Others (In Murtagh)
Hip And Buttock Pain
Hip and buttock pain is a clinical presentation arising from musculoskeletal, neurological, or referred sources—including osteoarthritis, bursitis, sacroiliac dysfunction, lumbar radiculopathy, or piriformis syndrome—causing discomfort in the hip joint, gluteal, or surrounding regions.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Lumbar disc herniation / sciatica | Buttock pain radiating below knee, dermatomal numbness, positive SLR [2] | 「隻痛有冇由pat pat落到去小腿、腳趾？」 | ~25% |
| Trochanteric bursitis (greater trochanteric pain syndrome) | Lateral hip pain, tender over greater trochanter, worse lying on affected side | 「瞓嗰邊痛唔痛？」(Pain lying on that side?) | ~20% | |
| Hip OA | Age > 50, groin pain worse with activity, limited IR, relieved by rest [1] | 「行路嗰陣腹股溝附近痛唔痛？」(Groin ache on walking?) | ~15% | |
| Serious Not To Miss | Neck of femur fracture (osteoporotic) | Elderly + fall + cannot weight-bear, shortened/ER limb [6] | 「有冇跌親之後行唔到？」 | ~2% |
| Malignancy (bone mets / primary bone tumour) | Constant pain, night pain, weight loss, known primary cancer | 「隻痛有冇越嚟越嚴重？夜晚痛醒？」 | ~1% | |
| Peripheral arterial disease (buttock claudication / Leriche) | Reproducible buttock/thigh cramping on walking, relieved standing still, absent femoral pulse [3] | 「行幾遠開始攰痛？停低企住幾耐好返？」 | ~1% | |
| Cauda equina syndrome | Bilateral leg symptoms, saddle anaesthesia, urinary retention | 「pat pat附近有冇痺？大小便控制得到？」 | < 1% | |
| Septic arthritis of hip | Fever, non-weight-bearing, extremely painful, ↑WBC/CRP | 「有冇發燒？隻腳完全唔夠膽踩落地？」 | < 1% | |
| Pitfalls | Spinal stenosis (neurogenic claudication) | Variable claudication distance, relief on bending forward ("park bench"), parasthesia [3] | 「彎低腰有冇舒服啲？」(Better bending forward?) | ~5% |
| Sacroiliac joint dysfunction | Localised pain over SI joint, FABER test positive | 「你指嘅痛係唔係喺pat pat呢度（指SI joint）？」 | ~4% | |
| Avascular necrosis of femoral head | Younger patient, steroid/alcohol use, groin pain, limited IR [5] | 「有冇長期食類固醇或者飲好多酒？」 | ~1% | |
| Masquerades | Depression | Widespread pain, poor sleep, low mood, anhedonia | 「心情點？有冇覺得好攰冇精神？」 | ~10% |
| Referred pain from abdominal/pelvic pathology | AAA, ovarian/pelvic mass, renal colic | 「個肚有冇脹或者痛？」 | ~2% | |
| Ankylosing spondylitis (young male) | Age < 45, insidious > 3 mo, morning stiffness > 30 min, improves with movement, not rest, starts SI joint [4] | 「你幾歲開始痛？郁下有冇好啲？」 | ~1% | |
| Trying to Tell Me Something? | Psychosocial distress / work disability | Fear of cancer, inability to work, fear of surgery, carer stress | 「呢個痛對你日常生活同工作有咩影響？你最擔心啲咩？」 | ~10% |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好！我係X醫生，今日由我負責睇你。請問我可以點稱呼你？」「你今日嚟有咩嘢想傾？」 | Interpersonal marks: greeting + open question |
| 0:30–1:30 | Chief complaint & HPI – SOCRATES for hip/buttock pain; onset, location (groin vs buttock vs lateral), radiation (to knee/leg?), character, aggravating/relieving, severity, timeline | 「隻髖骨/pat pat邊度最痛？可唔可以指俾我睇？」「痛咗幾耐？」「行路嗰陣痛唔痛？行幾遠開始痛？」「瞓覺痛唔痛醒？朝早起身有冇覺得好僵硬？」 | Distinguishes OA vs inflammatory vs referred vs vascular cause |
| 1:30–2:30 | Red flags & targeted systems review – weight loss, fever/night sweats, neuro symptoms (numbness/weakness/bladder/bowel), trauma, claudication distance, rest pain | 「有冇痺、冇力、或者大小便失禁？」「有冇發燒、出夜汗、體重輕咗？」「行路嗰陣隻腳pat pat有冇攰到要停低？休息之後得唔得返？」 | Must-not-miss: cauda equina, tumour, AVN, PAD, septic arthritis |
| 2:30–3:30 | PMH, DH, FH, Social Hx – past fractures, steroid use, DM/vascular RF, occupation, smoking, alcohol, exercise, ADL impact | 「以前有冇跌親？食緊咩藥？有冇食類固醇？」「你做咩工作㗎？有冇食煙飲酒？」「而家行路、著鞋襪、上落樓梯有冇困難？」 | Biopsychosocial assessment; identify occupation/functional impact |
| 3:30–4:30 | ICE – Ideas, Concerns, Expectations + uncover hidden agenda | 「你自己覺得呢個痛係咩嚟㗎？」「你最擔心咩嘢？」「你嚟睇醫生，最希望我幫到你啲咩？」 | ICE is directly examined in Case Report Form; hidden agenda scores high |
| 4:30–5:15 | Signpost, summarise, check understanding | 「等我總結返：你…（summarise）。我有冇聽漏咗啲咩？」 | Shows active listening and patient-centredness |
| 5:15–6:00 | Explain likely diagnosis, plan, safety-net, close | 「根據你講嘅情況，我最擔心/覺得最有可能係…我建議幫你照下X光/驗下血。如果隻腳突然冇力、大小便失禁、或者痛到完全行唔到，你要即刻返嚟急症室。」「你仲有冇嘢想問？」 | Safety-net + empowerment; closes consultation professionally |
