今日の臨床サポート

股関節痛(診察手順含む)

著者: 岡野徹 山陰労災病院整形外科 整形外科部長、副院長

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正済:2021/10/13
現在監修レビュー中
患者向け説明資料

概要・推奨   

  1. 股関節に由来する痛みは、鼡径部に生じることが多いが、大腿神経や閉鎖神経を介し大腿部前面や殿部、膝関節周囲にも生じ得る。
  1. 成人の場合、変形性股関節症の頻度が高く、単純X線で診断可能である。大腿骨頭壊死や軟骨下脆弱性骨折を疑う場合には、MRIを行う推奨度2
  1. 小児の場合、幼少期では、単純性股関節炎の頻度が高く、常にペルテス病を念頭におく。小学高学年から中学生の場合、大腿骨頭すべり症を念頭におく。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
岡野徹 : 特に申告事項無し[2021年]
監修:酒井昭典 : 講演料(旭化成ファーマ(株),第一三共(株),中外製薬(株)),奨学(奨励)寄付など(旭化成ファーマ(株),第一三共(株),中外製薬(株))[2021年]

改訂のポイント:
  1. 定期レビューを行い、股関節疾患の用語の変遷を元に加筆修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 股関節に由来する痛みは、関節前面の鼡径靱帯・縫工筋内縁・長内転筋外縁を3辺とするScarpa三角(大腿三角)に生じることが多いが、大腿神経や閉鎖神経を介し大腿部前面や殿部、膝関節周囲にも生じ得る。
  1. 健康診断時の調査ではわが国の30歳以上の日本人の2.6%が股関節痛を有し女性や高齢者で頻度が高くなるが、腰痛(22.5%)や膝関節痛(7.3%)と比べて低頻度である。
  1. 股関節痛は腰痛や膝関節痛に比べ、移動能力、日常活動や不安感への悪影響の程度が最も高いとする報告がある。
  1. 患者の股関節痛の訴えでは、腰椎疾患や膝関節疾患による痛みを股関節痛と訴える例も多く、また逆に股関節疾患に対し誤って腰椎部の治療をほどこした報告もある。それら疾患との鑑別には注意を要する。
  1. 日本における腰痛、股関節痛、膝関節痛の生活の質への負荷に関する疫学的調査[1]
  1. 股関節疾患に対し誤って腰椎部の治療をほどこした報告[2]
問診・診察のポイント  
  1. 代表的な変形性股関節症では発育性股関節形成不全(先天性股関節脱臼)や寛骨臼形成不全が原因である頻度が80%以上の高頻度であることが報告されている。

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文献 

著者: Machi Suka, Katsumi Yoshida
雑誌名: Clin J Pain. 2009 May;25(4):313-9. doi: 10.1097/AJP.0b013e31818c00c5.
Abstract/Text OBJECTIVES: To project the national burdens of low back, hip, and knee pains in Japan from 2005 to 2055 in terms of quality adjusted life years (QALYs).
METHODS: The age- and sex-specific prevalence rates of low back, hip, and knee pains in the questionnaire survey (3048 men and 1885 women) were multiplied by the corresponding age- and sex-specific Japanese population projections. The losses of QALYs associated with low back, hip, and knee pains were calculated as the projected numbers of men and women with pain at each site multiplied by the corresponding sex-specific mean differences of EQ-5D scores between those who reported pain at each site and those who reported no musculoskeletal pain in the questionnaire survey.
RESULTS: Among a total of 87.9 million Japanese people aged 30 years or older in 2005, 21.4 million (24.3%), 3.2 million (3.7%), and 9.1 million (10.4%) were estimated to have low back, hip, and knee pains, respectively. The prevalence rates of low back, hip, and knee pains will gradually increase in subsequent years, reaching 26.5%, 4.4%, and 12.9%, respectively by 2055. Consequently, the losses of QALYs associated with low back, hip, and knee pains per 1000 population will increase from 17.2, 3.8, and 8.9, respectively in 2005 to 18.8, 4.5, and 11.2, respectively by 2055.
DISCUSSION: Due to population aging, the national burden of musculoskeletal pain in Japan is projected to increase in the next 50 years. Musculoskeletal pain has not been counted among national healthcare priorities. However, the control of musculoskeletal pain should not be bypassed to improve QOL and extend healthy life expectancy.

