Extra-articular Hip Flashcards
Identify 6 likely causes of Extra-articular hip pn/sxs
- Greater trochanteric pain syndrome (GTPS)
- Piriformis Syndrome
- Snapping hip
- Hip stress fracture
- Femoroacetabular impingement syndrome
- Sports hernia
If a pt has a suspected hip condition, what do you want first RULE OUT?
Other regions that can refer to Hip (differential dx)
- Pelvic ring (incl sacroiliac jts)
- Lower thoracic (T7-12) and Lumbar spine
- Thigh and Knee
- Ankle & foot (potential referral from hip)
(can use a scanning exam to rule out potential contributors from adjacent regions)
T or F: Orthopedic injuries to the hip tend to be “age” specific
True
What are 3 “age” specific orthopedic injuries to the hip for
Age 0-3
- Congenital dislocations
- Septic arthritis
- Transient synovitis
What is 1 “age” specific orthopedic injury to the hip for
Age 4-8
Legg-Perthes Disease
= insufficient blood flow to femoral head –> bone death
What are 3 “age” specific orthopedic injuries to the hip for
Age 8-15
- Slipped Capital Femoral Epiphysis
- Apophysitis
- Osteochondritis Dissecans (OCD)
What are 4 “age” specific orthopedic injuries to the hip for
Age 15-30
- OCD
- Overuse injuries
- Strains
- FAI
What is 1 “age” specific orthopedic injuries to the hip for
Age 8-72
Labral tear
(labral tears have a better prognosis if managed between 17-35)
What are 3 “age” specific orthopedic injuries to the hip for
Age 30-50
- RA
- AVN (avascular necrosis - death of femoral head due to lack of blood supply)
- GTPS
What are 3 “age” specific orthopedic injuries to the hip for
Age 50+
- GTPS
- OA
- Hip fx
What is GTPS?
Pn & reproducible tenderness in region of greater troch, buttock, or lateral thigh
T or F: the most common pathology in GTPS is not bursitis, but tendinosis
True.
What are 7 risk factors for GTPS?
- > 40
- Female
- Obesity
- Knee or Hip OA
- RA
- Lumbopelvic back pn
- Core motor control impairment, gluteal mm weakness
What are 3 MOI for GTPS?
- Direct trauma to lat hip
- Cumulative microtrauma
- Intrinsic degenerative tendinosis of hip abd
- most common finding on MRI! Rarely is true trochanteric bursitis identified
How does a pt with GTPS present clinically?
-onset of pn
-region of pn
-radiating pn?
-what is the pn exacerbated by?
- Onset: acute OR insidious
- Location: lateral thigh region
- May radiate (occasionally down to calf)
- Pain exacerbated by:
- Lying on affected hip
- Repetitive hip flex-ext activities
(walking, running, climbing stairs) - Prolonged standing or single limb
activities - Repetitive hip int/ext rot
What should you include in your exam of a pt with suspected GTPS?
- Palpation (posterolateral area of GT)
- Ober’s test
- Hip AROM, AROM + resistance
- SLS for 30 sec
- Trendelenburg test/ obs amb
- Resisted external de-rotation test
- Tests to rule out lumbar spine radiculopathy
What are common exam findings for a pt with GTPS?
- Point tenderness in posterolateral area of GT (typically regional to glute med tendon insertion)
- Pn reproduced w/:
- Stretching of lat/ext hip mm
(ITB/TFL) (Ober’s test) - Active resistance to hip abd & ext
rot (occasional int rot) - SLS for 30 sec (100% SEN, 97.3%
SPEC) - (maybe) ecc contraction hip
rotators
- Stretching of lat/ext hip mm
- Rarely pain reproduced with hip ext
- trendelenburg test/sign
or coxalgic gait (pelvis level but trunk lean to affected side)
- trendelenburg test/sign
- Resisted external de-rotation test
SN 88%; SP 97%; +LR 32.6; -LR 0.12
(for gluteal tendinopathy)
Describe the etiology of Piriformis Syndrome
- Causes = multivariate
- Compression of sciatic n
- Muscle imbalances
- Trauma
- Strain
- Overuse
- May start as buttock pn, can progress to post thigh & calf pn
- May be aggravated by walking, extended sitting, external rotation of hip
What would you include in your exam of a pt with suspected piriformis syndrome?
- obs gait/posture
- hip AROM (esp. ER)
- hip MMT (esp ER)
- SLR
- Palpation
- FAIR test (piriformis test)
What are common exam findings for PIRIFORMIS SYNDROME?
