Examination of the Hip Flashcards
1
Q
Define Hip/Groin Pain.
A
- Pain suffered near the hip and/or groin can arise from a number of different sources including lumbar spine, pelvis, and sometimes knee.
- Primarily, true hip pathologies are of intraarticular origin (OA, labral tears) and will exhibit symptoms in the buttock and/or groin with referral to the knee.
- However, it is not unusual for the hip joint to refer pain outside the immediate hip and/or groin area.
2
Q
Há condições em que a causa da dor não está no quadril. Refere algumas dessas situações.
A
- Discogenic referred pain patterns.
- Primary pain zones: low back (including hip/buttock), proximal leg (thigh), and lower leg (below the knee).
- Lumbar zygapophyseal referred pain patterns.
3
Q
O que nos diz a prevalência?
A
- Hip pain associated with OA is the most common cause of hip pain in older adults with prevalence rates reported anywhere from 0.4% to 27%.
- Symptoms increased with age and were more prevalent in women.
- In younger patients, sports injuries about the hip and pelvis are most common in ballet dancers, soccer players, and runner (incidence of 44%, 13%, and 11%, respectively).
4
Q
Quais são os padrões mais comuns quanto à dor referida do quadril?
A
- Buttock 71%.
- Thigh 57%.
- Groin 55%.
- Leg 16%.
- Foot 6%.
- Knee 2%.
5
Q
Amy Moore is 32 years old and recently engaged. Amy’s left hip pain had gone from a being a bother after her last triathlon 6 months ago to being a true burden that has negatively influenced her work and her lifestyle. Initially, her pain levels were only 3 to 4 out of 10, but had worsened to 7/10 recently, especially when sitting, standing for long periods, or attempting to run and cycle. Her worsening condition had gotten to a point where she knew she had to seek help from a healthcare provider; specifically her general medical practitioner and finally an orthopedic surgeon. She also reports a prior history of low back pain. She did receive x-rays (of the hip) many months ago (which were negative) and had follow up imaging in 2 months after her symptoms didn’t resolve (again negative). She describes the pain as an intermittent, tight ache with episodes of sharp/pinching pain located in the anterior hip and groin. She denies any medication use as she reports she is against trying anything “unnatural”. Ms. Moore reports a history of low back pain. Which could be considered a likely contributor?
A
The L1/2 discogenic referred pain pattern is often into the anterior groin and thigh.
6
Q
Which of the following is NOT considered one of the 5 major ligaments of the hip joint?
Sacrotuberous ligament; Iliofemoral; Pubofemoral; or Ligamentum teres.
A
Sacrotuberous ligament. It is related to the pelvis and SI.
7
Q
Porque é que é importante conhecer a natureza e tipo de sintomas?
A
• It is important to identify all areas of pain to help rule in/rule out specific hypotheses – Ex: Bilateral, below the
knee?
• Identifying pain type helps to further narrow down hypothesis when considering differential diagnosis – Ex: Burning pain is more typical of nerve pathology versus a dull ache is most often associated with intraarticular pathology (hip OA).
8
Q
Que tipo de questões podemos colocar para perceber a irritabilidade dos sintomas?
A
• Aggravating Factors
– What activities make your symptoms worse? Ex: Sitting, Squatting, Rotation, Stairs, shoes.
– What is the pain level during these activities?
– Does it worsen immediately or over time?
– After stopping the activity, how long before your pain level returns to normal?
• Relieving Factors
– As above.
9
Q
Quais são as características mais comuns dos sintomas do quadril?
A
- Symptoms worse with activities
- Twisting, such as turning or changing directions
- Seated positions secondary to prolonged periods of hip flexion (muitas vezes associada a um impingement)
- Rising from seated position
- Difficulty stairclimbing
- Increased symptoms with entering/exiting automobile secondary to hip flexion in combination with twisting maneuver
- Difficulty don/doff shoes, socks.
10
Q
Exemplifica questões que nos ajudam a entender a história da condição presente.
A
- When and how did this start?
- How long have you been suffering from these symptoms?
- Do you have a previous history of these symptoms?
- Have you undergone any imaging?
- Course of symptoms – Are you better, worse, or the same?
- Have you undergone any previous treatment? – Was it effective?
11
Q
O que são yellow flags? Dá exemplos.
A
• Factors that may affect treatment plan • Psychosocial factors – Patient’s beliefs – Coping strategies – Distress/illness behavior – Willingness to change – Patient’s social, occupational and economic status
12
Q
Que fatores constituem as blue flags?
A
• Features of work generally associated with increased rate of symptoms (desempenham um fator importante para perceber como o utente irá responder ao tratamento). • Derived out of the stress literature – High demand and low control – Unhelpful management style – Poor social support from colleagues – Perceived time pressure – Lack of job satisfaction
13
Q
Quais as black flags?
A
• Established policy concerning work conditions
– Rates of pay
– Negotiated entitlements
– Sickness policy
– Restricted duties policy
– Organization size and structure
– Trade union support
– Also ergonomics (posture, lifting, etc)
– Temporal characteristics (length of shift).
14
Q
Exemplifica questões especiais que nos ajudam a determinar uma dor de origem não mecânica.
A
• Do you notice any feelings of numbness or pins and needles bilaterally?
• Have you suffered any recent weight loss?
• Do you ever feel as though you are stumbling while walking
• Have you suffered any recent bowel/bladder changes?
• Do you suffer from any pins/needle like feelings in the inner groin area?
(A presença destes sintomas pode ser revelar compressão da medula ou cauda equina, pelo que implicam referir para outro profissional de saúde)
15
Q
Para que servem as outcome measures na prática clínica? Enumera alguns benefícios.