PMID 19590480  Clin J Pain. 2009 May;25(4):313-9. doi: 10.1097/AJP.0b0・・・
著者: Robert L Swezey
雑誌名: Orthopedics. 2003 Feb;26(2):173-4; discussion 174.
Abstract/Text A retrospective analysis of 43 consecutive patients with hip osteoarthritis was performed. Twenty-four patients had previously been diagnosed with hip osteoarthritis, and 19 were treated solely for coexistent spine-related disorders without recognition of hip osteoarthritis. Four of 19 patients had previous spinal surgery for sciatica or spinal stenosis, 6 of 19 had epidural injections, 17 of 19 had magnetic resonance imaging or computed tomography, and 3 of 19 had electrodiagnostic studies.

PMID 12597222  Orthopedics. 2003 Feb;26(2):173-4; discussion 174.
著者: Junichi Nakamura, Kazuhiro Oinuma, Seiji Ohtori, Atsuya Watanabe, Tomonori Shigemura, Takahisa Sasho, Masahiko Saito, Masahiko Suzuki, Kazuhisa Takahashi, Shunji Kishida
雑誌名: Mod Rheumatol. 2013 Jan;23(1):119-24. doi: 10.1007/s10165-012-0638-5. Epub 2012 Apr 11.
Abstract/Text OBJECTIVES: Our aim was to clarify the distribution of hip pain in patients with osteoarthritis of the hip secondary to developmental dysplasia of the hip (DDH).
METHODS: We retrospectively studied 443 hips in 369 patients with osteoarthritis secondary to DDH; mean age was 61 years, and follow-up rate was 84 %. Hip pain was defined as preoperative pain that was relieved 3 months after total hip arthroplasty.
RESULTS: Distribution of pain originating in the hip was 89 % (393 hips) to the groin, 38 % (170 hips) to the buttock, 33 % (144 hips) to the anterior thigh, 29 % (130 hips) to the knee, 27 % (118 hips) to the greater trochanter, 17 % (76 hips) to the low back, and 8 % (34 hips) to the lower leg. When the groin, buttock, and greater trochanter were combined as the hip region, 95 % (421 hips) of pain was located in the hip region. On the other hand, when the anterior thigh, knee, lower leg, and low back were combined as the referral region, 55 % (242 hips) showed referred pain.
CONCLUSIONS: We suggest that rheumatologists be aware of hip disease masquerading as knee pain or low back pain.

PMID 22492057  Mod Rheumatol. 2013 Jan;23(1):119-24. doi: 10.1007/s101・・・
著者: J W Thomas Byrd, Kay S Jones
雑誌名: Am J Sports Med. 2004 Oct-Nov;32(7):1668-74.
Abstract/Text BACKGROUND: Hip arthroscopy has defined elusive causes of hip pain.
HYPOTHESIS/PURPOSE: It is postulated that the reliability of various investigative methods is inconsistent. The purpose of this study is to evaluate the diagnostic accuracy of these methods.
STUDY DESIGN: Retrospective review of prospectively collected data.
METHODS: Five parameters were assessed in 40 patients: clinical assessment, high-resolution magnetic resonance imaging, magnetic resonance imaging with gadolinium arthrography, intra-articular bupivacaine injection, and arthroscopy. Using arthroscopy as the definitive diagnosis, the other parameters were evaluated for reliability.
RESULTS: Hip abnormality was clinically suspected in all cases with 98% accuracy (1 false positive). However, the nature of the abnormality was identified in only 13 cases with 92% accuracy. Magnetic resonance imaging variously demonstrated direct or indirect evidence of abnormality but overall demonstrated a 42% false-negative and a 10% false-positive interpretation. Magnetic resonance arthrography demonstrated an 8% false-negative and 20% false-positive interpretation. Response to the intra-articular injection of anesthetic was 90% accurate (3 false-negative and 1 false-positive responses) for detecting the presence of intra-articular abnormality.
CONCLUSIONS: In this series, clinical assessment accurately determined the existence of intra-articular abnormality but was poor at defining its nature. Magnetic resonance arthrography was much more sensitive than magnetic resonance imaging at detecting various lesions but had twice as many false-positive interpretations. Response to an intra-articular injection of anesthetic was a 90% reliable indicator of intra-articular abnormality.

