Pain in upper leg area when put my weight on it

Hip, Groin and Thigh Pain – do you have a leg to stand on?

hip pain osteopath treatment BathThe hip and its surrounding muscles are the heavy load bearers of our lives, every time we get up, move and sit back down again they are taking the weight of the body and transferring it to a new position.  When we walk or run, they must cope with the full weight of our bodies while we are balanced on one leg. The hip joint and its surrounding muscles are working their hardest and have the most demands placed on it when we load them in this way (1). It is no surprise then that the hip is subject to a range of problems, most of which are specific to our age (2).  Muscle tears and hernias tend to be in the younger more sporty age groups, hip joint degeneration, such as seen in in osteoarthritis of the hip is mainly seen in people aged fifty or over (3).

The first task in attempting to get rid of pain in the hip is to first work out if the pain is indeed coming from the hip joint or its surrounding muscles.  There are several other parts of the body that can refer pain to the hip, most commonly the low back and the large sacroiliac joints at the base of the spine, but digestive and urinary problems can also produce pain in the hips (3).   A simple test is that if you have to limp due to pain and there is pain in your hip when you stand on one leg then you may have a problem with your hip.  If there is tingling or numbness around the hip and thigh the problem is more likely to be related to your back (3).  In this article we identify the most common causes of hip and thigh pain and the best ways to get rid of them. 

Gluteus Medius Strains, Chronic Tendon Problems, and Trochanteric Bursitis – So much in a small space!

The gluteus medius is an extremely strong muscle that lies beneath the gluteus maximus (which gives you the shape of your buttocks), its main function is to provide stability to the body when standing on one leg (1), if it does not function properly then walking and especially running are problematic at best.  Because of its important function it can be vulnerable to injury.  Due to its location, an injury to the gluteus medius will be felt on the outside of the thigh and possibly down to the outside of the knee and lower leg (4).  In a younger population it can be due to overuse (increasing exercise too quickly) or trauma (stepping off a high step).  These types of injury tend to respond well to rest and stretching (5). Glute strain treatment Bath

A more long term problem may develop over time by tiny but repeated tears to the tendon of the hip abductors (including the gluteus medius) causing damage to the tendon with a failure in the healing mechanism, this is called a tendinosis (3).   The repeated damage may cause inflammation in the muscles and tendons of the hip and also result in inflammation of a structure called the trochanteric bursa (6).  A bursa is a small fat pad that ensures smooth sliding of muscles over each other to reduce friction, however due to the nature of its job it exists in a very tightly packed space, this means it can easily be affected by changes in the surrounding structures (5).  The gluteal tendinosis and the trochanteric bursitis were previously seen as two separate conditions but after investigation they are now considered two stages of the same condition (7) and renamed ‘greater trochanteric pain syndrome’ (GTPS).

Pain in upper leg area when put my weight on itGTPS is the most common painful problem seen in the hip (3) and is seen more commonly in women, aged 40-60 who may also have osteoarthritis of the knee.  It is also very common in long distance runners (8).  It is usually described as being a deep ache around that outside of the thigh and bottom of the buttocks, it may be felt lower down towards the outside of the knee but rarely below the knee.  It can be aggravated by lying on the affected side, crossing the legs, standing for long periods and climbing stairs (9).

If you are unlucky enough to suffer from GTPS the best thing to do in the short term is to rest and avoid the things that make the pain worse (10).   The next thing to do is to get a diagnosis from a professional such as an osteopath so the correct treatment plan can be decided upon.  There is good evidence that several styles of treatment, including osteopathic techniques, that can be effective in the rehabilitation of GTPS, these include manual stretching of the hip and the prescription of stretches and strengthening of the hip muscles (10).

Hip Joint Osteoarthritis – Another very common problem that occurs in hips is osteoarthritis.  The surface of the hip joint is covered by smooth hyaline cartilage, as the hip joint is a weight bearing joint eventually the cartilage becomes thin and the bone below is exposed causing friction, inflammation and pain. Due to the problem being one of degeneration it tends to occur in people aged over 50. The risks can be increased by faulty loading of the hip joint due to poor biomechanics (possibly the influence of surrounding joints), obesity and previous injuries such as fractures to the pelvis or leg bones (5).  80% of all hip osteoarthritis is secondary to such factors (3).

The pain that hip joints produce tends to be felt in the groin and is worse with movement and better with rest.  It may also feel stiff to start moving and then get better as you move.  An accurate diagnosis is made with a combination of physical examination of the hip, then more definitively by an x-ray (3).

