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Extra-articular Hip Flashcards

1
Q

Identify 6 likely causes of Extra-articular hip pn/sxs

A
  1. Greater trochanteric pain syndrome (GTPS)
  2. Piriformis Syndrome
  3. Snapping hip
  4. Hip stress fracture
  5. Femoroacetabular impingement syndrome
  6. Sports hernia
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2
Q

If a pt has a suspected hip condition, what do you want first RULE OUT?

A

Other regions that can refer to Hip (differential dx)

  1. Pelvic ring (incl sacroiliac jts)
  2. Lower thoracic (T7-12) and Lumbar spine
  3. Thigh and Knee
  4. Ankle & foot (potential referral from hip)

(can use a scanning exam to rule out potential contributors from adjacent regions)

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3
Q

T or F: Orthopedic injuries to the hip tend to be “age” specific

A

True

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4
Q

What are 3 “age” specific orthopedic injuries to the hip for

Age 0-3

A
  1. Congenital dislocations
  2. Septic arthritis
  3. Transient synovitis
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5
Q

What is 1 “age” specific orthopedic injury to the hip for

Age 4-8

A

Legg-Perthes Disease

= insufficient blood flow to femoral head –> bone death

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6
Q

What are 3 “age” specific orthopedic injuries to the hip for

Age 8-15

A
  1. Slipped Capital Femoral Epiphysis
  2. Apophysitis
  3. Osteochondritis Dissecans (OCD)
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7
Q

What are 4 “age” specific orthopedic injuries to the hip for

Age 15-30

A
  1. OCD
  2. Overuse injuries
  3. Strains
  4. FAI
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8
Q

What is 1 “age” specific orthopedic injuries to the hip for

Age 8-72

A

Labral tear

(labral tears have a better prognosis if managed between 17-35)

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9
Q

What are 3 “age” specific orthopedic injuries to the hip for

Age 30-50

A
  1. RA
  2. AVN (avascular necrosis - death of femoral head due to lack of blood supply)
  3. GTPS
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10
Q

What are 3 “age” specific orthopedic injuries to the hip for

Age 50+

A
  1. GTPS
  2. OA
  3. Hip fx
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11
Q

What is GTPS?

A

Pn & reproducible tenderness in region of greater troch, buttock, or lateral thigh

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12
Q

T or F: the most common pathology in GTPS is not bursitis, but tendinosis

A

True.

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13
Q

What are 7 risk factors for GTPS?

A
  1. > 40
  2. Female
  3. Obesity
  4. Knee or Hip OA
  5. RA
  6. Lumbopelvic back pn
  7. Core motor control impairment, gluteal mm weakness
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14
Q

What are 3 MOI for GTPS?

A
  1. Direct trauma to lat hip
  2. Cumulative microtrauma
  3. Intrinsic degenerative tendinosis of hip abd
    • most common finding on MRI! Rarely is true trochanteric bursitis identified
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15
Q

How does a pt with GTPS present clinically?

-onset of pn
-region of pn
-radiating pn?
-what is the pn exacerbated by?

A
  1. Onset: acute OR insidious
  2. Location: lateral thigh region
  3. May radiate (occasionally down to calf)
  4. 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
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16
Q

What should you include in your exam of a pt with suspected GTPS?

A
  1. Palpation (posterolateral area of GT)
  2. Ober’s test
  3. Hip AROM, AROM + resistance
  4. SLS for 30 sec
  5. Trendelenburg test/ obs amb
  6. Resisted external de-rotation test
  7. Tests to rule out lumbar spine radiculopathy
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17
Q

What are common exam findings for a pt with GTPS?