PMID 15494331  Am J Sports Med. 2004 Oct-Nov;32(7):1668-74.
著者: S Nakamura, S Ninomiya, T Nakamura
雑誌名: Clin Orthop Relat Res. 1989 Apr;(241):190-6.
Abstract/Text Diagnostic criteria for primary osteoarthritis of the hip joint in the Japanese population were determined by the roentgenographic measurements of the center-edge (CE) angle, the Sharp angle, and the acetabular roof obliquity in 254 normal hips. Primary osteoarthritis must meet the following conditions: (1) absence of femoral head deformities; (2) a CE angle of Wiberg greater than 19 degrees; (3) a Sharp angle less than 45 degrees; and (4) acetabular roof obliquity less than 15 degrees. These measurements are taken from roentgenograms during the early stage of the disease. Under these criteria, primary osteoarthritis accounted for only 0.65% of 2000 consecutive cases of osteoarthritis. Observation of the natural course of primary osteoarthritis revealed two subtypes. The superolateral type developed from the subset of normal hips with a relatively greater degree of acetabular roof obliquity.

PMID 2924462  Clin Orthop Relat Res. 1989 Apr;(241):190-6.
著者: R Stephen J Burnett, Gregory J Della Rocca, Heidi Prather, Madelyn Curry, William J Maloney, John C Clohisy
雑誌名: J Bone Joint Surg Am. 2006 Jul;88(7):1448-57. doi: 10.2106/JBJS.D.02806.
Abstract/Text BACKGROUND: The clinical presentation of a labral tear of the acetabulum may be variable, and the diagnosis is often delayed. We sought to define the clinical characteristics associated with symptomatic acetabular labral tears by reviewing a group of patients who had an arthroscopically confirmed diagnosis.
METHODS: We retrospectively reviewed the records for sixty-six consecutive patients (sixty-six hips) who had a documented labral tear that had been confirmed with hip arthroscopy. We had prospectively recorded demographic factors, symptoms, physical examination findings, previous treatments, functional limitations, the manner of onset, the duration of symptoms until the diagnosis of the labral tear, other diagnoses offered by health-care providers, and other surgical procedures that these patients had undergone. Radiographic abnormalities and magnetic resonance arthrography findings were also recorded.
RESULTS: The study group included forty-seven female patients (71%) and nineteen male patients (29%) with a mean age of thirty-eight years. The initial presentation was insidious in forty patients, was associated with a low-energy acute injury in twenty, and was associated with major trauma in six. Moderate to severe pain was reported by fifty-seven patients (86%), with groin pain predominating (sixty-one patients; 92%). Sixty patients (91%) had activity-related pain (p < 0.0001), and forty-seven patients (71%) had night pain (p = 0.0006). On examination, twenty-six patients (39%) had a limp, twenty-five (38%) had a positive Trendelenburg sign, and sixty-three (95%) had a positive impingement sign. The mean time from the onset of symptoms to the diagnosis of a labral tear was twenty-one months. A mean of 3.3 health-care providers had been seen by the patients prior to the definitive diagnosis. Surgery on another anatomic site had been recommended for eleven patients (17%), and four had undergone an unsuccessful operative procedure prior to the diagnosis of the labral tear. At an average of 16.4 months after hip arthroscopy, fifty-nine patients (89%) reported clinical improvement in comparison with the preoperative status.
CONCLUSIONS: The clinical presentation of a patient who has a labral tear may vary, and the correct diagnosis may not be considered initially. In young, active patients with a predominant complaint of groin pain with or without a history of trauma, the diagnosis of a labral tear should be suspected and investigated as radiographs and the history may be nonspecific for this diagnosis.
LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions to Authors for a complete description of levels of evidence.