Renee Clinch from Keynsham

hip arthritis pain treatment Bath

Due to the degenerative nature of the condition a cure is very unlikely, however several options exist that can eliminate the symptoms and keep the hip functioning well (5).  Conservative treatment based around stretching and massage of the hip and it’s surrounding muscles is effective alongside advice on appropriate exercise, nutrition and weight loss if necessary (11).  If these measures are not effective or the pain is very severe then steroid injections and surgery are recommended (5).  Most people with osteoarthritis of the hip continue to be active as long as they receive individualised care from an early stage.

Iliopsoas Syndrome – The iliopsoas is a very strong muscle that lies deep in the front of the hip, travelling from the vertebrae in your low back, through the pelvis and attaching to the thigh bone.  It’s main role is to flex the hip (12).  Below the iliopsoas tendon, as it crosses the pubic bone lies a bursa, which if irritated can, alongside the tendon become inflamed (13).  The pain from this condition is again felt deep in the front of the groin.  However, unlike osteoarthritis it much more likely to be experienced in a younger population who are involved in sports such as martial arts, long distance running, dancing and gymnastics (5). One difference is that the pain may be felt up into the low back, and a ‘snapping’ sound may be felt while you are walking (10).

Pain in upper leg area when put my weight on itConservative management such as osteopathic treatment can help resolve the problem.  Stretching of the iliopsoas and other muscles of the hip, coupled with mobilisation of the low back and effective exercise and activity advice should relieve the symptoms in under 8 weeks (13, 5).

Hernia (Sports) – A less common reason for pain in the groin is a ‘sports hernias’.  This is where there is a complex tear in the muscular elements of the hip and abdomen that produce raising of the hip and inward motion.  Because it is usually traumatic it is more commonly seen in a younger age group who are involved in sports that involve repetitive bending backwards with twisting at the same time, such as football, hockey, or martial arts.  It is most commonly experienced as a rapid onset of disabling low back pain with some lower abdomen and groin pain, the pain is mainly aggravated by trying to do a sit up or trying to twist the trunk while lying down (3).  Rehabilitation options are dependent on the severity of the tear to the muscles.  Usually rest and stopping any activity that may aggravate is the first port of call.  Conservative treatment involving core muscle and hip strengthening should be tried before any surgical option is attempted (2).  If surgery is indicate d the good news is that it tends to have a very high success rate (95%) (3).

Meralgia Parathsetica – This is a less common condition that produces tingling, numbness, and pain on the front and outside of the thigh.  The pain is generated due to compression of the lateral Pain in upper leg area when put my weight on itfemoral cutaneous nerve.  Usually this is due to mechanical stress on the nerve due to the changes seen in pregnancy, or with obesity, it can also be seen in people who wear heavy work belts such as policemen and builders (3).  Treatment is mainly focused around correction of the mechanical factors by manual therapy, combined with rest.  If the symptoms persist then surgery can be performed to decompress the nerve.  (2).

Hip pain treatment BathKeeping Your Hips in Good Shape – As we have seen in the examples above, many hip complaints can arise from improper mechanics such as a lack of mobility or a lack of strength.  The hip, pelvis and low back are very closely linked in terms of how they share the load of movement, a change or restriction in one area can have profound impact on the others (1).  In many instances hip complaints can be addressed by restoring normal movement to the low back, pelvis and hip musculature either through manual treatment from an osteopath or through prescriptive exercise (3).  See below for our top four stretches to help prevent hip problems.

Do you want to know what is causing your pain and if we can help?  Why not take advantage of our new patient consultation introductory offer to get you started towards a tailor made recovery plan for only £19.

Pain in upper leg area when put my weight on it

Are you in a lot of pain and want to get better as soon as possible?  If so the why not book in for a new patient consultation, with treatment on the day, for £60.

Pain in upper leg area when put my weight on it

Try these stretches to help keep your hips mobile!

hip pain exercise osteopath Bath

1 — Levangie, P. and Norkin, C. (2005) Joint Structure and Function: A Comprehensive Analysis (4th ed). F. A. Davis, Philadelphia.

2 — Souza, T. (2009).  Differential Diagnosis and Management for the Chiropractor.  4th ed, Jones and Bartlett, Sudbury.

