The most informative examination of the hip joint. Hip examination

23.07.2021

The most complete answers to questions on the topic: "diagnosis of the disease hip joint".

The advanced age of many patients, the burden of concomitant diseases, the often observed excess body weight, physical inactivity caused by the underlying pathology - all this dictates the need for a comprehensive examination of patients. A careful approach to determining indications and contraindications for surgical treatment due to the fact that most operations on hip joint are very traumatic and are accompanied by significant blood loss. In addition, it must be remembered that the cause of some lesions of the hip joint, for example, avascular necrosis of the femoral head, can be systemic diseases (systemic lupus erythematosus, scleroderma, etc.) or taking hormonal drugs.

General examination of patients is usually carried out on an outpatient basis and includes: examination by a therapist and, if indicated, a neurologist, cardiologist, endocrinologist, pulmonologist, urologist, gastroenterologist, as well as other specialists; performing a clinical analysis of blood and urine, determining the duration of bleeding and blood clotting time; biochemical blood test with determination of levels of sugar, bilirubin, creatinine, transaminases, prothrombin index, Australian antigen and carriage of HIV infection. Instrumental research includes ECG, fluorography; If indicated, X-rays or MRIs of the lumbosacral spine are performed. Based on a comprehensive examination and expert opinion, preoperative preparation is carried out, upon completion of which the anesthesiologist, together with the surgeon, based on the scope of the proposed operation, determines the degree of anesthetic and surgical risk, as well as the strategy for medicinal perioperative protection.

Examination of the function of the hip joint is based on assessing the severity of pain, position and supportability of the limb, range of motion, state of the muscular system, shortening of the limb, functional state of the contralateral hip and knee joints, and lumbar spine. Highest value Patients' complaints include pain, which is the reason for visiting a doctor. Pain in the hip joint with coxarthrosis intensifies with load or movement and is felt primarily in groin area. However, it can radiate along the anterior and lateral surfaces of the thigh to the gluteal region, to the anterior part of the knee joint and along the anterior surface of the lower leg to the ankle joint. Sometimes the only manifestation of damage to the hip joint may be pain in the knee joint, for example, with initial stages aseptic necrosis of the femoral head (AFH).

Pain caused by diseases of the hip joint has a wide and variable irradiation (often in the initial stages of ANFH patients are treated for a long time and unsuccessfully for radiculitis or gonarthrosis), and it must be differentiated from the pain syndrome that occurs with other diseases: sacroiliitis, trochanteric bursitis, adductor enthesopathy muscles, neuropathy of the lateral cutaneous nerve of the thigh, prolapse of intervertebral discs with the appearance of radicular pain, symphysitis. There are anterior (inguinal), lateral (trochanteric) and posterior (gluteal) localizations of the pain syndrome. The most important and prognostically unfavorable is groin pain, which is usually associated with intra-articular pathology. Lateral pain is most often caused by bursitis of the trochanteric region and less often by coxarthrosis. Pain in the gluteal region is associated with spinal pathology or changes in the muscles. Difficulties in determining the source of pain are due to a number of anatomical and physiological features of the structure of the lumbar spine and hip joint. Firstly, the joint is innervated by the LIV (LIII) root of the spinal cord, so its irritation in vertebrogenic pathology and diseases of the hip joint can cause a similar pain syndrome. Secondly, there is a commonality of autonomic innervation of the structural elements of the lumbar motor segments and the tissues of the hip joint. Thirdly, with lumbar osteochondrosis, spondyloarthrosis and spondylolisthesis, zones of neuroosteofibrosis often form, due to the common autonomic innervation of the elements of the lumbar spine and hip joint. Fourthly, degenerative-dystrophic diseases (DDD) of the spine are characterized by the presence of myotonic reflex syndromes, many of which resemble symptoms of coxarthrosis.

From the anamnesis, we find out the intensity and nature of the pain, its presence at rest, whether it goes away with rest, whether the patient needs analgesics, whether the pain affects his lifestyle, whether it forces him to give up his usual activities, and how it affects him. professional activity. At the end of the conversation, it is necessary to ask the patient to formulate a request: what would he like to receive as a result of surgical treatment.

Assessment of joint function consists of determining the degree of daily activity and gait. The concept of daily activity includes the ability to climb stairs and use public transport, freedom and time of movement, the use of additional support when walking, the ability to put on socks and boots. Gait is characterized by the degree of support on the leg, lameness and the distance that the patient can walk. The data obtained are entered into the examination protocol of a patient with pathology of the hip joint.

