2021年最新观点 | 成年人髋关节疼痛：临床评估和鉴别诊断

来源：北京大学人民医院骨关节科
译者：陶可，李儒军

摘要

成年人常会因髋关节疼痛而去看医生，病因诊断对于开出有效的治疗方案很重要。髋关节疼痛通常位于髋关节的前方、外侧或后方。髋关节前方疼痛包括腹内或骨盆内原因引起的牵涉痛；髋关节外病因，如屈髋肌（髂腰肌）损伤；和关节内病因，而髋关节内病因通常由年轻人的盂唇撕裂或股骨髋臼撞击症或老年人的骨关节炎引起。

髋关节外侧疼痛最常由股骨大转子疼痛综合征引起，包括臀中肌肌腱病（炎）或撕裂、滑囊炎和髂胫束摩擦症。髋关节后方疼痛包括牵涉痛，如腰椎病理学改变、深部臀肌综合征伴坐骨神经卡压、坐骨股骨撞击症和腘绳肌腱病（炎）。

除了病史和体格检查外，可能还需要X线片、超声检查或磁共振成像（MRI, 双髋/单髋）来明确诊断。髋关节和骨盆的放射学检查（X线片/CT/MRI）应该是首要的影像学检查。超声引导下的麻醉（关节腔）穿刺有助于关节内疼痛的病因确诊。由于股骨髋臼撞击症、盂唇撕裂和臀中肌腱撕裂通常具有良好的手术效果，因此合理有效的影像学检查和/或早期诊断可能会改善患者的预后。

髋关节疼痛在所有年龄和活动水平的成年人中都均很常见。在非专业成年足球运动员中，臀关节和腹股沟受伤占女性所有伤害的28%至45%，占男性所有伤害的49%至55%。凸轮型畸形（股骨头畸形）的患病率在非专业男性足球运动员中为41%，而在男性非运动员中为17%。在45岁以上成年人中，6.7%至9.7%患有髋骨关节炎，1/4的成年人一生中会患上有症状的髋骨关节炎。在美国，2009年髋关节置换术的医疗卫生费用为137亿美元。

成年人髋关节疼痛-评估方法

（1）髋关节疼痛通常位于以下三个位置：前方、外侧或后方（图1）。重点询问病史和体格检查有助于区分髋关节疼痛的原因（表1）。诊断髋关节疼痛的原因对于制定有效的治疗方案很重要。

（2）病史应询问包括发育性髋关节发育不良、股骨头骨骺滑脱、体育活动和外伤史；髋关节疾病的家族史；以及疼痛的部位和性质、加重和减轻因素、机械症状。

（3）体格检查应包括步态分析，特别注意痛性步态或Trendelenburg步态（臀中肌），评估髋关节活动范围和相关疼痛，髋关节周围肌肉力量的测试，疼痛区域的触诊和特殊查体。

（4）如果要对患有无法确定的髋关节慢性疼痛的患者进行影像学评估时，站立位髋关节正位和骨盆X线片检查，通常是首选的影像学检查。根据病史和体格检查结果，磁共振成像（MRI）或超声检查可能有助于诊断。

临床推荐

图1.髋关节疼痛的定位。（A）前方图示。（B）后方图示。

表1

图2.股骨髋臼撞击症的原因。钳夹型畸形是由髋臼过度覆盖引起的，当髋关节屈曲时，这会导致盂唇在髋臼和股骨头之间受到撞击（挤压）。当沿着股骨头颈的外生骨撞击髋臼盂唇时，会发生凸轮型畸形。