- may have antalgic gait, or stand w/
inc ER in leg - hip AROM (esp. ER): ER may = pn
- hip MMT (esp ER): pn and/or weak
ER - SLR test
- Palpation: tenderness/trigger points in piriformis/lat hip
- FAIR test (piriformis test)
What is the FAIR test?
= Piriformis test
- sidelying on unaffected side
- affected hip flex 60 deg
- Add + IR hip (while stabilizing pelvis)
+ test: reproduction of pain in buttock/leg
What are the 3 classifications of Snapping Hip Syndrome?
- External
- Internal
- Intra-articular
T or F: snapping hip syndrome is more common in females?
true
Describe the 3 classifications of Snapping Hip Syndrome:
- External
- Internal
- Intra-articular
- External
- tight lat hip (TFL/ITB) or glute max
tendon over GT (ITB does not
change length but can lose
mobility)
- tight lat hip (TFL/ITB) or glute max
- Internal
- Iliopsoas tendon riding over ant
acetabulum OR - iliofemoral lig riding over femoral
head - Snapping common during hip
flex ~45 deg)
- Iliopsoas tendon riding over ant
- Intra-articular
- Loose body in jt, assoc w/ labral
tear or labral disruption
- Loose body in jt, assoc w/ labral
What should you include in your exam for someone with suspected snapping hip syndrome but you don’t know which classification they fall into?
- Rule out intra-articular causes w/: FIRST, FADIR, and Thomas tests
- Snapping Hip Sign: pt abd + ext rot leg, then move from flex to ext
+ test: reproduction of
snapping/pn usu around 45 deg
hip flex - Palpation: for snapping, point
tenderness
What two bones are stress fractures most common?
- Tibia
- Metatarsals
7-10% of stress fxs occur in the femur. What part of the femur are stress fxs most common?
Neck
What are the risk factors for femoral stress fractures, considering both extrinsic and intrinsic factors?
Extrinsic:
1. training/activity freq
2. duration of exercise
3. intensity of exercise
4. surface
5. footwear
Intrinsic:
1. poor mm endurance
2. dec mm mass
3. REDS (disordered eating, amenorrhea, and osteoporosis)
Compare and contrast a tension side stress fracture and compression side (of femoral neck)
Tension side: superior aspect
- HIGHER risk for non-
union/displacement/AVN
- Usu treated operatively (ORIF), given
high rate of complication (30%) if
managed conservatively
Compression side: inferior aspect
- can be treated conservatively w/ activity mod & mm training
Femoral stress fractures of the shaft most commonly occur in what region?
Medial proximal third
Are femoral shaft stress fractures more commonly treated conservatively or surgically?
Conservatively
How can you diagnose a stress fx with imaging?
Radiograph
Bone scan
MRI
What are common exam findings for a pt with a stress fracture in the hip region?
- Localized pn: groin, thigh, or knee
- Insidious onset
- Pn that occurs at the end of a run
- Will progress to occur earlier and eventually impact daily amb
- Usu related to change in activity level
- Often difficult to illicit pn w/ palpation
- Patellar-pubic percussion test
- Fulcrum test
What is the fulcrum test and what does it assess for?
Used to assess for possible prox 1/3 femoral stress fx
Pt’s femur levered over PTs forearm
+ test: reproduces pn
What is the etiology of Femoroacetabular Impingement Syndrome (FAI)
- Dysfunctional motor control –> contact btwn prox femur and acetabulum
- Has components that are both intra & extra articular
What are common exam findings for a pt with FAI syndrome?
- Ant/med groin pn
- Deep pn w/ click or “C” sign likely =
intra-articular (labral) - Pn w/ FADIR (SEN, not SPEC)
- Pn w/ flex, IR
- Limited IR
- Weakness in hip abd/ext, core, pelvic motor control, ecc hip flex
- Step down motor control deficits
- Dysfunction in squat (loss of
neutral pelvic posture) - ant tilt
often present
What is the etiology of a sports hernia?
- Primary cause = overuse
- Condition = weakened post wall for inguinal canal
- injury to ant fascia and mm of abdominal wall around insertion to ant pubis
- Tear of rectus abdominus is present in 6-8% pts w/ sports hernia
- Weakness of hip add compared to abd (add:abd strength ratio < 80% = prognostic)
How does hip add and abd strength compare for individuals with sports hernias?
Hip add strength is weaker than abd
T or F: diagnosis of a sports hernia is one of exclusion primarily
True
What are 2 exam findings for a pt with a sports hernia?
- pn reproduction w/ resisted ab curl up
- tenderness to palpation at superior pubic ramus
