Differential Diagnosis for the Hip Flashcards
Differential Diagnosis
What should we ALWAYS do to determine if it is the cause of hip symptoms ?
Always screen Lumbar Spine movement and provoke the spine to determine if it is the cause of hip symptoms.
Differential Diagnosis
What am I = ?
- Male, 54 y/o
- Buttock pain
- Decreased hip flexion & IR
- (+) Hip SCOUR
- (+) Stinchfield test
Think classification, characteristics, therapy and exercise
Hip OA
(a) Classification:
- Hip Osteoarthritis
- Hip DJD
- End stage Osteoarthritis (ESOA)
(b) Characteristics:
Pain Pattern =
- Buttock Pain
- Pain with weight bearing
Risk Factors =
- Male
- Over 50 y/o
- ↓ ROM hip IR & flexion
- Heavy loads / Physical Work
- History of labral or congenital hip conditions.
- FAI also sets up OA
- Higher BMI
Observation =
- ↓ overall hip ROM
- ↓ hip flexion & IR (most limited)
- Morning stiffness, w/ progression to limp.
- Trendelenburg
- Examination =
- (+) Hip SCOUR
- (+) FADIR
- (+) FABRE
- (+) Stinchfield test
- Flex. - 120
- Ext. - 30
- Abd. - 45
- Add. - 20
- Ext. Rot. - 45
- Int. Rot. - 45
Differential Diagnosis
Hip OA:
- Manual Therapy = ?
- Therapeutic Exercise = ?
(c) Manual Therapy:
Joint Mobilization
- Mobilizations for all ROM
- Hypomobility in hip IR, ER, and flexion.
- LE Traction & tractional manipulation
- Contract-relax stretching
STM/MFR
- Treat associated / co-occurring soft tissue dysfunction in glutes, piriformis, hip rotators, and hip flexors w/ cross friction, pin & stretch, ischemic compression, and sustained release techniques.
(d) Therapeutic Exercise:
Motor
- Joint mobility & flexibility exercises all ROM.
- Gluteal strengthening
- Beginner: Glut sets, supine hip snow angel (abd/add), isometrics, bridges, LE PNF patterns.
- Intermediate: Squatting & lunging in available ROM, bridging off one leg, hip IR & ER rotation mobility.
- Advanced: SL RDL’s, SL squats, SL step downs, side-planks with hip abduction.
Sensory:
- Balance retraining & proprioceptive awareness.
- Adding multi-task skills to previous therex activities.
- Core strengthening
Differential Diagnosis
True or False:
- Radiographic evidence of hip OA is a good marker of someone’s function and pain ?
- Radiographic evidence of hip OA is NOT a good marker of someone’s function and pain.
- Some individuals with hip OA do not have pain, some without OA have hip pain.
Differential Diagnosis
Hip Osteoarthritis:
- What ages are at greater risk = ?
- What pathologies are associated with development of OA = ?
Hip Osteoarthritis:
- Most common hip problem in adults.
- Degenerative changes of articular cartilage and subchondral bone.
- Prevalence rate is up to 27% of adults.
- Biggest risk factor for OA is age.
- Middle aged and older adults; ages 60-74 are at greater risk.
- Occupations lifting heavy loads over a long duration.
- Related to a larger BMI
- Developmental disorders can influence onset and progression.
- Dysplasia, retroversion, anteversion, coxa valga/vara, labral pathologies are associated with development of OA.
- Cutting and running sports may be a risk factor.
Differential Diagnosis
These variables make you think = ?
- Acetabular retroversion
- Older age
- Loss of hip IR
- Higher BMI
- Male
Hip OA:
(a) Anatomical Features:
- Acetabular retroversion is associated with OA.
- Cartilage defects and bone marrow lesions in anterior and central superiolateral regions of joint may lead to development of hip OA.
(b) Risk Factors:
- Hip development disorders
- Developmental Dysplasia of hip (DDH)
- Older age
- Loss of hip IR
- Higher BMI
- Male sex
Differential Diagnosis
Clinical Prediction Rules for diagnosing hip OA = ?
Clinical Prediction Rules for Diagnosing Hip OA:
(I) First version of CPR:
- Hip IR less than 15 degrees
- Hip flexion less than 115 degrees
- Age greater than 50
(II) Second version of CPR:
- Hip IR less than or equal to 15 degrees.
