Examination of the Hip Flashcards
Define Hip/Groin Pain.
- 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.
Há condições em que a causa da dor não está no quadril. Refere algumas dessas situações.
- 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.
O que nos diz a prevalência?
- 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).
Quais são os padrões mais comuns quanto à dor referida do quadril?
- Buttock 71%.
- Thigh 57%.
- Groin 55%.
- Leg 16%.
- Foot 6%.
- Knee 2%.
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?
The L1/2 discogenic referred pain pattern is often into the anterior groin and thigh.
Which of the following is NOT considered one of the 5 major ligaments of the hip joint?
Sacrotuberous ligament; Iliofemoral; Pubofemoral; or Ligamentum teres.
Sacrotuberous ligament. It is related to the pelvis and SI.
Porque é que é importante conhecer a natureza e tipo de sintomas?
• 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).
Que tipo de questões podemos colocar para perceber a irritabilidade dos sintomas?
• 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.
Quais são as características mais comuns dos sintomas do quadril?
- 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.
Exemplifica questões que nos ajudam a entender a história da condição presente.
- 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?
O que são yellow flags? Dá exemplos.
• 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
Que fatores constituem as blue flags?
• 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
Quais as black flags?
• 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).
Exemplifica questões especiais que nos ajudam a determinar uma dor de origem não mecânica.
• 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)
Para que servem as outcome measures na prática clínica? Enumera alguns benefícios.
- (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.
Quais os pricipais requerimentos que constituem uma outcome measure?
- Standardised Measurement
- Validity
- Reliability
- Able to detect change (when it has occurred) - MCID or Minimum clinically important difference
- (Acceptability to patients and others)
Quais as outcome measures com melhores propriedades psicométricas para problemas na anca?
- 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.
Identifica algumas fraquesas da utilização de outcome measures.
- 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.
Porque é que há uma fraca relação entre as outcome measures e as physical performance measures?
“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.
No que diz respeito a utentes com osteoartrose, quais as relações mais fortes existentes entre as performance measure e o self-reported physical function?
- 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.
O que são physical performance measures e para que servem?
- 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.
Quais as principais vantagens das physical performance measures?
- 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.
O que é a minimal clinically important difference (MCID)? E em que difere do minimal detectable diference (MDC)?
- 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.).
Refere alguns problemas associados à utilização do MCID.
- 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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
Qual o propósito da triagem e screening?
• Scanning for:
– Potential sources of the condition
– Contributing factors
– Precautions and contraindications
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
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.
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?”
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?”
Quais são as red flags específicas da anca?
- Appendicitis
- Ureter
- Colon Cancer
- Femoral neck fracture
- Avascular Necrosis
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).
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)
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.
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).
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.
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
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.
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.
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.
Porque é importante testar os movimentos fisiológicos passivos?
Passive physiological movements are necessary to identify potential noncontractile structures that are pain generators.
Que tipo de problemas os movimentos acessórios passivos nos podem ajudar a identificar?
Typically passive accessories used to identify intra-articular pathology.
Quais os movimentos acessórios que devemos testar na anca?
- Anterior-Posterior Glide
- Indirect Distraction
- Direct Distraction
- Lateral Glide
- Hip Quadrant
- Posterior-Anterior Glide.
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.
