Approach to Hip Complaint LECT and LAB Flashcards
What are newborn hip problems? (5)
Septic Arthritis (SA) DDH Fracture Congenital Somatic Dysfunction
What are Adolescent hip problems? (9)
SA Perthes SCFE AVN FAI Labral tear (LT) Trochanter bursitis (TB) Piriformis syn Somatic Dysfunction
What are common adult hip problems? (8)
SA Osteoarthritis AVN FAI Labral tear (LT) Trochanter bursitis (TB) Meralgia paresthetica (MP) Piriformis syn
What are common Geriatric hip problems? (9)
SA Osteoarthritis Fracture AVN FAI Labral tear (LT) Trochanter bursitis (TB) Meralgia paresthetica (MP) Piriformis syn
What are signs of Developmental Dysplasia of the Hip (DDH)?
NEWBORN, breech position, female sex, and first gestation
How to diagnose DDH?
Hip Clunk, Hip click, Mild instability
Hip clunk test?
Distinct and pronounced palpable (and at times audible) shift of femoral head, felt as the femoral head is dislocated or reduced on examination with the Ortolani and Barlow maneuvers 90 degree flexed hip
What is Perthes Disease?
(3-12 yr old) More common in boys. the blood supply to the head of the femur is interrupted. The femoral head then “necroses,” or loses blood supply, which weakens the bone and can lead to multiple fractures.
Signs of Perthes Disease
Limping
Pain or stiffness in the hip, groin, thigh or knee/Limited range of motion of the hip joint
Pain that worsens with activity and improves with rest
Xray: smashed femer head look above the growth plate.
What is Slipped Capital Femoral Epiphysis (SCFE)
SCFE is a disorder of adolescents in which the growth plate is damaged and the femoral head moves (“slips”) with respect to the rest of the femur. The head of the femur stays in the cup of the hip joint while the rest of the femur is shifted
Signs/ Diagnosis of SCFE?
8-15 obese boys. presenting with hip pain with limping and impaired internal rotation, occasionally after minor trauma
Pain in the groin, inner thigh, or knee.
May be a change in their gait or they may walk with the leg rotated outward.
What is Avascular necrosis (AVN)?
Avascular necrosis is a disease that results from the temporary or permanent loss of blood supply to the bone. When blood supply is cut off, the bone tissue dies and the bone collapses. If avascular necrosis happens near a joint, the joint surface may collapse. This may occur in any bone but most commonly happens in the ends of a long bone. Need X-ray
Signs and Diagnosis of AVN?
(30-50 yr old) This is like perthes but with an adult.
Long term use of corticosteroids or alcohol
Minimal early joint pain
Limited range of motion due to pain
Increased joint pain as bone and joint begin to collapse
Pain with activity and rest
Need X-ray
What is Trochanteric Bursitis?
inflammation of a bursa ontop of Trochanter
Risks of Trochanteric Bursitis?
Trochanteric bursitis, is often the result of injury, overuse, spinal/postural abnormalities, arthritis, or surgery.
Signs of Trochanteric Bursitis?
Pain on the outside of the hip and thigh or in the buttock.
Pain when lying on the affected side.
Pain when you press in or on the outside of the hip.
Pain with walking up stairs.
Pain worsening during activities such as getting up from a deep chair or getting out of a car.
Diagnosis of Trochanteric Bursitis?
History, Exam, X-ray
Symptoms of Osteoarthritis of hip
The MC symptom of osteoarthritis is pain after overuse or inactivity of a joint.
Pain, stiffness (especially after sleep or inactivity), and limited movement of joints.
Symptoms usually develop slowly over years with less movement in the joint over time.
A grinding feeling of the joint when moved, as the cartilage wears away (in more advanced stages)
Risks if Osteoarthritis of hip?
Most people over age 60 have osteoarthritis to some degree, but its severity varies Heredity, excess weight, injury or overuse
Diagnosis of Osteoarthritis of hip
X-rays: bone spurs with joint narrowing.
Diagnosis of xray of SCFE?
Femur head looks broken off and rotated above growth plate. IE its name.
What is Meralgia paresthetica?
Meralgia paresthetica is a condition characterized by tingling, numbness and burning pain in the outer part of your thigh. The condition is caused by compression of the lateral femoral cutaneous nerve, which supplies sensation to your upper leg.
Signs of Meralgia paresthetica?
Tingling and numbness in the outer (lateral) part of your thigh
Burning pain on the surface of the outer part of your thigh
These symptoms commonly occur on one side of your body and might intensify after walking or standing.
Causes of Meralgia paresthetica?
Tight clothing, obesity or weight gain, and pregnancy are common causes of meralgia paresthetica.
However, meralgia paresthetica can also be due to local trauma or a disease, such as diabetes.
What is Femoracetabular Impingement (FAI)?
Femoroacetabular impingement (FAI), also called hip impingement, is a condition where the hip joint is not shaped normally. This causes the bones to painfully rub together.