PMID 16818969  J Bone Joint Surg Am. 2006 Jul;88(7):1448-57. doi: 10.2・・・
著者: R R Bannuru, M C Osani, E E Vaysbrot, N K Arden, K Bennell, S M A Bierma-Zeinstra, V B Kraus, L S Lohmander, J H Abbott, M Bhandari, F J Blanco, R Espinosa, I K Haugen, J Lin, L A Mandl, E Moilanen, N Nakamura, L Snyder-Mackler, T Trojian, M Underwood, T E McAlindon
雑誌名: Osteoarthritis Cartilage. 2019 Nov;27(11):1578-1589. doi: 10.1016/j.joca.2019.06.011. Epub 2019 Jul 3.
Abstract/Text OBJECTIVE: To update and expand upon prior Osteoarthritis Research Society International (OARSI) guidelines by developing patient-focused treatment recommendations for individuals with Knee, Hip, and Polyarticular osteoarthritis (OA) that are derived from expert consensus and based on objective review of high-quality meta-analytic data.
METHODS: We sought evidence for 60 unique interventions. A systematic search of all relevant databases was conducted from inception through July 2018. After abstract and full-text screening by two independent reviewers, eligible studies were matched to PICO questions. Data were extracted and meta-analyses were conducted using RevMan software. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence Profiles were compiled using the GRADEpro web application. Voting for Core Treatments took place first. Four subsequent voting sessions took place via anonymous online survey, during which Panel members were tasked with voting to produce recommendations for all joint locations and comorbidity classes. We designated non-Core treatments to Level 1A, 1B, 2, 3, 4A, 4B, or 5, based on the percentage of votes in favor, in addition to the strength of the recommendation.
RESULTS: Core Treatments for Knee OA included arthritis education and structured land-based exercise programs with or without dietary weight management. Core Treatments for Hip and Polyarticular OA included arthritis education and structured land-based exercise programs. Topical non-steroidal anti-inflammatory drugs (NSAIDs) were strongly recommended for individuals with Knee OA (Level 1A). For individuals with gastrointestinal comorbidities, COX-2 inhibitors were Level 1B and NSAIDs with proton pump inhibitors Level 2. For individuals with cardiovascular comorbidities or frailty, use of any oral NSAID was not recommended. Intra-articular (IA) corticosteroids, IA hyaluronic acid, and aquatic exercise were Level 1B/Level 2 treatments for Knee OA, dependent upon comorbidity status, but were not recommended for individuals with Hip or Polyarticular OA. The use of Acetaminophen/Paracetamol (APAP) was conditionally not recommended (Level 4A and 4B), and the use of oral and transdermal opioids was strongly not recommended (Level 5). A treatment algorithm was constructed in order to guide clinical decision-making for a variety of patient profiles, using recommended treatments as input for each decision node.
CONCLUSION: These guidelines offer comprehensive and patient-centered treatment profiles for individuals with Knee, Hip, and Polyarticular OA. The treatment algorithm will facilitate individualized treatment decisions regarding the management of OA.

Copyright © 2019 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
PMID 31278997  Osteoarthritis Cartilage. 2019 Nov;27(11):1578-1589. do・・・
著者: T Yamamoto, P G Bullough
雑誌名: Arthritis Rheum. 1999 Dec;42(12):2719-23. doi: 10.1002/1529-0131(199912)42:12<2719::AID-ANR31>3.0.CO;2-X.
Abstract/Text OBJECTIVE: To document subchondral insufficiency fracture (SIF) of the femoral head and investigate its frequency.
METHODS: The study was based on a retrospective review of 464 removed femoral heads (from 419 patients) with both radiologic and histologic evidence of subchondral collapse. Gross photographs, specimen radiographs, and histologic sections were reevaluated in all cases. Available clinical notes and imaging studies were also reviewed.
RESULTS: Ten cases previously diagnosed as osteonecrosis were reinterpreted as SIF on a histopathologic basis. All of these patients were women over 65 years old (average age 75) with osteopenia. The initial symptom was acute onset of hip pain. Radiologically, a subchondral collapse, mainly in the superolateral segment of the femoral head, was noted. Magnetic resonance imaging, available in 3 cases, showed diffuse low intensity on T1-weighted images and high intensity on T2-weighted or fat-suppressed images. Bone scintigraphy, available in 4 cases, showed increased uptake in the femoral head. Histopathologically, a 1.0-2.5-cm long linear whitish gray zone, comprising fracture callus and granulation tissue, was found beneath the subchondral bone end plate. There was no evidence of antecedent osteonecrosis.
CONCLUSION: The results of this study indicate that SIF should be included in the differential diagnosis of acute onset of coxarthrosis in the elderly.