- Pain with hip IR
- Duration of morning stiffness of the hip less than 60 minutes
- Age greater than 50 y/o
(III) 3rd version:
- Self reported squatting as aggravating factor
- Active hip flexion causes lateral hip or groin pain
- (+) SCOUR test, and lateral or anterior hip pain
- Active hip extension causes pain.
Passive IR less than 25 degrees
Flex. - 120
Ext. - 30
Abd. - 45
Add. - 20
Ext. Rot. - 45
Int. Rot. - 45
Differential Diagnosis
Five variables associated to radiographic evidence of hip OA = ?
Five variables associated to radiographic evidence of hip osteoarthritis:
- Self reported squatting as aggravating factor
- Active hip flexion – causes lateral hip or groin pain
- Scour test (+) - lateral or anterior hip pain
- Active hip extension causes pain
- Passive IR less than 25 degrees
Differential Diagnosis
Impairments in people with hip OA = ?
Impairments in people with hip OA:
- Decreased ROM (Globally but specifically Flexion and Internal Rotation)
- Balance Disturbances
- Muscle tightness - Hip flexors and rotators
- Muscle weakness
Differential Diagnosis
Hip OA special test include = ?
Hip OA Special Test:
- FADIR
- Scour
- FABER
- Stichfield test (resisted STLR)
Differential Diagnosis
Describe how to carry out FADDIR Test = ?
(a) Client Position:
- Supine with bilateral legs lying extended and arms relaxed at side
(a) Clinician Position:
- Standing next to leg to be assessed, directly facing the client
(c) Movement:
- The combined motions of flexion (typically about 90°) and adduction to end range are initially performed as shown.
- The clinician then maintains adduction with overpressure while performing IR of the hip with overpressure to that motion as well.
(d) Assessment:
- Reproduction of the client’s concordant groin pain and/or clicking or popping with concordant pain is suggestive of hip impingement or labral tear.
- This combined movement engages the femoral head–neck junction into the anterior superior labrum and acetabular rim.
- It is suggested that this combined motion causes a mechanical abutment of the femoral head on the acetabulum and/or shearing force on the labrum.
Differential Diagnosis - Treatment for OA:
Most patients eventually progress to = ?
Treatment for OA - Progression and Management:
(a) Most patients eventually progress to total hip replacement.
(b) Management for Hip OA:
- A level evidence for manual therapy – short term relief
- A level evidence for exercises – flexibility and strengthening
- C level evidence for balance training
- B level Patient education
- B level evidence for ultrasound
Differential Diagnosis
Objective Measures for the Hip:
- Self report outcome measures = ?
- Functional Tests = ?
(a) Self report outcome measures:
- Hip disability and osteoarthritis outcome score (HOOS)
- Western Ontario McMaster University Index
- Visual Analog Scale
- Lower Extremity Functional Scale
- Harris Hip Score
(b) Functional Tests
(b.1) 30 second chair stand test:
- Sit to stand out of chair in 30 seconds
- 12.6 sit to stand (in hip OA population)
- Minimal detectable change (3.5 reps)
(b.2) Step Test:
- Feet placed on the ground
- The uninvolved foot started from the ground and then up to the step as many times as possible in in 15 seconds
- Compare to the uninvolved side
- Should complete 14 or more steps
(b.3) Timed Single-Leg Stance
- Single limb balance compare bilaterally
(b.4) Berg Balance Assessment
Differential Diagnosis
Hip Femoral Acetabular Impingement:
- Classification = ?
- Characteristics = ?
Hip Femoral Acetabular Impingement:
(a) Classification:
- FAI
- Hip Impingement
- Cam Lesion
- Pincer Lesion
- Pistol Grip Deformity of the hip
(b) Characteristics:
Groin Pain:
- Pain with end range of motion at the hip
- Stiffness in younger patient unlikely to have OA
- Progresses to limping
Risk Factors:
- Between 25-50 y/o
- Rigorous sports with end range of motion, twisting, pivoting
- Prior history of hip strain or trauma
- male gender slightly more common than females but later onset FAI may be more common in females in 40’s.
Observation:
- Decreased Hip ROM
- Pain
Examination:
- (+) FADIR
- (+) FAIR test
- (+) FABRE
- End range hip mobility restrictions and pain especially with IR.
Differential Diagnosis
What should the manual therapy and therapeutic exercise for Hip Femoral Acetabular Impingement include ?