A
- (Standardised) Measurement of health status
- Setting Goals for Treatment
- Monitoring change over time (progress)
- Informing clinical decision making (management)
- Evidence to patient and users
- Reimbursement
- Quality assurance and enhancement
- Provide evidence of health and need in groups
- Essential component of research assessing effectiveness.
16
Q
Quais os pricipais requerimentos que constituem uma outcome measure?
A
- Standardised Measurement
- Validity
- Reliability
- Able to detect change (when it has occurred) - MCID or Minimum clinically important difference
- (Acceptability to patients and others)
17
Q
Quais as outcome measures com melhores propriedades psicométricas para problemas na anca?
A
- The Hip Outcome Score (HOS) and the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS) received the best ratings for their psychometric properties.
- Authors report that HOOS has adequate psychometric properties when assessing patients with hip OA undergoing conservative treatment or THR.
- HOS has adequate psychometric properties when assessing young patients (inf 50 years) undergoing hip arthroscopy.
- OHS and PASI showed adequate test-retest and inter tester reliability but more information on internal consistency, floor and ceiling effects, and responsiveness is needed.
- INGUINAL PAIN QUESTIONNAIRE (IPQ) was the only identified questionnaire evaluating groin disability and doesn’t contain adequate measurement qualities.
18
Q
Identifica algumas fraquesas da utilização de outcome measures.
A
- Do not always differentiate between whether or why a specific task is not done or can’t be done
- Do not accurately characterize or quantify the impact of the health condition nor a change in that impact
- Errors in memory or judgment, impaired cognition, willingness and ability to answer accurately
- Poor correlation between self-report and PPM
- Appear to be highly reflective of changes in pain (and what the patient is experiencing) and less reflective of changes in function.
19
Q
Porque é que há uma fraca relação entre as outcome measures e as physical performance measures?
A
“The influence of pain on self-reported physical functioning serves as an explanation for the poor relationship between self-reported and performance based physical functioning”. Por exemplo, quando uma questão diz respeito a dificuldade em subir as escadas, eles só conseguem pensar na dor que sentem a subir as escadas, o que, por vezes, não corresponde à sua performance.
20
Q
No que diz respeito a utentes com osteoartrose, quais as relações mais fortes existentes entre as performance measure e o self-reported physical function?
A
- Pain was the principal determinant of WOMAC physical Function subscale scores
- Pain, exertion, and time or distance were strongly associated with the LEFS
- Change in pain was most strongly associated with change in self-reported physical function
- Educational level, life satisfaction, and number of comorbidities were identified as significant factors for both self-reported pain and physical functioning in patients with hip OA
- Performance measures are better predictors of physical function than pain
- Factors explaining disability and pain in hip OA are multidimensional.
21
Q
O que são physical performance measures e para que servem?
A
- An observed functional task or a group of functional tasks with defined beginning and end points that is scored in some fashion.
- PPM’s are used to document a change in status for either outcomes or predictive purposes.
22
Q
Quais as principais vantagens das physical performance measures?
A
- Can be used to characterize and quantify the impact of selected conditions.
- Can be used to guide and refine treatment
- May be less influenced by pain
- Lesser influence of psychological factors and cognitive impairments which may results in recall bias.
23
Q
O que é a minimal clinically important difference (MCID)? E em que difere do minimal detectable diference (MDC)?
A
- The MCID is defined as the smallest difference in an outcome measure’s score that patients perceive as beneficial and which would, therefore, mandate a change in the patient’s management
- MCID scores are utilized by healthcare practitioners to determine patient response to treatment, either positively or negatively.
- The minimal detectable change is the smallest change in score than can be detected beyond random error and is dependent upon sample distribution.
- MCID can occur on either side of any statistical threshold and is determined by the patients in quality of life measures.
- MCID is context specific and not a fixed attribute (ex: it can change with age, gender, etc.).
24
Q
Refere alguns problemas associados à utilização do MCID.
A
- The MCID is not a universal fixed attribute and cannot be transferred across patient populations or disease specific states
- Lack of a universally accepted methodology to determine the MCID results in a wide range of reported values for a single outcome measure
- MCID scores reported as single point estimates based upon the average score of a group lack associated confidence intervals representative of the wide distribution of actual change score values.
- Use of a single point estimate runs the risk of misclassifying patients as not improved when, in fact, they have.
25
E quais os pontos fortes da utilização do MCID?
* Clinically, the MCID may be used as a threshold to detect change beyond that of random error signaling patient response to treatment
* When using an anchor-based approach, the MCID is designed to bring the patient’s perspective to prominence to help guide clinical decision making during the course of treatment
* For the clinical researcher, the MCID is often used to determine sample size calculations needed to demonstrate treatment effectiveness.
* MCID scores are context specific and are not transferable across different populations, genders, treatments and joints
* A MCID is only valid in the population from which it was originally derived
* MCID scores should not be used in isolation when determining patient satisfaction.
26
Que questão poderíamos fazer para determinar o nível de recuperação aquando da alta?
* “Taking into account all the activities you have during your daily life, your level of pain, and your functional impairment, do you consider that your current state is satisfactory?”
* Basically, this helps to identify whether the patient is good versus are they better
* Better does not always equal satisfied.
27
The timed up and go test correlates well with self-reported measures of hip function. True or false?
False. Several studies have shown low correlations between the timed up and go test and the WOMAC, LEFS.
28
True or False? The minimal clinically important difference (MCID) is the same as the minimal detectable change.
False. Minimal clinically important differences (MCID) are patient derived scores that reflect changes in a clinical intervention that are meaningful for the patient. The minimal detectable change is based upon statistics and sample distribution.
29
Que tipo de posição o utente tende a adotar em caso de problemas na anca?
* Observation performed in both standing and seated positions.
