译者：陶可 北京大学人民医院骨关节科

髋关节疼痛的鉴别诊断范围很广，包括关节内病变、关节外病变和骨盆环的其他关节。随着当前关节镜技术的进步，越来越多的患者正在接受关节疼痛评估。近年来，我们对髋关节周围功能解剖学的理解有所提高。此外，由于磁共振成像的进步，髋关节疼痛软组织原因的诊断得到了改善。所有这些进步都拓宽了髋关节周围疼痛的鉴别诊断，并改进了这些问题的治疗。在这篇综述中，我们讨论了可以通过关节镜解决的髋关节内疼痛的原因：盂唇撕裂、游离体、股骨髋臼撞击症、关节囊松弛、圆韧带撕裂和软骨损伤等。此外，还讨论了可以通过关节镜进行治疗的关节外诊断，包括：髂腰肌肌腱炎、“关节内”弹响髋、“关节外”弹响髋、髂胫束和大转子滑囊炎，以及臀肌肌腱损伤。最后，我们讨论了髋关节疼痛的关节外原因，这些原因通常以非手术方式或开放方式处理：股骨颈应力性骨折、内收肌劳损、梨状肌综合征、骶髂关节疼痛、运动性耻骨痛、“运动疝”、“ Gilmore腹股沟”和耻骨炎。

随着当前髋关节镜手术的快速增长，越来越多的患者被推荐采用髋关节镜评估髋关节疼痛。这些患者中有许多是运动员，不愿意限制他们的活动，或者，对于专业或大学运动员，由于髋关节疼痛而退出运动。因此，近年来，对髋关节周围功能解剖的理解得到了改进和完善。此外，磁共振成像(MRI)的进步提高了诊断髋关节疼痛软组织原因的能力。所有这些进步显着拓宽了关节周围疼痛的鉴别诊断，并改善了我们对这些问题的治疗(表1)。

直到最近才更好地了解导致髋关节疼痛的几种情况。髋关节周围的疼痛通常通过长期的保守治疗来治疗，例如活动限制，如果失败，则开放手术。其中许多患者目前正在接受髋关节镜治疗，并且在完全恢复活动方面取得了巨大成功，包括各级体育活动。然而，并非所有髋关节周围疼痛的原因都是关节内的，也不是所有的都可以通过关节镜治疗。区分髋关节疼痛的各种原因对于治疗这些患者很重要。在这篇综述中，我们讨论了髋部周围疼痛的各种原因、做出诊断的关键以及循证治疗。

结论：髋关节和腹股沟区疼痛的鉴别诊断范围很广，包括关节内病变、关节外软组织和肌腱病变以及构成骨盆环的其他各个关节。髋关节疼痛的许多潜在原因都有重叠的症状或体检结果。仔细的病史和体格检查，结合适当的影像学检查和诊断或（髋关节囊内/外）治疗注射通常会有助于正确的诊断和适当的治疗。

表1.髋关节周围疼痛的原因

关节内：盂唇撕裂*；游离体*；股骨髋臼撞击症大*；关节囊松弛*；圆韧带断裂*；软骨损伤*

关节外：髂腰肌肌腱炎*；髂胫束紧张*；臀中肌或臀小肌*；大转子滑囊炎*；应力性骨折；内收肌紧张；梨状肌综合征*；骶髂关节病变

髋关节模拟器：运动性耻骨痛；运动疝；耻骨炎

图1.盂唇撕裂经常与凸轮撞击有关，如这些T1和T2加权MRI扫描所示。

(A)股骨头颈交界处的偏移量和非球面度(圆形)增加，导致头颈交界处出现特征性的骨“隆起”(粗箭头)，如T1图像所示。(B)在同一患者的T2加权图像中显示了前头颈交界处的盂唇病变(更长的细箭头)。

图2.滑膜软骨瘤病是髋关节内多种有症状的游离体的原因之一。使用钆造影剂或磁共振关节造影的MRl成像可用于识别软骨游离体。

(A)髋关节滑膜软骨瘤病的矢状位和(B)轴向T1加权磁共振成像扫描。箭头表示关节囊内的游离体。（A 髖臼；FH 股骨头；GT 大转子；I 坐骨。)

图3.(A)凸轮型股骨髋臼撞击症表明股骨头颈交界处的偏心距减小。(B)在屈曲和内旋时，头部的非球面部分在软骨/盂唇过渡区产生剪切，导致周围软骨损伤。(C)钳夹型股骨髋臼撞击症显示局部和/或整体髋臼过度覆盖。(D)在屈曲时，股骨颈紧靠髋臼边缘，挤压盂唇。随着时间的推移，髋臼中增生骨赘的慢性杠杄作用会导致后下髋臼的软骨损伤。