3 — Magee, D. Zachazewski, J. and Quillen, W., 2009. Pathology and Intervention in Musculoskeletal Rehabilitation, Missouri, Elselvier.

4 — Carnes, M, {amp}amp; Vizniak, N. (2011). Conditions Manual. Professional Health Systems, Canada.

5 — Brukner, P. and Khan, K. (2007).  Clinical Sports Medicine (3rd Ed).  McGraw Hill, Sydney.

6 — Ho GWK, Howard TM (2012). Greater trochanteric pain syndrome : more than bursitis and iliotibial tract friction. Current sports medicine reports, 11(5), pp.232-235.

7 — Klauser AS, Martinoli C, Tagliafico A, et al (2013). Greater trochanteric pain syndrome. Seminars in Musculoskeletal Radiology, 17(1), pp.43-48.

8 — Neil A et al (2007). Greater trochanteric pain syndrome: epidemiology and associated factors. Archives of Physical medicine and rehabilitation, 88(8), pp.988-992.

9 — Strauss EJ, Nho SJ, Kelly BT (2010). Greater trochanteric pain syndrome. Sports Medicine Arthroscopy, 18(3), pp.112-119.

10 — Wyss J, Patel A (2012).Therapeutic Programs for Musculoskeletal Disorder: Demos Medical Publishing.

11 — Peter WF,et al; Guideline Steering Committee — Hip and Knee Osteoarthritis. Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation. Acta Reumatol Port. 2011 Jul-Sep;36(3):268-81.

12 – Snell, R. S. (2003).  Snell Clinical Anatomy, 7th Ed.  Lippincott, Williams and Wilkins.  Baltimore.

13 — Johnston, C.A.M., Wiley, J.P., Lindsay D.M., {amp}amp; Wisemand D.A. (1998, April). Iliopsoas bursitis and tendinitis: A review. Sports Med, 25(4), 271-283 (Level of evidence: 1A)

A 73-year-old woman presented to the Saint Marys Hospital emergency department for anterior thigh pain. This pain began 2 weeks before presentation when she noticed difficulty lifting her right leg into her car. She noticed progressive worsening of these symptoms such that she could not put on her socks and shoes. On the day of presentation, while attempting to raise her right leg into bed, she developed severe burning pain in the anterior aspect of her thigh. The severity of the pain, 10 on a 10-point scale, prompted her to seek evaluation in the emergency department. She denied trauma, change in activity level, back pain, bladder or bowel dysfunction, and saddle anesthesia. Her medical history was notable for coronary artery disease with placement of a drug-eluting stent in the distal circumflex coronary artery 6 months previously via the right radial artery, paroxysmal atrial fibrillation, diabetes mellitus with a recent glycated hemoglobin concentration of 6.0%, and chronic lower extremity lymphedema. Her medications included aspirin, clopidogrel, diltiazem, lisinopril, simvastatin, metoprolol, warfarin, and glyburide. She had no recent changes in medications, was receiving a stable warfarin dose, and her international normalized ratio (INR) was within normal limits. She denied tobacco, ethanol, and intravenous drug use. In the emergency department, radiography of the femur and lumbar spine were performed, showing no evidence of fracture.

On admission, her vital signs were as follows: temperature, normal; pulse, 72 beats/min; and blood pressure, 126/68 mm Hg. Findings on cardiac and pulmonary examinations were within normal limits. Her abdomen was soft, obese, and nontender; no masses were palpable. Both lower extremities were warm and well perfused; dorsalis pedis and posterior tibial pulses were palpable. Musculoskeletal examination revealed intact internal and external rotation of her right hip. She was unable to do a straight leg raise or flexion/extension of both the hip and knee because of the severe pain. The spine and sacroiliac joints were not tender to palpation, but she did have tenderness to palpation over the greater trochanter of the right leg. She was able to perform transfers, but her ability to do so was limited by severe pain. During sensory testing, the patient noted a subjective difference in fine touch of the right vs the left anterior thigh.

  • On the basis of this patient’s description of her sensory deficit, which one of the following nerves is most likely involved?