Risks for FAI?
FAI is a common cause of hip pain in adolescents, adults, and athletes of all ages.
Signs and Diagnosis of FAI?
Limping
Stiffness in the hip
Hip pain that worsens during physical activity or long periods of sitting
Need History, Exam, Imaging
What is a hip Labral Tear?
Hip impingement occurs when the ball of the hip pinches against the socket. This can cause damage to the labrum, the cartilage that surrounds the hip socket, and lead to stiffness, pain and/or arthritis in the hip.
Symptoms of hip labral tear?
A locking, clicking or catching sensation in your hip joint
Causes of hip labral tear?
Trauma. Injury to or dislocation of the hip joint — Structural abnormalities. Repetitive motions.
What is a hip fracture?
Ahip fractureis a partial or complete break of the femur (thigh bone), where it meets your pelvic bone. It’s a serious injury that requires immediate medical attention.The MCC of hip fractures are falls in the elderly.
Risks of hip fracture?
Age - Women aged>85 years are 10 times more likely than women aged 60-69 years to sustain a hip fracture.
Sex - White women aged>65 years are at higher risk for hip fracture than black women.
Osteoporosis, tobacco and alcohol use
Signs of hip fracture?
Inability to get up from a fall or to walk Bruising and swelling in and around your hip area
Inability to put weight on your leg on the side of your injured hip
Severe pain in your hip or groin
Shorter leg on the side of your injured hip Outward turning of your leg on the side of your injured hip
What is a pelvic fracture?
Fracture of the os coxa.
Signs of pelvic fracture?
Significant trauma. A pelvic fracture is usually diagnosed by the presence of bone tenderness, difficulty walking or doing other movements and any loss of nerve function in the lower part of the. There may be injuries to organs within the pelvic ring such as the intestines, kidneys, bladder or genitals.
What is Septic Arthritis in the hip?
Septic arthritis is a painful infection in a joint. The infection can come from germs that travel through your bloodstream from another part of your body. Septic arthritis can also occur when a penetrating injury delivers germs directly into the joint.
Risks/Cause of SA of hip?
Infants and older adults are most likely to develop septic arthritis.
Knees are MC affected, but septic arthritis also can affect hips, shoulders and other joints.
Risk factors: Age >80, DM, RA, Prosthetic joint, recent joint surgery, skin infection, IV drug abuse,
previous intra-articular corticosteroid injection, etc
Signs of SA of hip?
Septic arthritis typically causes extreme discomfort and difficulty using the affected joint. The joint could be swollen, red and warm, and you might have a fever.
Xray looks similar to OA or FAI.
what is Piriformis Syndrome
Piriformis syndrome is a condition in which the piriformis muscle, located in the buttock region, spasms and causes buttock pain. The piriformis muscle can also irritate the nearby sciatic nerve and cause pain, numbness and tingling along the back of the leg and into the foot
Symptoms of Piriformis syndrome?
Increasing pain after sitting for longer than 15 to 20 minutes
Pain/paresthesia radiates to posterior thigh, usually stops above knee
Pain improves with ambulation
Pain with rising from seated to standing.
Change of position does not relieve pain completely
Buttock pain with posterior thigh radiation, sciatica symptoms.
Weakness and numbness are rare compared to lumbar radicular symptoms.
Tests of Piriformis Syndrome?
Positive log roll with sciatic notch tenderness
Unlike sciatica from disk herniation, piriformis syndrome is exacerbated by active external hip rotation
Hip Flexion (knee straight) ROM
90°
Hip Flexion (knee flexed) ROM
120-135°
Hip Extension ROM
15-30°
Hip Internal rotation ROM
30-40°
HIP External rotation ROM
40-60°
Abduction w/ knee extended
45-50°
Adduction w/ knee extended
20-30°
Reflex Scoring?
Documentation:
4+/4: Very brisk, hyperactive, with clonus (rhythmic
oscillation between flexion and extension)
3+/4: Brisker than average, possibly but not necessarily indicative of disease
2+/4: Average, normal
1+/4: Somewhat diminished, low normal
0/4: No response
Patellar Reflex root?
L3/L4 Nerve Root
Achilles Reflex root?
S1 Nerve Root
Muscle strength scoring?
+0/5: No muscular contraction detected
+1/5: Barely detectable flicker/trace of contraction
+2/5: Active movement with gravity eliminated
+3/5: Active movement against gravity
+4/5: Active movement against gravity and some resistance
+5/5: Active movement against full resistance without evidence of fatigue (normal muscle strength)
Hip Flexion muscle and nerves?
Iliopsoas muscle
Femoral nerve (L2-4)
Ventral rami of lumbars (L1-2)
Hip extension muscle and nerves?
Gluteus maximus muscle
Inferior Gluteal nerve (L5,S1, S2)
Hip Abduction muscle and nerves?
Gluteus medius & minimus m.