图3.屈髋内收内旋试验。检查者（A）被动弯曲，然后（B）内收和内旋髋关节。如果在髋关节前方/腹股沟区出现疼痛，则检测结果为阳性。

图4.屈髋外展外旋试验。检查者（A）被动弯曲，然后（B）外展和外旋髋关节。如果在髋关节前方/腹股沟区出现疼痛，则检测结果为阳性。

图5.臀肌肌腱病测试。（A）改良Trendelenburg试验。让患者站在患侧下肢/髋关节，抬起另一条腿30秒。如果髂嵴低于站立侧，表明髋关节外展肌（臀肌）无力，则结果为阳性。（B）外旋对抗测试。当患者躺在桌子上时，髋关节被动屈曲90°，然后外旋。要求患者将下肢返回到与工作台相同的轴向（0度旋转），推动检查者（对抗）的手。如果疼痛出现在髋关节外侧，则结果为阳性。

图6.坐位梨状肌牵拉试验。患者坐位，髋关节屈曲90°。检查者伸展膝关节，被动将髋关节内收和内旋，同时触诊坐骨外侧。如果梨状肌再现疼痛，则结果为阳性。

图7.长距离步幅测试。指导患者在未受影响的腿上迈出很长的一步，臀关节向前。这会缩小小转子与后方（受影响的）髋关节坐骨之间的距离，这可以再现坐骨股骨撞击症的疼痛。

文献出处：

Rachel Chamberlain. Hip Pain in Adults: Evaluation and Differential Diagnosis. Am Fam Physician. 2021 Jan 15;103(2):81-89.

原文阅读

Hip Pain in Adults: Evaluation and Differential Diagnosis

Abstract

Adults commonly present to their family physicians with hip pain, and diagnosing the cause is important for prescribing effective therapy. Hip pain is usually located anteriorly, laterally, or posteriorly. Anterior hip pain includes referred pain from intra-abdominal or intrapelvic causes; extra-articular etiologies, such as hip flexor injuries; and intra-articular etiologies. Intra-articular pain is often caused by a labral tear or femoroacetabular impingement in younger adults or osteoarthritis in older adults. Lateral hip pain is most commonly caused by greater trochanteric pain syndrome, which includes gluteus medius tendinopathy or tear, bursitis, and iliotibial band friction. Posterior hip pain includes referred pain such as lumbar spinal pathology, deep gluteal syndrome with sciatic nerve entrapment, ischiofemoral impingement, and hamstring tendinopathy. In addition to the history and physical examination, radiography, ultrasonography, or magnetic resonance imaging may be needed for a definitive diagnosis. Radiography of the hip and pelvis should be the initial imaging test. Ultrasound-guided anesthetic injections can aid in the diagnosis of an intra-articular cause of pain. Because femoroacetabular impingement, labral tears, and gluteus medius tendon tears typically have good surgical outcomes, advanced imaging and/or early referral may improve patient outcomes.

Hip pain is common in adults of all ages and activity levels. In nonelite adult soccer players, hip and groin injuries represent 28% to 45% of all injuries in women and 49% to 55% in men. The prevalence of the cam deformity (deformity of the femoral head) is 41% in nonelite male soccer players and 17% in male nonathletes.2 In adults older than 45 years, 6.7% to 9.7% have osteoarthritis of the hip, and one in four adults will develop symptomatic hip osteoarthritis in their lifetime.3 In the United States in 2009, hip replacements accounted for $13.7 billion in health care costs.3

Approach to Evaluation

Hip pain is often localized to one of three locations: anterior, lateral, or posterior (Figure 14). A focused history and physical examination can help differentiate the causes of hip pain (Table 1). Diagnosing the cause of hip pain is important for prescribing effective therapy.

The history should include personal history of developmental hip dysplasia, slipped capital femoral epiphysis, sports activities, and injuries; family history of hip problems; and the location and quality of pain, aggravating and alleviating factors, and mechanical symptoms. Physical examination should include gait analysis with particular attention to antalgic or Trendelenburg gait, evaluation of the range of motion in the hip joint and associated pain, strength testing of the muscles overlying the hip joint, palpation of the painful area, and special tests as indicated.

If imaging is performed in the evaluation of a patient with undifferentiated chronic hip pain, standing anteroposterior hip and pelvic radiography is typically the initial imaging study. Magnetic resonance imaging (MRI) or ultrasonography may be helpful in the diagnosis, depending on history and physical examination findings.