* Typically, patients with hip pain will attempt to alleviate symptoms by flexing the hip and knee to offload the joint or weight shifting away from the affected side.
30
Que pormenores costumam ser detetados na avaliação da marcha?
* Typically the stance phase will be shortened and hip flexion accentuated.
* Avoidance of hip extension.
* Trendelenburg gait – Abductor lurch; Hip hike.
* Look for stride length
* Stance phase – Shortened?
* Foot rotation – Externally rotated?
* Lumbar lordosis? – Secondary to hip flexion contracture.
31
Quais as adaptações na marcha que tendem a aparecer em casos de anca dolorosa?
– Gait analysis shows significant reduced step length (0.66 +/- .06m)
– Reduced range of motion at the knee and ankle
– Patients with hip pain walked with decreased external extension, adduction, and internal/external rotation moments
– Decreased hip extension significant correlated with increased level of pain (p
32
Quais as principais alterações da marcha em casos de utentes com osteoartrose da anca?
– Significant differences were observed in step length
– Significant differences were observed for total ground contact area between affected and healthy leg.
– Subjects with hip OA demonstrated 12.4% slower
walking speed.
33
O que é o sinal de Trendelenburg?
Patient in one foot. With normal abductor strength, the pelvis should remain level. With abductor weakness, the pelvis drops toward the contralateral side, reflecting a positive Trendelenburg test.
34
Além da marcha, que outros movimentos podemos observar?
* Deep Squat – Point of pain or weight shift
* Single leg hop – Pain reproduction
* Ascend/Descend Stairs – Which foot do they lead with; Pain reproduction.
35
Qual o propósito da triagem e screening?
• Scanning for:
– Potential sources of the condition
– Contributing factors
– Precautions and contraindications
36
Qual o tipo de questões comuns que geralmente se aplicam rm screening?
* Medical history
* Surgical history
* Weight loss
* Medications
* Other tests (radiographs, blood work, etc)
* Stress
37
O que poderemos questionar relativamente ao estado farmacológico?
* Oral Steroids – Prolonged use leads to bone density loss
* Anticoagulant therapy
* Aspirin
* Analgesics
* Nonsteroidal antiinflammatory drugs (NSAIDS)
* Hormone replacement therapy
* Recreational drug use – Altered pain perception.
38
Exemplifica questões que podem ser aplicadas para ajudar a descartar compressão da medula espinal.
– “Do you ever have pins and needles or numbness in both arms or both legs at the same time?”
– “Do you have problems with stumbling while walking?”
39
Indica duas questões que nos ajudam a descartar a síndrome da cauda equina.
– “Do you have any problems/changes with bowel and bladder?”
| – “Do you ever have pins and needles or numbness in the saddle/groin area?”
40
Quais são as red flags específicas da anca?
* Appendicitis
* Ureter
* Colon Cancer
* Femoral neck fracture
* Avascular Necrosis
41
Quais são os indicadores que podem estar associados a red flag apendicite?
* Right thigh, groin, testicular pain
* Low grade fever
* Nausea and vomiting
* Anorexia
* Rebound tenderness LR+ 1.99 (1.61, 2.45)
* Percussion tenderness LR+ 2.86 (1.95, 4.21)
* Rigidity LR+ 2.96 (2.43, 3.59).
42
Descreve o Blumberg's sign.
Find the midpoint between the umbilicus and the Right ASIS. Push directly downward (patient in supine) and release the pressure quickly. Pain upon rebound is considered a positive finding, indicative of peritonitis (SN 66; SP 75)
43
Que características apresenta a dor em problemas no ureter, que requerem referência imediata?
* Pain typically at the costovertebral angle;
* Radiate into lower abdomen, upper thigh, groin, genital;
* Intensity: excruciating.
44
Quais os sinais e sintomas que sustentam uma referência por cancro do colon?
* Age > 50
* Blood in stool
* Unexplained weight loss
* History of colon cancer in immediate family
* Pain unchanged by positions or movement
* Pain > 1 month
* Smoker?
* Hypoactive or high-pitched bowel sounds
* May have ascites (the accumulation of fluid in the peritoneal cavity, causing abdominal swelling).
45
Qual o teste específico para fratura do pescoço do fémur? Descreve-o.
Patellar-Pubic Percussion test - auscultatory percussion which is used in the assessment of bone integrity by analyzing its vibrations through the use of a stethoscope and bony prominence percussion. (SN 96; SP 86).
The patient is positioned in supine and the bell of the stethoscope is placed on the pubic symphysis, held in place by the patient. The patient's legs are positioned symmetrically and extended while the clinician percusses each patella. The clinician stabilizes the patella, insuring that the leg being tested remains in the neutral position. The clinician compares the sounds from each leg for differences in pitch and loudness. These sounds should be equal in the case of normal bony structure. If there is a bony disruption, the affected side will have a duller, more diminished sound when compared to the unaffected side.
46
Quais são os achados clínicos apontados como red flags para necrose avascular?
* History of long-term corticosteroid use
* History of avascular necrosis of the contralateral hip
* Trauma
* Sudden onset with rapid progression; may refer to groin, thigh, or medial knee
* Worse with weight bearing
* Global loss of movement
* 40-60% present with symptoms bilaterally
47
Como fazer o screen da coluna lombar em flexão e extensão?
No movimento de extensão, pede-se que o utente alance com uma das mãos a face posterior do joelho do mesmo lado, provocando extensão e rotação. Depois aplica-se overpressure.
No caso da extensão, o utente deve alcançar os pés. Para aplicar overpressure, o terapeuta estabiliza a crista ilíaca contralateral e abraça o pescoço até segurar o ombro e aplica pressão, causando uma rotação em direção a si.
