The second of three new Anatomy for the Clinician sessions introduced by ACR at this year’s meeting takes place Monday morning from 8:30 – 10:00 am in Salon B.
Hip Pain, Not from the Hip Joint — Posterior Hip Pain features David A. Bong, MD, of the Poal Institute of Rheumatology in Barcelona, Spain, describing relevant structures in the posterior hip that may generate pain and explain how complimentary diagnostic procedures assist in approaching non-articular sources of pain in the hip. Dr. Bong believes these new sessions offer rheumatologists, particularly those who are interested in performing musculoskeletal ultrasound, an invaluable “refresher course” in anatomy.
“Rheumatologists all around the world, particularly in Europe and the U.S., have become very interested in musculoskeletal ultrasound and have advanced quite significantly in their abilities to do it,” Dr. Bong said. “The ability to do it, however, does require a certain knowledge of anatomy and, as rheumatologists, we haven’t really had to know a lot of anatomy, only enough to practice our specialty. Since we aren’t surgeons, who deal with anatomy daily in the operating room, our skills and knowledge in this area may have atrophied a bit.”
Posterior hip pain not related to the joint has been historically a challenging diagnosis for rheumatologists, but advances in musculoskeletal imaging, including ultrasound, have allowed for a better understanding of this complicated region of the human anatomy.
“It’s an area covered by the gluteus maximus muscle, but underneath that is an extensive network of important muscular and neurovascular structures, all of which can be affected and cause pain in this area,” Dr. Bong said. “Before these advances in imaging technology, when patients presented with buttocks pain, for example, they were commonly labeled as having the so-called ‘piriformis syndrome’ and then sent off to the physical therapist. We know now that piriformis syndrome is a diagnostic wastebasket that has been overused to the point that it’s almost meaningless.”
Dr. Bong compared this to a diagnosis of trochanteric bursitis in patients who present with lateral hip pain.
“What we’ve found, related to recent advances in anatomy and musculoskeletal ultrasound, is that lateral hip pain is really a tendinopathy related to the insertion of the gluteus medius and gluteus minimus muscle at the greater trochanter and that bursitis, as a primary pathology, is actually quite unusual in this area,” he said. “Yet, looking back over 30 years of experience in clinical practice, the number of patients I labeled inaccurately with this kind of general diagnosis of trochanteric bursitis is quite astounding, when what these people had was tendinopathy.”
Similarly, relating to the posterior hip, he said, rheumatologists are well positioned to increase their anatomical knowledge of this important region of the body, advance their skills in performing musculoskeletal ultrasound, provide more precise diagnoses, and offer more effective treatments for their patients.
“What rheumatologists bring to the table is a very disciplined way of looking at disease, and this is an area, the posterior hip, that is incredibly complex and really needs our attention,” Dr. Bong said. “Because we have accepted this additional responsibility of using musculoskeletal ultrasound, I think it’s important that we become knowledgeable on the anatomy of this area behind the hip joint. Anything that we can do to promote that learning, whether you’re an ultrasonographer or not, I think will add quality and will benefit our patients.”
CLINICAL SCIENCE TRACK
Anatomy for the Clinician: Hip Pain, Not from the Hip Joint – Posterior Hip Pain
8:30 – 10:00 am Monday • Salon B