The patient is examined in an upright position, while walking and lying down. When examining in an upright position, you need to pay attention to the following signs:

Pelvic tilt, which is determined by the different levels of the anterior superior spines. The cause of the tilt may be damage to the hip joint with the development of adduction or abduction contracture, shortening of the leg, or primary scoliosis.
Rotational deformity, which is determined by the rotation of the patella and foot. The most common cause of external placement of the leg is unresolved anterior hip dislocation and dysplastic coxarthrosis in the later stages of the disease. Internal rotation is observed in the consequences of a fracture of the posterior parts of the acetabulum, as well as in posterior hip dislocation.
Emphasized lumbar lordosis, which may be caused by a fixed flexion contracture of one or both hip joints.
Muscle atrophy: secondary when the hip joint is damaged due to physical inactivity of the limb and primary when the muscles are damaged or neurological disease. Its degree is determined by measuring with a measuring tape at three levels of the hip.
The Trendelenburg test reveals significant weakness of the hip abductors (gluteus medius and minimus). Ask the patient to lift one leg off the floor. Normally, to maintain balance, the abductor muscles on the weight-bearing side contract and lift the opposite side (Figure 1). If the abductors are weak, the pelvis may “collapse” on the opposite side, and the patient loses balance/

Fig.1. Trendelenburg test:
a – normal; b – with pathology.

Most common reasons positive test Trendelenburg are diseases of the hip joint, damage to the Lv. When examining a patient while walking, two types of nonspecific gait disturbances are usually observed:

an antiphagic gait usually indicates a painful hip joint - the patient shortens the time of the phase of transferring body weight to the affected joint, as if jumping over the affected side, to avoid painful contraction of the hip abductor muscles;
Trendelenburg gait (abductor lameness) indicates weakness of the abductor muscles on the part of the pathologically altered hip joint. While walking when transferring the body to the affected side opposite side the pelvis drops down and the body tilts to the healthy side. When affected bilaterally, it resembles a “duck walk.”

When examining a patient in a supine position, it is necessary to make sure that both anterior superior spines are located at the same level and that the legs lie parallel. Please pay attention to the following violations.

1. Deformity, especially fixed flexion contracture, external rotation or adduction contracture. They often develop sequentially as hip disease progresses (Fig. 2a). With significant flexion contracture, the patient cannot fully straighten the leg until he sits on the couch. With a fixed adduction contracture, the affected limb may cross the healthy leg; any attempt to abduct the hip is accompanied by pain and leads to pelvic distortion. Decreased hip flexion may be compensated by increased lumbosacral lordosis, which masks a fixed flexion contracture. If this contracture is not clearly identified, then the Thomas test can be used. Lumbar lordosis is eliminated by bending the second leg at the hip joint to an angle of 90° (the position of the spine is controlled by placing a hand under the back), and at the same time the position of the test leg is monitored (Fig. 2b).

There is no laboratory test to determine the presence of hip osteoarthritis. Therefore, the physician must use a comprehensive approach to diagnose the cause of a patient's hip pain, starting with interviewing the patient and physical examination. In this article we will look at how to diagnose arthrosis of the hip joint.

Your doctor may order diagnostic imaging, such as an X-ray or MRI, to help confirm osteoarthritis. Doctors may also use laboratory tests to rule out other possible conditions, such as.

The methods used to diagnose hip osteoarthritis are the same as those used to diagnose knee osteoarthritis. However, in general, hip osteoarthritis can be a little more difficult to diagnose. Because hip pain can be more widespread, radiating into the back and legs, and mimic other conditions such as sacroiliac joint dysfunction.

Below is a more detailed description of the process doctors use to determine whether hip pain is due to osteoarthritis.

How to diagnose hip arthrosis

Patient interview. During the appointment, the doctor should ask the patient to describe the symptoms, including the onset and pattern of pain and swelling, and how the symptoms affect their lifestyle. Patient reports of symptoms are important for diagnosis and treatment.

Physical examination. The doctor will check your hip's range of motion and examine it for swelling and pain. The doctor will also evaluate the patient's gait.

Testing. The doctor learns a lot from interviewing the patient and physical examination. He or she will likely also order follow-up tests as part of the diagnostic process to get more information about the extent of arthritis in the hip or to rule out others possible reasons patient pain.

X-rays. Hip degeneration is indicated on x-ray by the loss of joint space between the femur and the acetabulum of the pelvis. X-rays may also show bone spurs or osteophytes. Osteophytes are a normal sign of aging, as almost everyone over 50 years old experiences them. And they can get larger as the bones try to compensate for the loss of cartilage. Growing bones can create additional friction and lead to pain.

A patient may have an x-ray that shows significant signs of osteoarthritis in the hip joint, called radiographic osteoarthritis of the hip, and yet have no pain. In contrast, some patients may not exhibit noticeable radiographic osteoarthritis but experience significant pain if damaged cartilage or bony osteophytes are in a sensitive location. Therefore, x-rays are just one tool that can be used in conjunction with patient interview and physical examination.