Hip Femoral Acetabular Impingement - Manual Therapy & Therapeutic Exercise:
Joint Mobilization:
- Perform mid-range mobilizations for all hip ranges of motion.
- Address hypomobility in the hip, avoiding end-range pain with mobilization.
- Consider LE Traction.
- Administer Soft Tissue Release to hip flexors and deep hip rotators.
Soft Tissue Mobilization/Myofascial Release (STM/MFR):
- Target associated/co-occurring soft tissue dysfunction in glutes and deep hip rotators using techniques such as Cross Frictional Release, Pin and Stretch, and Ischemic Compression.
Therapeutic Exercise:
- Motor:
- Utilize Isometric Control and Coordination exercises to limit end-range contact.
- Perform strengthening exercises within pain-free mid-range and end-range motion, avoiding overly vigorous stretching/flexibility exercises.
- Focus on strengthening glutes, short hip rotators, and core stability with combined exercises.
- Exercise examples include Isometrics, quadruped hip mobility, Bridges, side planks, pelvic drops, RDL’s, Single leg step downs, Monster walks/lateral band walking, and Hip flexor mobility within pain-free range.
- Sensory:
- Implement Balance retraining for control of hip joint and distal Lower Extremity (LE) to reduce hip forces.
- Incorporate additional cognitive, visual, or auditory tasks into therapeutic exercises.
- Introduce Blazepod training and Hip alphabet exercises for sensory enhancement.
Differential Diagnosis
Hip Acetabular Impingement:
- Pincer lesion = ?
- Cam lesion = ?
(a) Structural variations of femur and or acetabulum.
- Can have labral tear with impingement.
(b) Avoid activities of impingement;
- End range flexion
- IR
(c) Classified as;
- Pincer
- CAM
- Combo (pistol grip deformity)
Differential Diagnosis
What am I = ?
- Pain in groin,
- Pain in anterior & lateral hip,
- Pain w/ flexion, adduction, and internal rotation
- Hip IR < than 20 degrees at 90 degrees of flexion
- “Popping” , “Clicking” , “Locking”
Diagnosis and Classification of Hip Impingement:
- Pain in anterior hip/groin
- Pain in lateral hip
- Achy or sharp pain
- Pain w/ flexion adduction internal rotation (FADIR)
- Hip IR less than 20 degrees at 90 degrees of flexion
- Signs and symptoms: “popping”, “clicking” , “locking”
Radiological features:
- Alpha angle greater than 60 degrees
- Crossover sign for hip retroversion
Differential Diagnosis
Treatment for Hip FAI includes = ?
Treatment for Hip FAI:
(a) Avoid end ranges of motion/stretching
- Focus on better control of mobility.
(b) Start with isometrics and controlled segmental movements
- Progress to stretching with limitations on how vigorous it is performed.
(c) Strengthening:
- Beginner: Glut sets, Supine hip snow angel (abd/add), isometrics, bridges, piriformis & hip flexor stretching avoiding terminal range if painful, LE PNF patterns, Clamshells, core control exercises.
- Intermediate: Squatting & lunging in available ROM, Bridging off one leg or on Swiss ball, Hip IR & ER rotation mobility, lateral band walking, pelvic drops off step.
- Advanced: Single leg RDL’s, Single leg squats, Single leg step downs, Side-planks with hip abduction, Y balance, 3 way lunges,
Differential Diagnosis
Hip Labral Pathology:
- Classifications = ?
- Characteristics = ?
Hip Labral Pathology:
(a) Classification:
- Hip Labral Tear
- Femoral Acetabular Labral Tear
(b) Characteristics:
Pain Pattern =
- “Clicking”, “Popping” , “Catching”
- Anterior hip
- Groin Pain
- Pain with end ROM (hip)
- Stiffness in younger patient unlikely to have OA
- Progresses to limping
Risk Factors =
- Pre-existing FAI
- Trauma
- Capsular Laxity
- Hip hypermobility
- Dysplasia
- DJD
- Repetitive Microtrauma
- Prior history of hip strain/trauma
- Female gender more common
- Males = more traumatic labral injuries
- Hyperabduction, Hyperextension, Hyper-flexion, and ER all place labrum at risk
(b.3) Observation
- Females = Increased hip ROM
- Males = Decreased Hip ROM
- Pain
- “Clicking”
(b.4) Examination
- (+) FADIR
- (+) FAIR test
- End range hip mobility restrictions w/ pain especially with IR
- Inguinal “clicking” and “giving way”
Differential Diagnosis
Manual therapy & therapeutic exercise for hip labral pathologies include = ?