48
Which findings decreases the likelihood that a patient presents with avascular necrosis?
Patients presenting with signs and symptoms of AVN typically present with bilateral presentation of symptoms, severe loss of range of motion in multiple planes, sudden onset with rapid progression and often present with a history of trauma or long term corticosteroid use.
49
Para que servem os testes funcionais?
* Functional tests are designed to provide a glimpse of pain provocation with various activities.
* Also, these tests serve as a “reassessment sign” to determine response to treatment.
50
Porque é importante testar os movimentos fisiológicos passivos?
Passive physiological movements are necessary to identify potential noncontractile structures that are pain generators.
51
Que tipo de problemas os movimentos acessórios passivos nos podem ajudar a identificar?
Typically passive accessories used to identify intra-articular pathology.
52
Quais os movimentos acessórios que devemos testar na anca?
* Anterior-Posterior Glide
* Indirect Distraction
* Direct Distraction
* Lateral Glide
* Hip Quadrant
* Posterior-Anterior Glide.
53
How to perform indirect distraction passive accessory glide?
The patient begins in a supine position. The clinician cradles the ankle of the patient into both of his or her hands or cradles the foot and ankle. The clinician then takes up the slack to preposition the hip into targeted motion. Generally, resting position of the hip includes a moderate degree of hip flexion, abduction, and slight external rotation. The clinician then provides an inferior force by leaning backward while holding the ankle.
54
Describe how to apply hip quadrant passive accessory.
The technique is performed in the supine position after assessment of resting symptoms. At 90 degrees of hip flexion, the clinician passively moves the hip into full flexion toward the ipsilateral shoulder. The clinician continues to assess patient symptoms by moving the hip into varying degrees of hip flexion and adduction to assess for reproduction of patient symptoms.
55
Quais são os principais testes de flexibilidade da anca?
* Thomas Test
* Ober Test
* FABER test.
56
How to perform Thomas Test?
The patient sits at the edge of the table or plinth. The patient is then instructed to lie back, pulling both knees to his or her chest. The asymptomatic knee is held to the chest and the other is slowly lowered into extension of the hip and the knee is allowed to extend. The patient is instructed to pull his or her pelvis into posterior rotation for a neutral spine. A positive test is significant tightness of the hip flexors of the extended leg as seen by the extension angle of the hip and/or knee.
57
Describe the Ober's test.
The patient assumes a sidelying position. The symptomatic leg is placed upward. The examinder prepositions the knee into flexion while stabilizing the pelvis at the iliac crest. The examiner then guides the lower extremity into hip extension and slight abduction. The examiner then measures the degree of abduction or adduction. A positive test is failure of the knee to drop to the plinth and is indicative of tightness of structures.
58
How to apply the FABER test?
The examiner passively positions the testing limb in a position of hip flexion, abduction, and external rotation. The examiner assesses the perpendicular distance from the knee on the tested lower extremity to the table. An increase in this distance or pain, when compared to the uninvolved side, is suggestive of intra-articular hip pathology.
59
When referring to the pubic clock, which structure is located at the 9 o’clock position?
Inguinal ligament. The inguinal ligament connects from the pubic tubercle to the ASIS.
60
The greater trochanter is often palpated for what condition?
Greater trochanteric pain syndrome. Some authors propose the benefit of palpation of the greater trochanter for ruling in/out greater trochanteric pain syndrome.
61
During the FABER test, why does an increase of the distance (from the table) or pain, when compared to the uninvolved side is suggestive of intra-articular pathology?
With intra-articular pathology, an increase in this distance or pain, when compared to the uninvolved side, is a positive test due to capsular restriction.
62
O que envolve a quality special test?
* Involves identifying or determining the etiology of a disease or condition through evaluation of patient history, physical examination, and review of laboratory data or diagnostic imaging; and the subsequent descriptive title of that finding.
* Good tests can discriminate different, similar conditions.
63
Quando usar testes com boa sensibilidade vs. especificidade?
* In the beginning of the exam as a screen – SNnOUT
| * At the end of an exam as the “icing on the cake” – SPpIN.
64
What are the guidelines for "best" special tests?
* No fatal flaws in design
* LR+ of 5.0 or higher
* LR- of 0.2 or lower
* Sensitivity of .90 or higher
* QUADAS of 10 or higher
* A test that matters.
65
Quais as cinco variáveis que podem ajudar a determinar se o utente tem osteoartrite?
* Squatting as aggravating factor;
* Scour test with adduction causing groin or lateral pain;
* Active hip flexion causing lateral pain;
* Passive internal rotation inf 25 degrees;
* Active hip extension causing hip pain.
```
5 predictors (SN .14; SP .98; LR+ 7.3; LR- .87)
4 predictors (SN .48; SP .98; LR+ 24.3; LR- .53)
3 predictors (SN .71; SP .86; LR+ 5.2; LR- .33)
2 predictors (SN .81; SP .61; LR+ 2.1; LR- .31)
```
66
Quais os testes que nos podem ajudar a determinar uma fraturas da anca ou femur?
* Patellar-pubic percussion test (SN 96; SP 86).
| * Stress Fracture Fulcrum Test (SN 100; SP 0.0; LR+ 1.0; LR- NA).
67
Descreve o Stress Fracture Fulcrum Test.
The patient sits with bilateral feet over the edge of the table. The examiner places one forearm under the patient’s thigh to be tested. The examiner’s upper extremity is used as a fulcrum under the thigh and is moved from the distal to proximal thigh as gentle pressure is applied to the dorsum of the knee with the opposite upper extremity. A comparison of both sides is warranted.
(SN 100; SP 0.0; LR+ 1.0; LR- NA).
68
What are the main tests for femoroacetabular impingement and/or labral tear?