    1. Obturator nerve

    2. Femoral nerve

    3. Saphenous nerve

    4. Medial sural nerve

    5. Ilioinguinal nerve

    The obturator nerve provides cutaneous innervation to the medial aspect of the thigh. Injury to the obturator nerve can result in paresthesias of the medial aspect of the thigh and weakness of adduction that results in gait instability. This patient’s fine touch sensation alteration does not correspond with this distribution. In contrast, injury to the femoral nerve will result in weakness of the quadriceps, with associated knee extension weakness and paresthesias of the anterior aspect of the thigh. Given the patient’s physical examination findings, the femoral nerve is the most likely to be involved. Damage to the saphenous nerve, a branch of the femoral nerve that can be injured during procedures such as knee arthroscopy, knee arthrocentesis, and cut-down of the saphenous vein, results in paresthesias of the medial aspect of the leg distal to the knee. This patient described no distal leg involvement. The sural nerve innervates the posterior leg distal to the knee and lateral foot. The patient’s description of anterior thigh pain does not correlate with the sural nerve innervation pattern. Originating from the lumbar plexus, the ilioinguinal nerve innervates the skin overlying the medial femoral triangle, which is bounded by the inguinal ligament, the adductor longus, and the sartorius.1 Injury to this nerve would not explain the large area of involvement experienced by this patient. Her description of pain and paresthesias and her denial of any history of trauma were consistent with spontaneous femoral neuropathy.

    Because of the substantial tenderness over the greater trochanter of the right leg, a trochanteric bursa injection was performed. The area of maximal tenderness was identified and injected with methylprednisolone and lidocaine. After 15 minutes, the local tenderness had resolved, but her anterior thigh pain remained unchanged. On evaluation of her gait, an important finding was made.

  • Given this patient’s presentation, which one of the following would be her expected gait?

    1. Trendelenburg gait

    2. Steppage gait

    3. Festinating gait

    4. Scissor gait

    5. Knee “buckling”

    The Trendelenburg gait describes the result of weakness of the gluteal muscles often associated with muscular dystrophy, L5 radiculopathy, and myopathies. The pelvis drops on the opposite side, making the opposite leg “too long,” resulting in leaning toward the affected side to clear the opposite foot. This gait is not associated with femoral neuropathy because the femoral nerve does not innervate the gluteal muscles. The steppage gait is associated with foot drop that requires flexion at the hip to raise the leg higher than with a normal gait in order to “clear” the foot. This is classically associated with L5 radiculopathy or peroneal nerve damage. In the case of injury to the L5 root, this gait can occur in conjunction with a Trendelenburg gait. A festinating gait (ie, a Parkinsonian gait) is usually characterized by short, shuffling steps and increasing step acceleration, resulting in a high risk of falls. The scissor gait refers to thigh adduction during leg swing that can result in legs crossing each other. The increased tone leads to decreased motion of the hip and knee joints during the gait cycle, resulting in a stiff gait. Such a gait can be seen in association with upper motor neuron lesions in patients with cerebral palsy and multiple sclerosis.2 Femoral neuropathy can result in quadriceps muscle weakness and the sensation of the knee buckling during the loading response, making knee buckling the correct response.3

    During ambulation, the patient required the support of a walker and described feeling “unsteady” while walking with the feeling that her knee would “give out.” Physical therapy was consulted for assistance with her ambulation, and pain control was attempted with oral oxycodone. She continued to have difficulty with her gait and had ongoing pain despite physical therapy and oral narcotics. Because of the unknown etiology of her femoral neuropathy, further investigation was necessary.

  • At this stage, which one of the following laboratory investigations would be most helpful?

    1. Serum glucose levels

    2. Ionized calcium levels

    3. INR

    4. Thyroid-stimulating hormone levels

    5. Vitamin B12

    Hypoglycemia can result in a sensation of generalized weakness; however, this patient’s most prominent symptom was pain. Although diabetes mellitus is most commonly associated with a distal symmetric neuropathy affecting sensory and autonomic fibers in the classic stocking/glove distribution, it can also cause mononeuropathies, including the femoral nerve and diabetic lumbosacral radiculoplexus neuropathy (DLRPN).4,5 Initially, DLRPN can present as an asymmetric lower extremity pain that is often followed by weakness and often occurs in the setting of weight loss. Although DLRPN may explain her symptoms, a single glucose measurement would provide little insight into the etiology of pain, particularly when DLRPN can occur in patients with well-controlled diabetes.5 Hypocalcemia can cause generalized paresthesias, classically in a perioral distribution; a femoral nerve distribution would be less likely. Hypercalcemia can result in weakness but does not explain the patient’s predominant symptoms of pain and paresthesias. Because the patient was taking warfarin for paroxysmal atrial fibrillation, checking an INR would be appropriate. One adverse event that can be associated with anticoagulation is spontaneous bleeding, which includes bleeding in the retroperitoneal space that results in a the sudden onset of femoral neuropathy.6 On rare occasion, hypothyroidism results in meralgia paresthetica, causing pain and paresthesias in the anterolateral thigh.7 However, this patient did not describe any of the other symptoms associated with hypothyroidism. Vitamin B12 deficiency can result in paresthesias and varied neurologic symptoms in addition to hematologic effects; however, it would classically present over a longer time course than did this patient’s symptoms and would not explain her pain.8