图4.(A)髋臼撞击症在股骨头颈交界处的撞击性骨病变(箭头)的关节镜图像，其特征是与盂唇（L）邻接并导致（现已修复的）盂唇撕裂（星号）。

(B)病变的关节镜下磨锉骨成形术（闭合箭头可）减轻盂唇撞击。

(C)屈曲髋关节的关节镜图像，显示关节镜下磨锉骨成形术（闭合箭头）后盂唇（L）撞击减轻。星号表示盂唇修复。

图5.松散和多余的关节囊可能是非创伤性（髋关节）不稳定的原因或结果。此外，类似于肩部，这可能导致继发性撞击和相关的前盂唇撕裂。对于保守治疗后仍持续髋关节疼痛的患者，关节镜下关节囊切开术

（A）以及随后的盂唇修复和关节囊折叠（紧缩缝合）术通过外侧和内侧髂带（B）可以恢复关节稳定性并解决疼痛。

图6.（A）关节囊切开术和骨成形术（实心箭头）后关节囊松弛和继发性股骨髋臼撞击症的关节囊外的关节镜图像显示凸轮撞击。

（B）类似于肩关节松弛的治疗，在盂唇修复和其他关节内手术后进行不可吸收缝合线（星号）的关节囊折叠（紧缩缝合）。在此图像中，在背景中可见第二个已完成的紧缩缝合针迹。(C 关节囊；FH 股骨头。)

图7.在凸轮型股骨髋臼撞击症中，髋臼软骨分层是由于髋关节屈曲时持续的剪切力造成的。

（A）邻近盂唇撕裂（已经修复，弯曲的开放箭头）的髋臼软骨分层（直箭头）的关节镜图像。（B）病变的基底部可以微骨折并用聚二恶烷酮缝合线（译者注：可吸收缝合线）（星号）缝合修复。（C）已完成的软骨修复（星号）直接覆盖盂唇修复（弯开箭头）。(A 髋臼；FH 股骨头；L 盂唇。）

文献出处: Lisa M Tibor,Jon K Sekiya.Differential diagnosis of pain around the hip joint. Arthroscopy,2008 Dec;24(12):1407-21.

Differential diagnosis of pain around the hip joint

Abstract

The differential diagnosis of hip pain is broad and includes intra-articular pathology,extra- articular pathology,and mimickers,including the joints of the pelvic ring.With the current advancements in hip arthroscopy,more patients are being evaluated for hip pain recent years, our understanding of the functional anatomy around the hip has improved addition,because ofadvancements in magnetic resonance imaging,the diagnosis of soft tissue causes of hip pain has improved.All of these  advances have broadened the differential diagnosis of pain around the hip joint and improved the treatment of these problems. In this review.we discuss the causes of intra articular hip pain that can be addressed arthroscopically:labral tears,loose bodies femoroacetabular impingement,capsular laxity,tears of the ligamentum teres,and chondral damage.Extra-articular diagnoses that can be managed arthroscopically are also discussed,including: iliopsoas tendonitis, internal snapping hip,external snapping hip,iliotibial band and greater trochanteric bursitis,and gluteal tendon injury.Finally,we discuss extra-articular causes of hip pain that are often managed nonoperatively or in an open fashion: femoral neck stress fracture,adductor strain piriformis syndrome,sacroiliac joint pain athletic pubalgia,sports hernia,Gilmores groin,and osteitis pubis.

With the current explosion in hip arthroscopy procedures,patients are being referred in ever increasing numbers for the evaluation of hip pain.Many of these patients are athletic and unwilling to limit their activity or,in the case of a professional or collegiate athlete retire from their sport because of their hip pain.As a result,in recent years,the understanding of the functional anatomy around this joint has been improved and refined.In addition. advancements in magnetic resonance imaging (MRI)have improved the ability to diagnose soft tissue causes of hip pain.All of these advances have significantly broadened the differential diagnosis of pain around the hip joint and improved our treatment of these problems (Table 1).

Several conditions causing hip pain have only recently become better understood.Pain around the hip was often treated with prolonged conservative management, such as activity restriction,and if that failed, open procedures.Many of these patients are currently being treated arthroscopically and are having great success at returning fully to their activities,including sporting activities of all levels.Not all causes of pain around the hip are intraarticular,however,and not all can be treated arthroscopically.The distinction between the various causes of h pain is important for treating these patients.In this review,we discuss the various causes of pain around the hip,the keys to making the diagnosis,and evidence-based treatments.

CONCLUSIONS:The differential diagnosis of pain around the hip and groin is broad and includes intra-articular pathology,extra articular soft tissue and tendon pathology,and mimickers,including the joints that make up the pelvic ring.Many potential causes of hip pain have overlapping symptoms or physical exam findings.A careful history and physical examination in combination with appropriate imaging and diagnostic or therapeutic injections generally leads to the correct diagnosis and appropriate therapy.