PMID 10616023  Arthritis Rheum. 1999 Dec;42(12):2719-23. doi: 10.1002/・・・
著者: M Postel, M Kerboull
雑誌名: Clin Orthop Relat Res. 1970 Sep-Oct;72:138-44.
Abstract/Text
PMID 5459776  Clin Orthop Relat Res. 1970 Sep-Oct;72:138-44.
著者: John C Clohisy, Evan R Knaus, Devyani M Hunt, John M Lesher, Marcie Harris-Hayes, Heidi Prather
雑誌名: Clin Orthop Relat Res. 2009 Mar;467(3):638-44. doi: 10.1007/s11999-008-0680-y. Epub 2009 Jan 7.
Abstract/Text Femoroacetabular impingement (FAI) is considered a cause of labrochondral disease and secondary osteoarthritis. Nevertheless, the clinical syndrome associated with FAI is not fully characterized. We determined the clinical history, functional status, activity status, and physical examination findings that characterize FAI. We prospectively evaluated 51 patients (52 hips) with symptomatic FAI. Evaluation of the clinical history, physical exam, and previous treatments was performed. Patients completed demographic and validated hip questionnaires (Baecke et al., SF-12, Modified Harris hip, and UCLA activity score). The average patient age was 35 years and 57% were male. Symptom onset was commonly insidious (65%) and activity-related. Pain occurred predominantly in the groin (83%). The mean time from symptom onset to definitive diagnosis was 3.1 years. Patients were evaluated by an average 4.2 healthcare providers prior to diagnosis and inaccurate diagnoses were common. Thirteen percent had unsuccessful surgery at another anatomic site. On exam, 88% of the hips were painful with the anterior impingement test. Hip flexion and internal rotation in flexion were limited to an average 97 degrees and 9 degrees, respectively. The patients were relatively active, yet demonstrated restrictions of function and overall health. These data may facilitate diagnosis of this disorder.

PMID 19130160  Clin Orthop Relat Res. 2009 Mar;467(3):638-44. doi: 10.・・・
著者: Reinhold Ganz, Javad Parvizi, Martin Beck, Michael Leunig, Hubert Nötzli, Klaus A Siebenrock
雑誌名: Clin Orthop Relat Res. 2003 Dec;(417):112-20. doi: 10.1097/01.blo.0000096804.78689.c2.
Abstract/Text A multitude of factors including biochemical, genetic, and acquired abnormalities may contribute to osteoarthritis of the hip. Although the pathomechanism of degenerative process affecting the dysplastic hip is well understood, the exact pathogenesis for idiopathic osteoarthritis has not been established. Based on clinical experience, with more than 600 surgical dislocations of the hip, allowing in situ inspection of the damage pattern and the dynamic proof of its origin, we propose femoroacetabular impingement as a mechanism for the development of early osteoarthritis for most nondysplastic hips. The concept focuses more on motion than on axial loading of the hip. Distinct clinical, radiographic, and intraoperative parameters can be used to confirm the diagnosis of this entity with timely delivery of treatment. Surgical treatment of femoroacetabular impingement focuses on improving the clearance for hip motion and alleviation of femoral abutment against the acetabular rim. It is proposed that early surgical intervention for treatment of femoroacetabular impingement, besides providing relief of symptoms, may decelerate the progression of the degenerative process for this group of young patients.

PMID 14646708  Clin Orthop Relat Res. 2003 Dec;(417):112-20. doi: 10.1・・・
著者: Moritz Tannast, Klaus A Siebenrock, Suzanne E Anderson
雑誌名: AJR Am J Roentgenol. 2007 Jun;188(6):1540-52. doi: 10.2214/AJR.06.0921.
Abstract/Text OBJECTIVE: The purpose of this article is to show the important radiographic criteria that indicate the two types of femoroacetabular impingement: pincer and cam impingement. In addition, potential pitfalls in pelvic imaging concerning femoroacetabular impingement are shown.
CONCLUSION: Femoroacetabular impingement is a major cause for early "primary" osteoarthritis of the hip. It can easily be recognized on conventional radiographs of the pelvis and the proximal femur.

PMID 17515374  AJR Am J Roentgenol. 2007 Jun;188(6):1540-52. doi: 10.2・・・

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