    On the morning of the patient’s admission, her INR was 3.0, and her hemoglobin concentration was 13.3 g/dL (reference ranges provide parenthetically) (13.5-17.5 g/dL). However, approximately 24 hours later her hemoglobin concentration decreased to 10.2 g/dL. She remained hemodynamically stable without orthostatic hypotension. Her platelet count remained within normal limits at 139 × 109/L (150-450 × 109/L). She denied melena, hematochezia, epistaxis, and hemoptysis.

  • Which one of the following imaging studies would be least helpful in identifying the etiology of this patient’s symptoms and laboratory findings?

    1. Indium In 111–labeled white blood cell scan

    2. Plain radiography

    3. Ultrasonography

    4. Computed tomography

    5. Magnetic resonance imaging

    An indium In 111–labeled white blood cell scan would be the least helpful. Although it can provide information about infection and inflammation, it is unlikely to reveal the cause of her pain and paresthesias. Also, this test has the disadvantage of taking up to 24 hours to complete. Plain radiography can provide diverse information about underlying pathology, including fractures. Further, asymmetry of the psoas muscle can be present in the setting of retroperitoneal hemorrhage; however, this can also occur in other pathologies as well as normal variants.6 Ultrasonography can be used to evaluate the abdomen, including retroperitoneal structures, and to rapidly visualize retroperitoneal hemorrhage with little risk to the patient. However, success can be limited by the patient’s particular anatomy, including body habitus.6,9 Computed tomography is an excellent imaging modality for evaluating retroperitoneal hemorrhage, which can be recognized by increased density areas that are typically asymmetric. Magnetic resonance imaging also provides very exact anatomic information about the extent of involvement of retroperitoneal hemorrhage. Further, it can provide information about nerve compression.6,9

    Magnetic resonance imaging showed rounded foci of slightly increased T1 and T2 signals within the right iliacus and inferior psoas muscle consistent with intramuscular hematomas.

  • Which one of the following interventions would be most appropriate?

    1. Continue warfarin at a lower dose

    2. Discontinue warfarin until the INR has normalized

    3. Discontinue warfarin and give oral vitamin K

    4. Discontinue warfarin and give intravenous vitamin K and fresh-frozen plasma (FFP)

    5. Discontinue warfarin and start low-molecular-weight heparin therapy

    In the setting of severe bleeding, continuing warfarin even at a lower dose would place the patient at severe risk of adverse outcomes from bleeding. Although withholding warfarin without giving vitamin K is recommended in the setting of a minimally elevated INR without substantial bleeding, this patient has signs of substantial bleeding and should be treated more aggressively. Per American College of Chest Physicians recommendations, withholding warfarin and giving oral vitamin K would be sufficient for substantially elevated INR without evidence of bleeding.10 For substantial or life-threatening bleeding, regardless of INR level, the recommendation is to use intravenous vitamin K for INR reversal along with FFP or recombinant vitamin factor VIIa. The clinical status of the patient is what dictates whether FFP or recombinant factor VIIa is necessary. Low-molecular-weight heparin would not be recommended in the setting of active bleeding. Further, low-molecular-weight heparin is not readily reversible and thus poses an additional risk in the setting of bleeding.10

    Careful risk-benefit analysis was considered for this patient with “triple” anticoagulant therapy, including warfarin, aspirin, and clopidogrel in the setting of atrial fibrillation and a drug-eluting stent. Warfarin and aspirin were discontinued. Fresh-frozen plasma and 10 mg of vitamin K were given intravenously. Clopidogrel was continued because guidelines recommend clopidogrel continuation for 1 year to prevent in-stent thrombosis.11 The patient’s pain was controlled with opioid therapy. Physical therapy assisted throughout the hospitalization, and at dismissal she was able to ambulate with the aid of a walker. She was discharged to a skilled nursing facility for further work with physical therapy; 2 weeks later, she returned home with no requirement for pain medications.

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