How to diagnose hip arthrosis using MRI. (MRI) may be ordered for additional information because this test provides images of soft tissue (ligaments, tendons, and muscles) as well as bone. A doctor may order an MRI if the X-rays are inconclusive or the doctor suspects something other than osteoarthritis. In most cases, an MRI is not necessary as it takes longer, requires the patient to remain completely still for approximately 30 minutes, and is significantly more expensive than an X-ray.

Laboratory tests cannot identify the presence of hip osteoarthritis, but they can be used to rule out other problems, such as infection or gout, that can also cause hip pain. Laboratory tests may require blood draws or aspiration of the hip joint.

Arthrosis of any localization can be treated better the earlier it is started. Advanced arthrosis of the hip joint leads to disability, so its treatment must be started in a timely manner. But if treatment is carried out at random, it may not only not help, but also worsen the situation, so first you need to make a correct diagnosis. Accurate diagnosis of coxarthrosis is especially important, since due to the localization of pain, this disease is often mistaken for others, and vice versa. When making a diagnosis, it is necessary to rely on the results of a survey and physical examination of the patient, x-rays, and laboratory tests. There are other methods for diagnosing arthrosis of the hip joints.

Examination procedure

Making a diagnosis of coxarthrosis begins with studying the medical history and analyzing the patient’s complaints. Particular attention should be paid to cases of arthrosis in the family history; the presence in the patient’s life history of such diseases and pathologies:

hip dysplasia;
previous injuries to the hip joint, leg;
chronic vascular, endocrine, metabolic disorders;
hip joint (coxitis);
flat feet, scoliosis;
osteochondropathy (aseptic necrosis of the femoral head, Perthes disease)

The patient, as a rule, complains of a feeling of stiffness, pain in the groin, hip, and less often in the knee joint. If the disease has progressed far enough, the range of motion in the joint is limited. After the interview, the doctor conducts examination, palpation, auscultation, and functional tests to assess range of motion. On early stage coxarthrosis examination does not reveal any deviations from the norm; later the doctor notes the following points:

the patient leans on the toes of the sore foot and limps when walking;
the pelvis is skewed, tilted towards the affected leg;
the leg is bent at the hip joint and does not fully straighten;
when trying to lean on the entire foot, the buttock on the affected side drops significantly;
lumbar lordosis becomes more pronounced;
the diseased leg is shorter than the healthy one, its muscles are atrophied (at stage 2 this can be detected by measurements, at stage 3 changes can be noticeable);
when the patient lies on his back, the position of the legs is asymmetrical;
gait is waddling, tied legs syndrome is observed.

Palpation of the joint is painful; with deep palpation, a violation of the boundaries of the joint and its deformation can be detected. Performing passive movements in the joint is accompanied by crepitus (crunching, creaking), the doctor’s palm feels resistance and springing. A number of tests are performed to assess range of motion; its reduction is typical for stages 2–3 of the disease.

After completing a personal examination of the patient, the doctor necessarily prescribes x-rays of the hip joints and tests. In complex, doubtful cases, the following are additionally prescribed:

Ultrasound of the joint;
CT or MRI;
joint puncture and analysis of synovial fluid.

Range of motion assessment

The hip joints undergo movements in 3 planes, their normal volume (in degrees) is:

flexion – approximately 120;
extension – 15;
casting – 30;
lead – 40;
external and internal rotation –45.

At stage 1 of coxarthrosis of the hip joint, no noticeable deviations from the norm are noted, at stage 2 the angle of abduction and internal rotation decreases, at stage 3 the volume of all movements in the joint is significantly reduced.

All functions, in addition to extension, are checked with the patient lying on his back, extension - in the prone position. Flexion assessment. The patient bends his leg at the knee, relaxing it as much as possible. hips. The doctor, clasping the ankle with one hand and placing the other on the knee, tries to bring the front surface of the thigh as close as possible to the patient’s stomach and chest.
Lead. The patient straightens his leg, the doctor fixes the iliac crest with one hand on the side opposite to the joint being examined. With the second hand he moves his leg to the side, holding it by the shin.
Adduction is assessed in the same position, the leg that is in this moment not checked, it must be moved to the side by about 30°. The test leg is adducted, trying to achieve its contact with the abducted one, not forgetting to fix the pelvis.
To assess internal and external rotation, the leg is bent at the knee, held by the knee and heel, the shin is rotated in and out, and the thigh is rotated along with it.
Extension. The patient turns over on his stomach, the doctor places one hand on the lumbar rhombus to prevent elevation of the pelvis. With the other hand, clasps the front surface of the thigh just above the knee and lifts the straightened leg.

All tests are carried out for both joints, and the results obtained are compared. Also, for unilateral coxarthrosis, it is recommended to measure the length of both legs. The absolute and relative length of each leg (measured using different bony landmarks) and both indicators for the right and left legs are compared.