Uncovering the hidden agenda: The patient may not come because of pain alone — they may fear cancer, worry about needing a hip replacement, have functional difficulty at work, or be anxious about disability/dependency. Always ask 「你最擔心呢個痛代表啲咩？」 (What worries you most about this pain?) early enough to address it.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Site | Where exactly is the pain? Point with one finger | 「你可唔可以用手指指邊度最痛？」 | Groin pain = true hip joint; buttock/posterior = lumbar spine/SI joint; lateral = trochanteric bursitis [1] | Groin→OA/AVN; Buttock→lumbar disc/SI joint; Lateral→bursitis |
| Onset | When did it start? Sudden or gradual? | 「幾時開始痛？係慢慢嚟定突然間嚟？」 | Acute onset + trauma → fracture; insidious → OA/AS | Fracture; OA; AS |
| Radiation | Does the pain go anywhere else – knee, leg, foot? | 「隻痛有冇落到去膝頭、腳或者腳趾？」 | Hip pathology may refer to knee [1]; buttock→leg = radiculopathy | L5 radiculopathy [2]; hip OA; sciatica |
| Character | What does it feel like – aching, sharp, cramping? | 「個痛係噏住痛、拮住痛、定抽住痛？」 | Cramping on walking → vascular claudication; deep ache → OA | PAD buttock claudication [3] |
| Aggravating | Worse with walking, stairs, rest, sitting up? | 「行路痛啲定休息痛啲？上落樓梯呢？」 | Worse with activity, better rest → OA; worse rest/night → inflammatory/tumour | OA; AS; malignancy |
| Morning stiffness | Morning stiffness? How long? | 「朝早起身有冇覺得好硬？硬幾耐？」 | > 30 min morning stiffness + age < 45 → inflammatory (AS/SpA) [4] | AS; SpA |
| Night pain | Does it wake you at night? | 「半夜有冇痛醒？」 | Night pain → tumour, infection, inflammatory | Bone tumour; AVN; AS |
| Walking distance | How far can you walk before stopping? | 「你行到幾遠先要停低？停低之後點樣好返？」 | Claudication distance → PAD; variable + improves bending → neurogenic claudication [3] | PAD (Leriche); spinal stenosis |
| Neuro symptoms | Numbness, tingling, weakness, bladder/bowel? | 「有冇痺、冇力？大小便有冇問題？」 | Cauda equina = emergency; radiculopathy level | Cauda equina; L5 radiculopathy [2] |
| Systemic | Fever, weight loss, night sweats, fatigue? | 「有冇發燒、瘦咗、出夜汗？」 | Red flags for malignancy, infection, TB | Bone mets; TB spine; septic arthritis |
| Trauma | Any fall, injury, lifting heavy objects? | 「有冇跌親或者搬重嘢？」 | Osteoporotic fracture in elderly; disc prolapse in younger [2] | NOF fracture; disc herniation |
| PMH | DM, vascular disease, cancer, steroid use, osteoporosis? | 「有冇糖尿、心臟病、癌症、骨質疏鬆？食緊類固醇？」 | Steroids → AVN [5]; DM → PAD; cancer → mets | AVN; PAD; bone mets |
| Drug Hx | Current medications? Steroids? Anticoagulants? | 「而家食緊啲咩藥？有冇食薄血丸或者類固醇？」 | Steroid → AVN; anticoagulant → haematoma | AVN; retroperitoneal bleed |
| Social Hx | Smoking? Occupation? ADL? | 「有冇食煙？做咩工作？著鞋襪自己得唔得？」 | Smoking = PAD risk; occupation → disability; ADL = functional assessment | PAD; functional impairment |
| Family Hx | Family history of arthritis, AS, cancer? | 「屋企人有冇風濕、強直性脊柱炎、或者癌症？」 | HLA-B27 association in AS; hereditary | AS; malignancy |
| Sexual/GU (if young male) | Erectile dysfunction? Urethritis? Eye inflammation? | 「有冇小便痛、眼紅或者…嗰方面功能有冇影響？」 | Leriche triad: buttock claudication + absent femoral pulses + ED [3]; reactive arthritis | PAD (Leriche); reactive arthritis/SpA |
Case Report Form Answer Builder
- CC: "Hip/buttock pain for [duration]"
- HPI must capture: Precise location (groin vs buttock vs lateral); onset and duration; character; radiation (knee? below knee?); aggravating factors (walking, stairs, rising from sitting); relieving factors (rest vs movement); morning stiffness duration; night pain; functional impact (walking distance, ADL); red flags screened (neuro deficit, systemic symptoms, trauma); relevant PMH/DH (steroids, DM, smoking)
- Examples: "Pain affecting ability to work/walk" / "Worry about needing hip replacement" / "Fear that pain may be cancer" / "Wants pain relief" / "Cannot perform ADL"
- How to phrase: Focus on the patient's expressed reason, not your medical concern. Write: "Patient consulted because of worsening hip pain limiting walking to work, and is worried it may need surgery."