* Flexion Internal Rotation (SN .96; SP .17; LR+ 1.12; LR- .27).
* Impingement Provocation Test (SN .97; SP .11; LR+ 1.1; LR- .27).
* Thomas Test (SN .89; SP .92; LR+ 11.1; LR- .12).
69
Describe the flexion internal rotation test.
The patient lies in a supine position. The examiner passively performs the combined motions of flexion to 90 degrees and internal rotation.
(SN .96; SP .17; LR+ 1.12; LR- .27).
70
How to apply Impingement Provocation Test?
The patient is supine, bilateral lower extremities in neutral, and close to the edge of the plinth on the side to be assessed. The examiner guides the involved hip into hyperextension, abduction, and external rotation.
(SN .97; SP .11; LR+ 1.1; LR- .27).
71
Qual é o teste para uma strain do glúteo médio?
Trendlemburg's test.
Patient in one foot. With normal abductor strength, the pelvis should remain level. With abductor weakness, the pelvis drops toward the contralateral side, reflecting a positive Trendelenburg test.
(SN .23; SP .94; LR+ 3.6; LR- .82).
72
What are the main tests for greater trochanter pain syndrome?
* Single leg stance for 30 seconds (SN 100; SP .973; LR+ 37; LR- 0.0).
* Resisted External Derotation Test (SN .88; SP .973; LR+ 32.6; LR- 0.12).
73
Como aplicar o Resisted External Derotation Test?
The patient lies supine with the hip and knee flexed at 90 degrees, hip in external rotation. The examiner slightly diminishes the external rotation. The patient then actively returns the lower extremity to neutral rotation against resistance.
(SN .88; SP .973; LR+ 32.6; LR- 0.12).
74
Que testes estão associados a athletic chronic groin pain?
* Bilateral adductor test (SN .54; SP .93; LR+ 7.7; LR- 0.49).
* Squeeze test (SN .43; SP .91; LR+ 4.8; LR- 0.63).
* Single adductor test (SN .30; SP .91; LR+ 3.3; LR- 0.66).
75
Descreve o teste bilateral dos adutores.
The patient is supine with both hips flexed to 30 degrees, slightly abducted, and slightly internally rotated. The examiner places their forearms on the patient’s medial foot arches and instructs the patient to resist the examiner’s attempt to abduct the patient’s hips.
(SN .54; SP .93; LR+ 7.7; LR- 0.49).
76
Describe the squeeze test.
Athlete lays supine, hips flexed to 45 degrees and knees flexed to 90. The examiner places his or her forearm between the patients knees and instructs the patient to squeeze maximally.
(SN .43; SP .91; LR+ 4.8; LR- 0.63).
77
Como aplicar o Single adductor test?
The patient is supine and flexes the test leg to 30 degrees. The examiner places their hand on the medial aspect of the patient’s heel and instructs the patient to resist the examiner’s attempt to abduct the patient’s hips.
(SN .30; SP .91; LR+ 3.3; LR- 0.66).
78
Quais as sete dimensões que constituem o construto da função?
* Sensory
* Affective
* Evaluative
* Cognitive
* Behavioral
* Physical
* Social
79
Quais são as physical performance measures of the hip validadas maioritariamente para a população artrítica?
* Timed Up and Go
* 40m self paced walk test
* 30 second chair stand
* Stair Climb
80
Which are the best Functional Performance Testing of the Hip in Athletes?
The Single leg stance, deep squat, single-leg squat, and star excursion balance tests demonstrated evidence of validity and normative data for score interpretation.
81
Explain the star excursion balance. What is the interpretation?
The test is performed with the patient standing on one leg at the center of the “star”. While maintaining single leg stance, the patient reaches with the free limb in 3 different direction (anterior, posteromedial, and posterolateral) in relation to the stance foot.
Patients with greater than 4cm of difference in their anterior reach are 2.5 times more likely to be injured. A composite score standardized to leg length inferior to 94% is associated with a 6 fold increase for risk of injury.
82
How to perform the Sock Test?
Participants are instructed to sit on an elevated bench with their feet off the ground. Participants are instructed to flex the knee and hip in the sagittal plane and reach down toward their foot with both hands, one on each side grabbing the toes with the fingertips of both hands. The foot must not touch the bench and should be in the air at all times during the test. Scores are given as ordinal values from 0 (can grab the toes with fingertips and perform the action with ease) to 3 (can hardly, if at all, reach as far as the malleoli).
83
What is the best test designed to test the walking ability in patients with hip osteoarthritis?
The 40 meter self paced walk test demonstrates the best measurement properties relative to assessment of walking ability in patients with hip and knee osteoarthritis.
The timed up and go is a better test of sit to stand ability versus walking ability. The Deep Squat test is a test for femoroacetabular impingement and hip pain in athletes.
84
Which test is designed to test the balance of the athlete with tendinopathy of the gluteus medius?
The single leg stance test demonstrates a sensitivity of 100% and specificity of 97.3% in detecting tendinopathy of the gluteus medius and minimus with reproduction of pain within 30 seconds of the single leg stance.
85
O que nos diz a evidência relativamente aos performance-based methods for measuring the hip or knee?
NO PPM RECOMMENDATIONS CAN BE MADE SECONDARY TO A LACK OF SUFFICIENT EVIDENCE REGARDING THE PSYCHOMETRIC PROPERTIES OF PPM.
86
Qual a evidência em relação às measurement properties of performance-based measures to assess physical function in hip and knee osteoarthritis?
Based on limited evidence, the 40m self paced walk tests was the best rated walk test, the 30 second chair stand and timed up and go were the best rated sit to stand tests, and the Stratford Battery, Physical Activity Restrictions, and Functional Assessment System were the best rated multi activity measures.