X-ray examination

The main method for diagnosing arthrosis of the hip joint is x-ray. It allows you to visualize the changes that occur in bone tissue. Usually the picture is taken in a direct projection; the doctor may decide to perform additional radiography in other projections. The most reliable assessment of the width of the joint space is provided by separate radiography, which achieves optimal centration (the central beam passes through the center of the femoral head). But with this approach, the radiation dose increases. For unilateral and bilateral coxarthrosis, a photograph of both hip joints is taken. If the process is one-sided, changes in the diseased joint are more noticeable against the background of the healthy one.

Coxarthrosis is manifested by the following radiological signs:

narrowing of the joint space, from slight, uneven at stage 1 to thread-like at stage 3;
osteophytes. At first they are pointlike, localized along the edge of the acetabulum, then they enlarge, extend beyond the articular labrum, and at a late stage cover the head of the femur;
subchondral osteosclerosis (increased bone density under the cartilage), the severity of which gradually increases. First, foci of osteosclerosis form in the area of the acetabulum, then in the upper part of the femoral head;
single or multiple cysts (voids in bone tissue) in areas of maximum load;
bone deformities.

The edges of the fossa are sharpened, where the round ligament is attached to the head of the femur. The head of the femur gradually acquires a mushroom shape, then flattens and grows in width, and the neck becomes thicker and shorter. There is ossification of the cartilaginous articular lip running along the edge of the acetabulum. The floor of the acetabulum may become thinner, resulting in an increase in its depth.

If a large wedge-shaped osteophyte forms in the middle part of the cavity, the femoral head is displaced, shifted sideways and upward, and its subluxation is visible on the picture. Coxarthrosis is often accompanied by cyst-like restructuring of bone tissue (an optional sign of arthrosis), but free bodies (articular mice) are rarely detected by x-rays.

Other diagnostic methods

Tests for joint diseases are prescribed for the differential diagnosis of arthrosis and arthritis. Minimum set: general and biochemical blood tests, general analysis urine. With arthrosis, no abnormalities in the blood picture are detected, and a urine test is normal. Severe signs of inflammation (significant increase in ESR and leukocyte levels). Biochemical analysis and rheumatic tests help determine the nature of inflammation. A microscopic examination of the synovial fluid, for the collection of which a puncture is performed, is highly informative. This procedure is usually resorted to in cases of severe inflammation of a presumably infectious nature in order to identify the pathogen.

CT (computed tomography) and MRI (magnetic resonance therapy) are more informative compared to x-rays. CT allows you to obtain images of the joint from different angles, in the form of many sections. This way you can identify changes that go unnoticed with x-rays. CT and X-ray are designed to examine the hard tissues of the joint, and MRI allows you to visualize changes in cartilage, synovium and the outer layer of the joint capsule, muscles, ligaments, tendons. Ultrasound is the most informative in inflammatory processes, since it allows one to assess the volume of inflammatory effusion and changes in the characteristics of synovial fluid.

There is also an invasive method for diagnosing joint diseases - arthroscopy. A type of endoscope is inserted into the joint cavity through a small incision or puncture. Such diagnostics are resorted to in complex cases when other methods are not sufficiently informative, as well as before arthroscopic operations.

Differential diagnosis

Focusing only on clinical symptoms, coxarthrosis is often mistaken for other diseases. Most informative method differential diagnosis is x-ray, but you can also focus on some features of clinical symptoms, in particular pain. With inflammation of the femoral tendons (trochanteritis), the pain is similar to arthrosis, but the mobility of the leg is not limited, and there are no radiological changes. With damage to the lumbar spine (radicular syndrome, piriformis muscle syndrome), the pain increases rapidly, usually after unsuccessful movement or stress, and is equally pronounced day and night.

With coxarthrosis, referred pain never falls below the middle of the lower leg. In diseases of the spine, they can reach the tips of the toes. Bends forward and lifting the straight leg are accompanied by sharp pain, pain and limitation of mobility during leg abduction and rotational movements in the hip joint are not noted.

With arthritis, pain is felt mainly at night, morning stiffness lasts longer than half an hour, tests indicate an inflammatory process. If the patient complains of pain in the knee joint, and his X-ray does not reveal changes characteristic of gonarthrosis, a series of functional tests and an X-ray of the hip joint should be performed.

Although it manifests itself with quite characteristic symptoms, specialists often make mistakes when making a diagnosis. One of them is due to the fact that doctors look at the image, rely on the conclusion of the radiologist, but neglect the personal examination of the patient.

The opposite extreme is when the doctor focuses on the patient’s complaints and makes a diagnosis based on subjective symptoms, without sending him for an x-ray. To make an accurate diagnosis, a comprehensive examination is necessary: examination, functional tests, x-rays and other imaging methods, laboratory tests. Making a diagnosis is complicated by the fact that coxarthrosis often occurs in combination with osteochondrosis and coxitis.