| Likely Examples | Exact Wording for CRF | |
|---|---|---|
| Ideas | "I think it's wear and tear" / "Maybe a slipped disc" / "Could it be bone cancer?" | "Patient thinks the pain is due to joint wear and tear (OA)" |
| Concerns | Fear of needing hip replacement; fear of cancer; worry about being unable to work/care for family | "Patient is concerned the pain may require surgery and worried about recovery time" |
| Expectations | Wants X-ray; wants pain medication; wants referral to ortho; wants reassurance | "Patient expects an X-ray and pain relief medication" |
- Hip OA (if patient is > 50, groin/anterior thigh pain, worse with activity, stiffness after rest < 30 min, limited ROM)
- Minimum evidence: age > 50 + groin pain on activity + reduced internal rotation + no morning stiffness > 30 min
- OR Lumbar radiculopathy (if buttock pain radiating below knee + numbness/weakness + positive SLR)
- Minimum evidence: dermatomal radiation + neurological deficit + mechanism (lifting) [2]
- Choose based on the stem — pain from the hip joint = groin; pain at the back of the hip = usually lumbar spine [1]
| DDx | Key Discriminator |
|---|---|
| 1. Lumbar disc herniation / radiculopathy | Buttock pain radiating below knee, dermatomal neuro deficit, +SLR [2] |
| 2. Greater trochanteric pain syndrome (bursitis) | Lateral hip tenderness, worse lying on side, full ROM |
| 3. Peripheral arterial disease (Leriche syndrome) | Reproducible exercise-induced buttock/thigh cramping, absent femoral pulse, ±ED [3] |
(Swap in AVN, spinal stenosis, or AS depending on stem age/context)
| Domain | Problem |
|---|---|
| Biological | Progressive joint destruction / nerve compression causing pain and disability |
| Psychological | Anxiety about diagnosis (fear of cancer/surgery); frustration from pain disrupting sleep |
| Social | Impaired mobility affecting work capacity / financial strain; difficulty performing ADL (dressing, climbing stairs); social isolation |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Hip OA (most likely) | Reduced internal rotation of the hip [1] | Patient supine, hip and knee flexed to 90°; rotate foot laterally (= IR of hip). Compare sides. | Internal rotation is the first and most limited movement in hip OA; combined with groin pain on testing confirms intra-articular hip pathology [1] |
| Lumbar radiculopathy (L5) | Weakness of extensor hallucis longus (EHL) + numbness lateral leg/dorsum foot | Ask patient to dorsiflex big toe against resistance; test sensation L5 dermatome | L5 root supplies EHL; weakness + sensory loss in L5 dermatome = L5 radiculopathy [2] |
| Greater trochanteric bursitis | Point tenderness over greater trochanter | Palpate lateral hip over greater trochanter with patient lying on opposite side | Localised tenderness at trochanter with no ROM restriction differentiates from intra-articular pathology |
| PAD (Leriche) | Absent or diminished femoral pulse [3] | Palpate femoral artery at mid-inguinal point bilaterally | Absent femoral pulse + buttock claudication + ED = Leriche triad [3] |
| Ankylosing spondylitis | Positive FABER test (sacroiliac provocation) + reduced modified Schober's | FABER: Flex, Abduct, Externally Rotate hip – press knee down → pain at SI joint; Schober: mark 10 cm above PSIS → forward flex → should increase by ≥ 5 cm [4] | SI joint pain on provocation + restricted lumbar flexion = sacroiliitis |
| NOF fracture | Shortened and externally rotated limb; unable to SLR | Inspect limb position supine; measure limb length (ASIS to medial malleolus) [6] | Classic posture of displaced NOF fracture; real shortening confirms fracture above knee |
Top Traps That Lose Marks
- Confusing hip joint pain with buttock/back pain — True hip joint pain is felt in the GROIN, not the buttock. Pain at the back of the hip is usually from the lumbar spine [1]. This distinction drives your entire DDx.