Hip Labral Pathology- Manual Therapy & Therapeutic Exercise:
Joint Mobilization:
- Perform mid-range mobilizations for all hypomobile ranges of motion.
- Avoid mobilizations that induce end-range pain.
- Consider LE traction.
- Utilize Soft tissue release techniques targeting hip flexors and deep hip rotators.
- Soft Tissue Mobilization/Myofascial Release (STM/MFR):
- Address associated soft tissue dysfunction in glutes, deep hip rotators, and psoas.
- Employ techniques such as Cross Frictional Release, Pin and Stretch, and Ischemic Compression.
Therapeutic Exercise:
- Motor:
- Begin with Isometric Control and Coordination exercises to limit end-range contact.
- Perform exercises within pain-free mid-range and end-range motion.
- Avoid overly vigorous stretching/flexibility exercises for all hip musculature.
- Strengthen glutes and short hip rotators.
- Incorporate Core stability exercises combining glute, adductor, and abductor strengthening.
Exercise Examples:
- Isometrics, quadruped hip mobility, Bridges, side planks, pelvic drops, RDL’s, Single leg step downs, Monster walks/lateral band walking, Hip flexor mobility within available pain-free range.
Sensory:
- Focus on Balance retraining for hip joint control and distal lower extremity control to minimize hip forces.
- Introduce SL exercises for sensory enhancement.
Differential Diagnosis
Labrum functions to provide = ?
Labrum functions to provide
- Stability
- Shock absorptions
- Maintains fluid pressure
- Deepens the joint
- Expands surface area of the Acetabulum
Differential Diagnosis
Five major etiologies linked to labral tears = ?
(a) Five major etiologies linked to labral tears:
- Trauma
- FAI
- Capsular laxity/hip hypermobility
- Dysplasia
- Degeneration
Differential Diagnosis
What am I = ?
- Pain with FADIR and FABER
- Inguinal clicking and giving way
- Feeling of instability
Diagnosis and classification of labral tears, osteochondral lesions and loose bodies:
- Inguinal clicking and giving way correlated (r = 0.79) with labral tear.
- Sharp pain, especially with clicking for labral tear, helps to rule out (SN 100, −LR 0) and rule in (SP 85, +LR 6.7)16 labral tear.
- More recently, the most commonly reported locations of pain were the central groin and the lateral peritrochanteric area. The least common were the ischial tuberosity and the anterior thigh.
- Pain with FADIR and FABER
- Popping, locking or snapping
- Feeling of instability
Differential Diagnosis
Hip Labral Tears:
- Examination Procedures = ?
Hip Labral Tears - Examination Procedures:
(a) FAIR test
(b) Range of motion (all planes)
- Seated, supine, and prone
- Assess for excessive mobility – stretching contraindicated.
- Assess for possible retroversion and anteversion.
(c) Strength testing -
- Flexors
- Extensors
- Abductors
- Adductors
- Rotators
Treatment for Labral Dysfunctions:
- Focus more on Mid or End-Range = ?
Treatment for Labral Dysfunctions: The difference treating labral tears and OA =
- Avoid end range mobilizations.
- Focus on mid-range control and strengthening of hip and core.
Intra-Articular Hip Disorders
Hip Labral Dysfunctions:
- Patient outcome measures = ?
Hip Labral Dysfunctions - Patient Outcome Measures:
- Modified Hip Harris Score
- Hip Disability and osteoarthritis outcome score (HOOS)
- WOMAC score
- Functional testing (Trendelenburg gait pattern, squat)
Differential Diagnosis
What am I = ?
- Female
- Marathon runner
- Anterior hip pain
- Pain at rest and at night
- Hip & groin pain
- “Clicking” sound
- (+) Patellar-pubic percussion test
- (+) Fulcrum Test
Hip Stress Fractures:
(a) Classification:
- Bone stress injury
- Stress Fracture
- Pathological Fracture
(b) Characteristics:
(b.1) Pain Pattern:
- Insidious of gradual onset of worsening hip/groin/leg pain
- Increase pain during late stages of sporting event or activity
- Progresses to pain at rest and at night
(b.2) Risk Factors
- Marathons / long distance running
- Basic Training in the military
- Female
- Poor baseline physical fitness
- Sharp increase in training intensity
- Female triad: Amenorrhea, eating disorder, and decreased bone mineralization disorder.
