Pain in the Butt!
June 6, 2013
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.