recommendations for all adults over 40:

1. All post-menopausal women need to be screened for OP
2. Everyone with a FF, regardless of age or sex, needs to be evaluated and treated for OP; without treatment, the chance of a second FF is very high
3.  Take 1000-1200mg of Calcium (dietary preferred) and 400-800 IU of Vitamin D supplements each day
4. Engage in daily weight bearing exercises using the upper extremities as well as the lowers
5. Do not smoke
6. Limit alcohol to no more than two drinks a day
7. Take BPs if prescribed; while taking BPs, be cognizant of any persistent thigh pain and report it to your doctor. After 5 years of continuous use of BPs, discuss possible cessation with your doctor; do not stop them on your own

 OP, like Hypertension, is a silent disease, slowly progressing without causing symptoms.  In both conditions proactive treatment will avert serious complications.

NHOC will be open during regular business hours on Monday 12/24, and also regular business hours on Monday 12/31. We will be closed on Tuesday 12/25, but a physician will be on-call for emergencies as always.

We all know that to be successful in a sport we must get in shape. Did you know the same principle applies to surgery? Just as running a marathon takes its toll on the body, so does surgery. Recovering optimally from both requires planning and preparation.

Stop Smoking

Even a few weeks of not smoking prior to surgery reduces the risk of post op breathing complications. This has particular importance to the orthopedic surgeon since smoking impairs bone healing.

Stop Excess Alcohol Intake

What constitutes “heavy drinking” is somewhat controversial, and its effect on liver function varies from person to person. If you have more than 2 to 3 drinks a day, however, consider stopping or at least reducing your intake well before your surgery date. The liver breaks down many of the medications used during your hospitalization. You want it at its best.

Exercise

Continue to exercise, even if it causes some discomfort. There are very few medical conditions that are not helped by exercise. Athletes, regardless of age, tend to be “quick healers” . This is in large part due to their commitment to exercise. By staying active right up until surgery, you too can be “athletic” and improve your chances for a rapid recovery.

Eat Healthfully

Poor nutrition can impair wound healing. If your diet is not balanced, and you think you might be malnourished, talk to your primary physician. A dietary consultation and/or blood tests can determine if you would benefit from nutritional supplements prior to and after surgery. Remember, overweight people can be just as malnourished as thin people.

Address Emotional Issues

Anxiety and depression can have a detrimental effect on your post op functional recovery. Make sure you understand the reasons for surgery and the rehabilitation goals expected of you after surgery. If you feel you need emotional support, talk to your surgeon or primary physician. He or she will refer you to the appropriate professional.

Unlike emergencies, elective surgery gives us a chance to plan ahead. “Getting in shape” makes good medical sense.