87
Quais as medidas de multi-atividades ao nível das Physical Activity Restrictions?
```
• Multi-activity measure included:
– 6 minute walk test
– Five or nine stair ascent/descent
– Lift and Carry test (timed)
– Car Test (in/out car timed).
```
88
Quais as medidas que compõem a Stratford Battery?
```
• Multi activity measure included:
– Walk 2 x 20m fast-paced
– Stand, 3 m walk, turn, return, sit
– Up and down nine stairs
– 6 min walking.
```
89
Que atividades podemos utilizar em Functional Assessment System?
```
• Multi-activity measure included:
– Rise from half stand max no.
– Sit to stand lowest height
– Step (max height)
– Stand one leg
– Stair climbing
– Gait speed over 65m
– Walking aid.
```
90
Qual a relação entre o deep squat e o single leg squat e a hip function?
Patients with femoroacetabular impingement demonstrated less squat depth and altered lumbopelvic kinematics.
Subjects graded as “poor” on the single leg squat test exhibit weaker and slower muscle activation of the hip abductors than those graded as “good”.
91
O que nos ajuda a concluir o single leg stance? E qual a interpretação?
Provocation of pain during 30 second single leg stance has shown sensitivity (100%) and specificity (97.3%) in detecting tendinopathy of the gluteus medius and minimus.
Positive test = increase of pain within 30 seconds of single leg stance; Normal function of the hip abductors maintains the pelvis nearly perpendicular to the femur in a single leg stance position; Normal = 30 second of single leg stance without pain.
92
Enumera condições de diagnóstico diferencial para osteoartrite da anca.
* Femoral neck or pubic ramus stress fracture
* Avascular necrosis
* Bursitis
* Tendinitis/tendinosis
* Chondral damage
* Labral tear
* Muscle strain
* Rheumatoid arthritis
* L2-3 radiculopathy
* SIJ dysfunction.
93
Quais são os critérios clínicos para o diagnóstico de osteoartrose da anca? Altman clinical criteria.
* Patient walks with hip pain
* Hip flexion less than 115 degrees
* Hip internal rotation less than 15 degrees
* Hip pain with internal rotation of the hip
* Duration of morning stiffness of the hip inf 60 minutes
* Age sup 50.
Se o utente apresenta algum dos grupos de critérios, pode ser diagnosticado com osteoartrite da anca (SN 86; SP 75).
94
Além dos critérios de Altman, que outros critérios podem ajudar a diagnosticar osteoartrite da anca?
Critérios de Sutlive:
1) Self-reported squatting as an aggravating factor;
2) Scour test with adduction causing groin or lateral pain;
3) Active hip flexion causing lateral pain;
4) Active hip extension causing hip pain;
5) Passive hip internal rotation less than or equal to 25 degrees.
5 critérios (SN .14 ; SP .98 ; LR+ 7.3 ; LR- .87 ; PTP 75).
4 critérios (SN .48 ; SP .98 ; LR+ 24.3 ; LR- .53 ; PTP 91)
3 critérios (SN .71 ; SP .86 ; LR+ 5.2 ; LR- .33 ; PTP 68)
2 critérios (SN .81 ; SP .61 ; LR+ 2.1 ; LR- .31 ; PTP 46)
1 critério (SN .95 ; SP .18 ; LR+ 1.2 ; LR- .27 ; PTP 33).
95
Quais os 5 principais fatores que podem causar labral tear?
```
• 5 etiologies of labral tears
– Trauma
– FAI (femoroacetabular impingement)
– Capsular laxity
– Dysplasia
– Degeneration.
```
96
Qual a apresentação clínica habitual de lesão labral? Como se comportam os sintomas?
* Anterior hip and groin pain
* Acute or chronic
* Aged 25-40
* Male to female ratio is roughly equal
* Sport with rotational activity (golf/hockey)
* Insidious onset (61%)
* Constant “deep” hip/groin pain with intermittent periods of “sharp” pain
* Limitation/pain with rotation
* Clicking, catching, giving way.
* Aggravating activities – Walking, pivoting, running
* Easing activities – Avoidance of aggravating activity
* 24 hour pain pattern – Often report pain at night.
97
Quais são as condições que geralmente "competem" com a rotura labral em diagnóstico diferencial?
* Sports hernia
* Femoral neck stress fracture
* Hip flexor muscle/tendon strain/groin pull
* Snapping hip syndrome
* Athletic pubalgia
* Assume OA or FAI.
98
Que alterações mecânicas estão associadas ao femoroacetabular impingement (FAI)?
* CAM impingement – With increased flexion and rotation of the hip, the bump at the femoral head and neck can cause damage to the articular cartilage and labrum.
* PINCER impingement – With hip flexion and rotation, the femoral head will abut (confinar) the acetabulum at the pincer spur causing tearing of the labrum and associated articular cartilage.
Those lesions on cartilage can lead to osteoarthritis.
99
E quais são os fatores de risco para o FAI?
```
• Cam
– Slipped Capital Femoral Epiphysis (SCFE)
– Femoral head anteversion
– Coxa Vara
– Legg-Calve Perthes
• Pincer
– Acetabular retroversion
– Coxa profunda
– Acetabular protrusion.
```
100
Refere algumas características clínicas comuns em pessoas com FAI. Descreve também o comportamento dos sintomas.
* Young, active
* 2nd-4th decade of life
* Insidious onset (50-65%)
* Sharp, ache (73%)
* Groin pain (81-88%)
* Worse with sitting
* Limited hip flexion and IR
* + Quadrant test (88.6% - 99%)
* + FABER’s (98.7%)
* + FADDIR test
* Aggravating activities – Prolonged sitting, squats, walking, sports (lateral movement, cutting)
* Easing activities – Rest, walking, heat
* 24 hour pain pattern – Typically associated with movement alone.