A
  1. Point tenderness in posterolateral area of GT (typically regional to glute med tendon insertion)
  2. 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
  3. Rarely pain reproduced with hip ext
    • trendelenburg test/sign
      or coxalgic gait (pelvis level but trunk lean to affected side)
  5. Resisted external de-rotation test
    SN 88%; SP 97%; +LR 32.6; -LR 0.12
    (for gluteal tendinopathy)
18
Q

Describe the etiology of Piriformis Syndrome

A
  1. Causes = multivariate
    • Compression of sciatic n
    • Muscle imbalances
    • Trauma
    • Strain
    • Overuse
  2. May start as buttock pn, can progress to post thigh & calf pn
  3. May be aggravated by walking, extended sitting, external rotation of hip
19
Q

What would you include in your exam of a pt with suspected piriformis syndrome?

A
  1. obs gait/posture
  2. hip AROM (esp. ER)
  3. hip MMT (esp ER)
  4. SLR
  5. Palpation
  6. FAIR test (piriformis test)
20
Q

What are common exam findings for PIRIFORMIS SYNDROME?

A
  1. may have antalgic gait, or stand w/
    inc ER in leg
  2. hip AROM (esp. ER): ER may = pn
  3. hip MMT (esp ER): pn and/or weak
    ER
    • SLR test
  5. Palpation: tenderness/trigger points in piriformis/lat hip
    • FAIR test (piriformis test)
21
Q

What is the FAIR test?

A

= Piriformis test

  • sidelying on unaffected side
  • affected hip flex 60 deg
  • Add + IR hip (while stabilizing pelvis)
    + test: reproduction of pain in buttock/leg
22
Q

What are the 3 classifications of Snapping Hip Syndrome?

A
  1. External
  2. Internal
  3. Intra-articular
23
Q

T or F: snapping hip syndrome is more common in females?

24
Q

Describe the 3 classifications of Snapping Hip Syndrome:

  1. External
  2. Internal
  3. Intra-articular
A
  1. External
    • tight lat hip (TFL/ITB) or glute max
      tendon over GT (ITB does not
      change length but can lose
      mobility)
  2. Internal
    • Iliopsoas tendon riding over ant
      acetabulum OR
    • iliofemoral lig riding over femoral
      head
    • Snapping common during hip
      flex ~45 deg)
  3. Intra-articular
    • Loose body in jt, assoc w/ labral
      tear or labral disruption
25
What should you include in your exam for someone with suspected snapping hip syndrome but you don't know which classification they fall into?
1. Rule out intra-articular causes w/: FIRST, FADIR, and Thomas tests 2. 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 3. Palpation: for snapping, point tenderness
26
What two bones are stress fractures most common?
1. Tibia 2. Metatarsals
27
7-10% of stress fxs occur in the femur. What part of the femur are stress fxs most common?
Neck
28
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)
29
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
30
Femoral stress fractures of the shaft most commonly occur in what region?
Medial proximal third
31
Are femoral shaft stress fractures more commonly treated conservatively or surgically?
Conservatively
32
How can you diagnose a stress fx with imaging?
Radiograph Bone scan MRI
33
What are common exam findings for a pt with a stress fracture in the hip region?
1. Localized pn: groin, thigh, or knee 2. Insidious onset 3. Pn that occurs at the end of a run 4. Will progress to occur earlier and eventually impact daily amb 5. Usu related to change in activity level 6. Often difficult to illicit pn w/ palpation 7. + Patellar-pubic percussion test 8. + Fulcrum test
34
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
35
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
36
What are common exam findings for a pt with FAI syndrome?
1. Ant/med groin pn 2. Deep pn w/ click or "C" sign likely = intra-articular (labral) 3. Pn w/ FADIR (SEN, not SPEC) 4. Pn w/ flex, IR 5. Limited IR 6. Weakness in hip abd/ext, core, pelvic motor control, ecc hip flex 7. Step down motor control deficits 8. Dysfunction in squat (loss of neutral pelvic posture) - ant tilt often present
37
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)
38
How does hip add and abd strength compare for individuals with sports hernias?
Hip add strength is weaker than abd
39
T or F: diagnosis of a sports hernia is one of exclusion primarily
True
40
What are 2 exam findings for a pt with a sports hernia?
1. pn reproduction w/ resisted ab curl up 2. tenderness to palpation at superior pubic ramus

MM I (9 decks)

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