- Forgetting hip pathology can present as KNEE pain only — always examine the hip when a patient presents with knee pain [1].
- Missing vascular claudication — buttock claudication from aortoiliac disease mimics hip/buttock pain; always check femoral pulses and ask about claudication distance and ED [3].
- Missing cauda equina red flags — bilateral leg symptoms, saddle anaesthesia, bladder/bowel dysfunction → emergency MRI and referral.
- Not asking about steroids/alcohol → misses AVN of femoral head in younger patients [5].
- Forgetting ICE — the Case Report Form awards separate marks for ICE; must ask explicitly.
- Writing the DDx location wrongly — if the patient points to the lateral hip, think trochanteric bursitis, NOT hip OA.
Must-Not-Miss Red Flags → Urgent Referral:
- Cauda equina: bilateral neuro deficit + saddle anaesthesia + bladder dysfunction → same-day emergency
- Septic arthritis: fever + unable to weight-bear + red hot joint → same-day emergency
- Pathological fracture / bone tumour: night pain + weight loss + known cancer → urgent ortho/oncology
- Critical limb ischaemia: rest pain, absent pulses, tissue loss → same-day vascular
Safety-net line (closing): 「如果你突然隻腳冇力、大小便控制唔到、或者發高燒，你要即刻去急症室，唔好等。」 (If you suddenly lose leg strength, lose bladder/bowel control, or develop high fever, go to A&E immediately — don't wait.)
High-yield GC lecture points:
- Pain arising in the hip joint is felt in the groin, down the front of the thigh and sometimes in the knee; pain at the BACK of the hip is seldom from the joint — it usually derives from the lumbar spine [1]
- Trendelenburg test: standing on affected leg → pelvis tilts DOWN on opposite side = positive = gluteal weakness (e.g. hip OA, NOF fracture) [1]
- Thomas' test reveals fixed flexion deformity hidden by lumbar lordosis [1]
- Internal rotation is the first movement lost in hip OA [1]
- Hip OA: pain in groin after activity, positive Trendelenburg, limited IR, X-ray shows decreased joint space + osteophytes + subarticular sclerosis [1]
- L5 radiculopathy: buttock pain radiating to lateral leg/dorsum foot, EHL weakness, normal ankle jerk [2]
- Leriche syndrome: buttock claudication + absent femoral pulses + ED [3]
- AS: inflammatory back/buttock pain — age < 45, > 3 months, insidious, morning stiffness > 30 min, improves with movement, starts at SI joint [4]
High Yield Summary
What to ASK: Precise pain location (groin vs buttock vs lateral); radiation to knee/below knee; morning stiffness duration; claudication distance; neuro symptoms; red flags (systemic, bladder/bowel); steroid/alcohol use; ICE.
What to WRITE: CC with location and duration; HPI covering SOCRATES + red flag screen + functional impact; RFC as patient's own words; ICE explicitly; most likely Dx with 3 supporting features; 3 DDx with discriminators; biopsychosocial problems; one physical sign (reduced IR for OA, +SLR/EHL weakness for L5, absent femoral pulse for PAD).
What NOT to MISS: Cauda equina, septic arthritis, malignancy, PAD/Leriche, AVN (steroids). Always check femoral pulses. True hip = groin pain; buttock pain = spine until proven otherwise.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: LL exam Clinical Skill Practice Session 2023.pdf (pp. 39–42, 59) — Hip clinical assessment, Trendelenburg test, Thomas' test, ROM, OA features [2] Past papers: 2022 Fourth Summative MCQ.pdf (Q16) — L5 radiculopathy: buttock pain, lateral leg numbness, EHL weakness, normal ankle jerk [3] Senior notes: Ryan Ho Cardiology.pdf (pp. 205–206) — Intermittent claudication, Leriche syndrome triad, vascular vs neurogenic claudication [4] Senior notes: Maksim Medicine Notes.pdf (p. 324) — Ankylosing spondylitis: inflammatory back/buttock pain criteria, FABER test, modified Schober test [5] Senior notes: MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (p. 730) — AVN of femoral head from steroid use / SLE vasculitis [6] Past papers: 2022 Fourth Summative MCQ.pdf (Q17) — NOF fracture: undisplaced fracture, DEXA T-score, clinical features
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