101
Quais os critérios que podem ajudar a determinar o diagnóstico de FAI?
* Insidious onset
* Young, active
* Activity related pain pattern
* Groin pain location
* Worse pain in sitting
* Limited hip flexion and internal rotation
* Positive Quadrant Test.
102
Quais as principais condições assocadas ao diagnóstico diferencial do FAI?
* Labral Tear
* Sports Hernia
* Femoral Neck Stress Fracture
* Hip Flexor Muscle/Tendon Strain
* OA
* Referred pain from L1/2 nerve root
* Snapping hip syndrome
* Psoas muscle strain.
103
Quais os fatores de risco intrínsecos e extrínsecos associados a fraturas de stress?
```
Extrinsic factors:
• Participation in running or jumping sports
• Increase frequency, duration, or intensity of runs
• Hard or cambered running surfaces
• Lack of rest
• Poor shoe health
• Smoking
• Nutrition (vitamin D and calcium).
```
```
Intrinsic factors:
• Decreased muscle mass
• Poor muscular endurance
• Narrow tibial width
• Women sup men
• Decreased bone density
• Hormonal or menstrual disorder
• Leg length discrepancy.
```
104
Em caso de fratura por stress, qual é a apresentação clínica comum? Como se comportam os sintomas?
* Endurance athletes
* Deep, aching groin/anterior thigh pain
* ROM is limited with pain occurring at end range
* Pain can refer down to knee
* Aggravating activities – Running; Increased duration/intensity of activity; Hopping on one leg.
* Easing activities – Rest
* 24 hour pain pattern – Pain at night.
105
Que condições constituem o diagnóstico diferencial de fraturas por stress?
* Synovitis
* Labral tears
* Neoplasm
* Strains
* Avascular necrosis
* OA.
106
Aponta fatores de risco modificáveis e não-modificáveis associados ao desenvolvimento de athletic pubalgia.
• Modifiable
– Adductor to abductor strength ratio
– Decreased levels of pre-season sport specific training
– Delay of abdominal muscle recruitment.
```
• Non-modifiable
– Previous injury
– Age
– Sport experience
– BMI
– Decreased dominant femur diameter.
```
107
Descreve a apresentação clínica comum em pubalgia atlética.
* Athletic population
* Male
* High intensity sports (ice hockey, soccer, rugby)
* 6-8 week history of symptoms
* Acute sudden onset with gradual worsening
* Pain and tenderness to palpation in the groin, pubic, and medial thigh
* Pain at or above pubic crest on affected side
* Pain with resisted sit up, hip adduction, ASLR
* Decreased hip extension
* Increased lumbar extension
* Non-responsive to treatment.
108
Quais as patologias mais comuns que originam dor anterior na anca?
* Hip Osteoarthritis
* Labral Tear
* Femoroacetabular Impingement
* Femoral Stress Fracture
* Athletic Pubalgia
* Avascular Necrosis.
109
Explain the pathogenesis behind osteoarthritis.
* Not completely understood
* It is not caused by aging and does not necessarily progress
* OA is a metabolically active, dynamic process that involves all joint tissues (cartilage, bone, synovium/capsule, ligaments, and muscle) and function
* Pathological changes likely begin with degradation of the articular cartilage in a non-uniform manner
* Next, comes subsequent thickening of the subchondral bone resulting in osteophyte formation and mild to moderate synovial inflammation.
* Continued tissue damage and inability to repair results in symptomatic OA.
110
Qual a prevalência da osteoartrite na anca?
* Radiographic primary hip OA in 5% to 10% of the general adult population
* Estimated that 68% of individuals older than age 55 have radiographic evidence of OA.
111
Quais os fatores de risco para a osteoartrite?
* Age
* Female gender
* Joint laxity
* Muscle weakness
* Previous hip injury
* Participation in weight bearing sports
* Occupations involving heavy lifting, vibration, or walking on uneven ground.
112
Qual a apresentação clínica típica da osteoartrite? E como se comportam os sintomas?
* Typically older
* Male sup female
* BMI 30+
* Previous hip injury
* Anterior/lateral hip pain
* Muscle weakness – Greatest loss in hip abduction
* Trendelenburg sign
* Pain, stiffness, reduced function (ex: climbing stairs).
* Pain typically described as constant, deep, aching discomfort present for years
* ROM limitation – (IR sup flexion sup abduction sup extension).
* Aggravating activities – Stairs, walking long distances, deep squat
* Easing activities – Rest
* 24 hour pain pattern – Typically worse toward end of day; Report morning stiffness.
113
Como tendem a variar os sintomas na pubalgia?
* Aggravating activities – Active hip adduction or sit-up, sprinting, lifting activities, kicking, jumping, lunges, cutting, sudden changes in direction.
* Easing activities – Rest; Ice, NSAIDs; Avoidance of aggravating activities.
* 24 hour symptom pattern – Pain in AM getting in/out of bed; Returns on resumption of sport; Rest and sleep not usually disturbed.
114
Quais os achados clínicos que nos ajudam a diagnosticar pubalgia atlética?
* Deep groin or lower abdominal pain with exertion
* Pain exacerbated by kicking, sprinting, cutting, situps
* Tends to be relieved by rest but returns upon resumption of activity
* Palpable tenderness over pubic ramus at the insertion of rectus abdominis and/or conjoined tendon
* Pain with resisted hip adduction
* Pain with resisted abdominal curl up.
115
Enumera diagnósticos diferencias em pubalgia atlética.