Superior Gluteal nerve (L5, S1)
Hip adduction muscles and nerve
Adductor longus muscle, Adductor brevis, Addcutor magnus, Pectineus, Gracilis Obturator nerve (L2-4)
HIP internal rotation muscle and nerve
Iliopsoas Femoral nerve (L2-4)
HIP external rotation muscles and nerve
Internal and external obturators, quadratus femoris, Superior and Inferior gemelli Sacral plexus (L4-S2)
Knee dermatome root
L4
Inguinal ligament dermatome root
L1
Great toe dermatome root
L5
Posterolateral calf and little toe dermatome root
S1
Pulse Scoring?
\+4/4: Bounding \+3/4: Strong, full, increased \+2/4: Average intensity (normal) \+1/4: Diminished, barely palpable 0/4: Absent, not palpable
Edema Scoring
0: Absent (normal)
1+: Barely detectable, slight pitting (2mm); disappears rapidly
2+: Slight indentation (4mm); 10-15 sec
3+: Deeper indentation (6mm); >1 min
4+: Very marked indentation (8mm); 2-5 min
How to do Log Roll test
Roll the patient’s leg into internal and external rotation.
(+) Test: Pain
Log Roll Indications:
Anterior/groin pain: indicates intra-articular pathology (SCFE, FAI, AVN, etc.)
• Posterior pain: indicates piriformis syndrome with TTP in sciatic notch.
How to do FAIR test
Flexion, Adduction, Internal Rotation, while stabilizing the hip.
Indications of a FAIR test
(+) Test: Pain in the sciatic/gluteal area
• Indicates: Piriformis syndrome
What is a C-sign and what does it indicate?
Patient characteristically points to the source of pain with two fingers or cups just above the trochanter with the thumb and index finger
• Indicates: Intra-articular pathology
What is Labral Loading?
Flex the patient’s knee and hip to 90 °, load into the femur towards the innominate
What does Labral loading test for?
- (+) Test: hip pain
* Indicates: Labral or cartilaginous pathology
What is Labral Distraction?
Distract patient’s femur away from innominate
What does labral distraction test for?
(+) Test: Improvement of pain
• Indicates: Labral or cartilaginous pathology
What is a scour test?
Flex and externally rotate patient’s hip. Load into socket and articulate through annular range of motion.
What does a scour test for?
(+) Test: Pain
• Indicates: Labral or articular cartilage pathology
What is a FABER test?
Patient’s hip is flexed, abducted and externally rotated. Physician induces further external rotation by applying a posterior force at the knee.
What does a FABER test for?
(+) Test= anterior subluxation of hip or pain
• Indicates: Intra-articular pathology.
Also -iliopsoas bursitis/strain, SI joint dysfunction.
What is a jump sign?
Patient seated. Pressure is applied to greater trochanter
What does jump sign test for?
(+) Test: patient withdraws or “jumps” with pressure
• Indicates: Trochanteric Bursitis
What is a Straight Leg Raise Test?
Patient supine. Passively flex patient’s ipsilateral hip with knee extended
What does Straight Leg Raise Test for?
Pain with resisted straight leg raise= SCFE, femoral acetabular impingement
(+) Test: Lateral leg pain occurring between 15-30˚ indicates IT band contracture
• (+) Test: Pain occurring between 30-60˚indicates lumbosacral radiculopathy and/or sciatic neuropathy
• (+) Test: Pain occurring between >70˚ is more likely mechanical low back pain due to muscle strain or joint disease.
What is the Modified Trendelenberg?
Patient stands with feet shoulder width apart and lifts one leg off the ground
What does Modified Trendelenberg test for?
(+) Test: Drop in the height of the iliac crest on the side of the lifted leg
• Positive test indicates weakness in hip abductor muscles, including gluteus medius and gluteus minimus on planted leg side
What is Ober’s Test
Patient lateral recumbent with physician standing behind patient. Physician abducts the top leg and then lowers leg to the table (adducts) while stabilizing hip.
What does Ober’s test for?
(+) Test: Inability to adduct
• Indicates: IT band contracture
What is Thomas test?
• Patient supine and pulls knees to chest. One leg is lowered to the table to test the flexibility of the hip flexors.
What does the thomas test look for?
(+) Test: Inability to fully extend leg, or opposite leg raises off table
• Indicates: Hip flexor (iliopsoas) contraction
How to treat Psoas?
MET/ART for Hip Flexion SD
how to treat Hamstrings
MET/ART for Hip Extension SD: Hamstrings
patient supine with leg on shoulder of physician
How to treat Gluteus maxiumus?
MET/ART for Hip Extension SD
supine with hip and knee flexed.
How to treat Internally Rotated Hip SD
Hip and knee flexed and go into external rotation
How to treat Hip Abduction?
ITB/Tensor fascia lata
Go into hip adduction with patient supine
How to treat long Adductors?
Supine with leg extended and abduct the leg.
How to treat short adductors?
Supine with knee flexed. One hand on contralateral hip and on on the ipsilateral knee. and pushes down on the knee to abduct it.
