There are important muscles which attach to the outer prominence of the thigh bone (greater trochanter of the femur) by wide flat tendons. The bony prominence is lubricated from the overlying skin by a fluid filled sac called the trochanteric bursa. This bursa can become inflamed (bursitis) because of overuse or due to small tears in the broad flat tendons of the gluteus medius and minimus. Pain is felt over this prominent area and the cardinal feature is that is painful to lie on the affected side. Diagnosis is confirmed on MRI or ultrasound scans and by excluding other hip conditions: occasionally pain coming from the hip joint is felt in this area.
The mainstay of treatment is injections of a cocktail of local anaesthetic and anti-inflammatory steroid into the area, ideally whilst visualising the area by ultrasound to ensure accuracy. Whilst two or three injections are sufficient for the majority of patients, more refractory cases may require injection with platelet rich plasma (PRP). This is a new, but promising, technique which delivers the body’s own healing factors directly to the damaged area. Surgery for trochanteric pain is used as a last resort because its success rate is only 50-65%.
Young women commonly experience clicking at the front of the hip. This is due to the tendon of the psoas muscle flicking either side of the prominence of the hip joint as it passes from inside the pelvis to its attachment at the top of the femur. This is usually entirely normal. However an increase in clicking associated with pain may warrant attention as it may indicate other problems in the hip joint such as hip dysplasia or a labral tear. Diagnosis is confirmed with a dynamic ultrasound scan and by excluding other hip conditions with X-ray, MRI and possible CT scan.
Provided there are no other hip conditions, the mainstay of treatment is physiotherapy to stretch the tendon and strengthen the muscles of the hip girdle and core. Occasionally an injection of a cocktail of local anaesthetic and anti-inflammatory steroid into the tendon as it passes over the hip joint is necessary. Very rarely arthroscopic surgical release of the tendon is necessary; this may be done arthroscopically or open determined by the circumstances.
Snapping ilio-tibial band (ITB)
The ilio-tibial band (ITB) is a ribbon of fibrous tissue that originates on the outside of the pelvis and attaches to the outer side of the knee. As it passes over the outside of the hip it may flick in front of and behind the bony prominence (greater trochanter) causing clicking or pain from trochanteric bursitis. The condition is most common in young women. Provided there are no other hip conditions, the mainstay of treatment is physiotherapy to stretch the ITB and strengthen the muscles of the hip girdle and core.Occasionally an injection of a cocktail of local anaesthetic and anti-inflammatory steroid into the tendon as it passes over the trochanter is necessary. Surgical release of the ITB is very successful but is only occasionally required.
Whilst avascular necrosis (AVN) can affect many areas of the skeleton, its consequences are perhaps most serious when it affects the head of the femur: the ball of the ball and socket joint. Usually no cause is identified but it may follow severe fractures round the hip, prolonged treatment with steroids (often in the context of kidney disease or chemotherapy), alcohol abuse and various metabolic disorders. Sickle cell disease is the commonest cause of AVN in Mr Bankes’ practice and he has extensive experience of treating the condition in this patient group.
The condition is characterised by disruption to the blood supply of the femoral head, making the bone extremely painful. Pain in the groin and upper thigh that tends to be particularly bad at night in the presence of a normal range of motion are the hallmarks of early disease. Intervention at this early stage to decompress bone by drilling (core decompression) can relieve pain and stimulate healing of the bone, provided not too much bone is affected.
Bisphosphonate therapy may also be helpful in the early stages. As well as being painful, dead bone is also soft and so the affected area may collapse, leading to flattening of the femoral head. In addition the cartilage no longer adheres to the dead bone. These two factors combine to produce secondary osteoarthritis. In this circumstance total hip replacement may be necessary when there are significant progressive symptoms.Given the improvement in results of hip replacements in younger patients, there has been a move away from femoral osteotomy and vascularised fibular bone graft procedures.