* Snapping hip syndrome
* Labral tear
* FAI
* Femoral neck stress fracture
* Lumbar radiculopathy
* Obturator nerve entrapment
* Inguinal hernia
* Endometriosis
116
Quais as estruturas que tendem a ser mais afetadas na pubalgia?
```
Anatomical Defects Identified in 100 Consecutive MRIs of Athletic Pubalgia Patients in 2006:
• Pubic symphysis 93% incidence
• Rectus Abdominis 76
• Adductor longus 46
• Pectineus 38
• Adductor brevis 20
• Iliopsoas 6
• Rectus femoris 2
• Sartorius 1
• Pubic ramus 1
• Obturator ext 1
• Gracilis 1
• Hamstring 1
• Adductor magnus 1
• Hip 16
```
117
Que tipo de imagiologia diagnóstica é geralmente aplicada em pubalgias?
* Radiographs (rule out)
* Bone scan (rule out)
* MRI (rule out)
* CT
* Ultrasound.
118
O que é a necrose avascular? E qual a incidência?
• Osteonecrosis is the death of bone that results in the collapse of the architectural bone structure, leading to joint pain, bone destruction, and loss of function.
* Annual incidence ranges from 10,000 to 20,000 cases per year
* AVN accounts for 5-12% of of the THA performed annually in the US.
119
Aponta os fatores de risco associados a necrose avascular.
* Trauma
* Corticosteroids
* Alcohol
* Systemic lupus erythematosus
* Dialysis
* Pancreatitis
* Pregnancy
* Cancer chemotherapy
* Vasculitides
* Male
* Hyperlipidemia
* Gaucher’s disease
* Rheumatoid arthritis
* Hypercoagulable states
* Radiation therapy
* Dysbaria
* Osteomyelitis
* Smoking
* HIV
* Idiopathic.
120
Qual pode ser a apresentação clínica em casos de necrose avascular?
* Mild/moderate groin or anterior thigh pain
* Pain with WB or extreme limits of ROM
* Decreased global ROM
* Antalgic gait pattern
* Sudden onset with rapid progression
* Male sup female 8:1
* 40-60% have symptoms bilaterally
121
Qual a condição que mais se verifica em caso de dor lateral na anca?
Greater trochanteric pain syndrome.
122
Qual a apresentação clínica de greater trochanteric pain syndrome (GTPS)?
* Lateral hip and thigh pain
* Female sup male (4:1)
* 4th-6th decades
* Tender to palpation over greater trochanter
* Tenderness over distal ITB
* Low back pain
* + Trendelenburg sign.
123
Quais os fatores que agravam e aliviam em casos de síndrome de dor trocantérica?
* Aggravating activities – Lying on affected side; Stairs; Walking; Difficulty transferring from sit to stand
* Easing activities – Rest; Sitting.
124
Que condições podem estar associadas ao diagnóstico funcional de greater trochanteric pain syndrome?
* Snapping hip syndrome
* Femoral neck stress fracture
* Avascular necrosis
* FAI
* Labral injury
* OA.
125
Qual a condição que mais origina dor posterior da anca?
Piriformis syndrome.
126
Qual a etiologia da síndrome do piriforme?
• No one knows!!
– Maybe hip abductor weakness
– Maybe trauma
– Maybe back.
127
Que características clínicas costuma apresentar a síndrome do piriforme? O que tende a agravar a mesma?
* Insidious onset
* Buttock pain and tenderness
* Tender to palpation in sciatic notch and buttock pain in flexion, adduction, and internal rotation of the hip
* “Sciatica”.
• Aggravating activities – Prolonged sitting.
128
Que outros diagnósticos podem estar a competir com a síndrome do piramidal?
* Sacrotuberous ligament inflammation
* Sacroiliac joint dysfunction
* Proximal hamstring tendinopathy
* Lumbar stenosis
* Labral tear.
129
Which of the following is NOT included as part of Sutlive’s clinical criteria for diagnosis of hip OA?
Self-reported squatting as an aggravating factor; Scour test with adduction causing groin or lateral pain; Passive hip internal rotation less than or equal to 15 degrees; Active hip extension causing hip pain.
Passive hip internal rotation less than or equal to 15 – passive hip internal rotation less than or equal to 25 degrees is the inclusion of Sutlive's criteria.
130
Patients with femoroacetabular impingement primarily report pain in which of the following locations?
Posterior thigh; Groin and lateral hip; Lateral thigh and knee; Low back.
Groin and lateral hip. It has been reported that 88% and 67% of patients with FAI report groin pain and lateral hip pain, respectively.
131
Pain exacerbated by sprinting, resisted hip adduction, resisted abdominal curl-up, and relieved upon rest. What can be the differential diagnosis?
Athletic pubalgia. This condition is chronic inguinal or pubic-area pain in athletes that is exertional only and not explained preoperatively by a palpable hernia or other medical diagnosis.
132
Which of the following tests is most useful for ruling out avascular necrosis? MRI; X-ray; Ultrasound; CT.
MRI. It has a sensitivity of 91% and can detect AVN before the appearance of radiographic abnormalities.
133
Quais os achados clínicos que nos ajudam a diferenciar patologia intra-articular da extra-articular?
Findings to suspect Intra-articular Pathology:
• Pain ‘C sign’
• Asymmetric ROM
• Positive provocative tests
• Functional hemipelvic muscle weakness.
These clinical findings are confirmed with radiographic findings.
If there are soft radiographic findings with pelvis, lumbar, radiculopathic pain, hip range of motion is symmetric, negative provocative tests and selective muscle weakness/dysfunction, then we should suspect extraarticular pathologies.
134
Como pode ser classificada a dor no quadril?
Hip Pain:
• Intra-articular – Artrítica vs. Não artrítica.
• Extra-articular – Tecido envolvente vs. Tecido distante.
