Ask Dr James: Can you explain my nocturnal hip pain that’s wrecking my sleep?

Dear Dr James,

“For almost 10 years now I have had a painful left hip that’s worse on climbing stairs and especially at night. During this time I have consulted three rheumatologists and a hip surgeon, had X-rays and an MRI scan – all normal – taken anti-inflammatory pills and been given cortisone injections. None of this has done much good.”

A: The hip is a biomechanical marvel encompassing the seemingly contradictory tasks of both stability and mobility – sustaining the downward weight of the body while allowing for the full range of movement entailed in running, jumping, squatting and pirouetting.

At its centre is a ball and socket joint whose glistening surfaces roll over each other as smoothly as a skater on ice, held in place by a band of fibrous ligaments and manoeuvred by no fewer than 22 powerful overlapping muscles. The practicalities of how all these anatomical structures function so well together is predictably complex with diverse ways of their being impaired so as to cause “the painful hip”.

Arthritis

The most familiar is arthritis, the “wear and tear” erosion of those smooth surfaces so bone grinds on bone to cause a constant toothache-like pain and prevent a good night’s sleep. This is readily diagnosed on an MRI scan and warrants a hip replacement, which ranks amongst the most successful of all surgical procedures. But what if, as with this query, there is no radiological evidence of arthritis? There are three main explanations whose differentiation from each other necessary for appropriate treatment can be most problematic.

Trochanteric bursitis

Several of the hip muscles insert in or around the prominent greater trochanter on the outer aspect of the head of the femur from which they are cushioned by a fluid-filled sac, or “bursa”, analogous to bubble wrap. So far, so well designed. But repetitive trauma to the bursa from over-exertion, heavy lifting or prolonged standing can cause it to become swollen and inflamed. Hence “trochanteric bursitis”, experienced as pain at night when lying on the affected side and on climbing stairs. This can be mitigated by the regular application of hot and cold packs and anti-inflammatory drugs such as Nurofen. The definitive treatment however requires injecting a potent steroid (cortisone) into the bursa to suppress the inflammation.

Gluteal tendinopathy

It became clear a decade ago that the cortisone injection was not nearly as effective as thought, providing relief for just over half of those receiving it. This prompted recognition of an alternative explanation of painful hip: gluteal tendinopathy – irritation and weakness of the tendons of the major gluteal muscles at the site where they are anchored into the upper femur. The treatment here is quite different, involving a specific programme of tendon strengthening exercises lasting several months.

Trapped nerves

To complicate matters yet further, the cause of the pain may not lie in the hip at all but be referred from elsewhere. Specifically, pressure on the nerves exiting the lower lumbar spine can also be experienced as nocturnal hip pain. This warrants spinal manipulation and similar measures to relieve the pressure.

Email queries and comments in confidence to Drjames@telegraph.co.uk