Observation:
- Often non-specific examination
- Pain at end range of mobility
- Pain in anterior hip or inguinal area
- ‘Clicking’
Examination:
- (+) Patellar-pubic percussion test
- (+) Fulcrum Test
- Log rolling of LE or STLR may also aggreviate.
- X-rays, MRI, Bone scan used to detect
Differential Diagnosis
Hip Stress Fractures:
- Treatment = ?
Hip Stress Fractures:
(a) Treatment:
(a.1) Initial Treatment:
- Non-weight bearing crutch usage 6-8 weeks
- 12 weeks before resuming activity/athletics
(a.2) Joint Mobilization:
- Not indicated early in case
- Later on these could be used to treat preexisting impairments
- Soft tissue release to hip flexors, deep hip rotators
(a.3) STM/MFR:
- Treat associated/co-occurring soft tissue dysfunction in glutes, deep hip rotators with Cross Frictional Release
- Pin and Stretch
- Ischemic Compression
Differential Diagnosis
Describe how to carry out the Patellar-Pubic Percussion Test = ?
Patellar-Pubic Percussion Test:
(a) Client Position:
- Relaxed supine position with bilateral lower extremities straight
(b) Clinician Position:
- Standing at the side of the lower extremity to be tested, directly facing the client
(c) Movement:
- The clinician places a stethoscope over the pubic tubercle on the ipsilateral side of the lower extremity being tested (right as shown). The clinician listens through the stethoscope as they tap the ipsilateral patella. Tapping and placing a tuning fork over the patella can also be used in place of tapping the patella directly.
(d) Assessment:
- A (+) test is a diminished percussion noted on the side of pain indicating a potential femur fracture.
Statistics:
- SN = 95 (92-97)
- SP = 86 (78-92)
- Positive (+) LR = 6.11
- Negative (−) = LR 0.07
Differential Diagnosis
Describe how to carry out the Stress Fracture Test (Fulcrum Test) = ?
Stress Fracture Test (Fulcrum Test:
Client Position:
- Relaxed sitting position on the end of the table, with bilateral feet over the edge.
Clinician Position:
- Sitting at the end of the table, directly the facing client.
Movement:
- The clinician places one forearm (left as shown) under the client’s thigh to be tested. With their other hand (right as shown), the clinician applies a downward pressure to the proximal knee. This test can be repeated in successively more proximal areas on the femur assuming the test is negative with testing of previous location.
Assessment:
- A test is considered (+) for stress fractures if the client reports pain with the maneuver.
Statistics:
- SN = 93 (NR)
- SP = 75 (NR),
- Positive (+) = LR 3.7,
- Negative (−) LR = 0.09
- QUADAS = 5
Differential Diagnosis
What am I = ?
- Insidious onset
- Anterior hip pain
- Pain with weight bearing
- Single Hop test recreates pain
Hip Stress Fracture:
- Anterior hip pain with weight bearing.
- Better with rest until fracture progresses.
- Insidious onset
- Need to Normalize running mechanics
- Rest 6 week up to 12 months depending on the type of fracture
- Assess and treat muscle imbalances at the hip and lower extremity
- Address Nutritional Deficits RED syndrome (Relative Energy Deficit)
- Prior history of Bone Stress Injury is number one risk factor.
- Focal tenderness to Palpation <10 cm
- Single Hop test recreates pain
- 85% of stress fractures are missed on first x-ray so don’t rule out stress fracture even if the x-ray is clean.
Differential Diagnosis
What am I = ?
- Patient reports to PT with anterior hip and groin pain after a car accident.
- Presents with limited mobility and guarding.
Hip Dislocation:
(a) Classifications:
- Hip Dislocation
- Hip posterior dislocation
(b) Characteristics:
(b.1) Pain Pattern:
- Anterior hip and groin pain
- Patient will come to PT after period of immobilization; potentially after surgery if boney fractures occurred to acetabulum.
- On crutches or with significant limping.
(b.2) Risk Factors:
- Congenital or Acquired
- After a total hip replacement (early on due to lack of surgical healing or later due to failure of prosthetic components)
- Car Accidents
- Serious falls (Football or Rugby)
(b.3) Observation:
- Pain
- Limited mobility and guarding
- Patient will come in with hip abductionbrace
(b.4) Examination:
- NA due to ER / hospital management of dislocation and known patholgy upon presentation to therapy.