Hip Flashcards
What are 5 potential causes of intraarticular hip pain?
-OA
-Labral Pathology
-Avascular Necrosis
-Legg-Calve-Perthes
-Slipped Capital Femoral Epiphysis
What are 6 potential causes of extra-articular hip pain?
-Iliopsoas Bursitis
-Femoral Neck Stress Fracture
-Osteitis Pubis
-Obturator nerve entrapment
-Iliolinguinal nerve entrapment
-SIJ referral
What are 4 potential non-musculoskeletal causes of hip pain?
-Retrocecal appendicitis
-Hernia
-Renal referral
-Ureteral referral
Signs of hip OA?
-Older patient >60 y/o
-Groin, posterior, or lateral hip pain
-Commonly refers pain to the knee
-High frequency of associated L-spine DJD
What is the hip osteoarthritis cluster?
-Hip pain
-IR >= 15 degrees
-Pain with IR
-Morning Stiffness <60 minutes
-Ages 50 or older
Is the Hip OA cluster better for ruling in or ruling out?
Ruling out.
What are common symptoms of acetabular labral tears?
-Pain
-Clicking
-Locking
-Catching
-Instability
-Giving way
-Stiffness
What are differential diagnoses of hip labral tears?
-Snapping hip syndrome
-Lumbar/SIJ referred pain
-Stress Fracture
When does avascular necrosis of the hip typically show up?
-4th decade of life
Predisposing factors to consider when thinking about avascular necrosis?
-Steroid usage
-Renal Disease
-Alcoholism
-Sickle Cell Disease
-Radiation
-Gout
-Previous trauma esp. femoral neck fracture and hip dislocation
What are signs of hip avascular necrosis?
-Nonspecific groin/hip pain
-Hip AROM WNL (unless progressed)
-Predisposing factors present
What ages typically have Legg-Calve-Perthes?
<15 years old
What are signs of Legg-Calve-Perthes?
-Pain in hip, knee, and groin
-Hip Flexion Contracture
-Limited IR
-Positive FADIR
What ages are typically impacted with slipped capital femoral epiphysis?
9-17
What are signs of a slipped capital femoral epiphysis?
-Antalgic Gait: hip held in ER
-Pain poorly localized from going to medial knee
-**Decreased hip IR with increased hip flexion
What are signs of iliopsoas bursitis?
-Presenting in hip flexion and ER for relief
-Pain with passive hip extension
-Pain with resisted hip flexion
-Bursa tender to palpation
-Positive snapping hip maneuver
-Positive supine heel raise
What is the snapping hip maneuver?
pt is supine, PT hand on the inguinal crease as the hip is brought into flexion, then abduction and ER back to neutral feeling for a painful snap
What is the supine heel raise?
Pt is supine with hip flexed to 15, PT places hand on the psoas below the lateral half of the inguinal crease and resists hip flexion; positive with pain under the fingers
What are signs of a femoral neck stress fracture?
-Pain at extreme ROM most consistent finding
-Pain with weight bearing
-Positive hop test
-Positive heel tap
-Postive FABER/scour/quadrant
-Positive fulcrum
-Overall, tests that add torsion/bending stresses are most diagnostic
What is the fulcrum test?
Test for femoral neck fracture:
-PT arm under the seated patient’s thigh with downward pressure applied over the anterior aspect of the distal end of the femur; positive with sharp thigh pain and apprehension also
What is the best test for femoral neck fracture detection?
Bone Scan
What are signs of osteitis pubis?
-Tenderness along the pubis
-PROM hip adductors limited with pain
-Hip adductors weak w/pain
Who are more likely to have osteitis pubis?
-Long distance runners
-Weightlifters
-Fencers
-Soccer players
-Football players
What are signs of obturator nerve entrapment?
-Medial thigh pain with exercise
-Pain continues with activity and recedes with rest
-Medial thigh paresthesias
-Adductor muscle weakness w/o pain
-Pain reproduced with weight bearing hip ER and ADD
What is the diagnotic tool for obturator nerve entrapment?
EMG
MRI & Xray of little value
What is the hallmark sign of neuropathy?
Muscle weakness without pain
What is the mechanism of obturator nerve entrapment?
Entrapment due to the course of the obturator nerve diving under the pubic ramus and commonly entrapped between the adductor brevis and longus
What does the ilionguinal nerve supply cutaneous innervation to?
Groin, scrotum, labia
What are signs and predisposing factors for ilioinguinal nerve entrapment?
-Pain wtih hip hyper extension from inguinal region to genitals
Predisposing factors:
-Abdominal muscle hypertrophy
-Pregnancy
-Prior iliac crest bone graft harvesting
-Overtaining in athletes
What is the referral pattern of the SIJ?
Anterior groin and from sacrum down the back of the leg; similar to sciatic
What are signs of retrocecal appendicitis?
-Pain at McBurney’s point, medial inquinal region, and right scrotum
-Pain typically preceded by nausea
-Low grade fever >1.5 degrees; often with chills/sweats
-Pain with resisted hip flexion MMT
-Pain with obturator test (Hip IR and ER while flexed to 90)
What are symptoms of a hernia?
-intermittent or persistent bulge and pain
-localized and sharp pain
-increased pain with changes in position, physical exertion, bowel movements, and valsalva
What is the difference between a direct/indirect hernia and a femoral hernia?
The femoral hernia is more rare (4%) and goes down into the leg
What are signs and symptoms of renal referral?
Unilateral low back and front abdominal area pain unrelieved by position; possibly nausea/vomiting
How to test for kidney pain reproduction?
With the pt in prone, place one hand over the costovertebral angle on the back and thump the hand with the other fist; pain is positive test
What are signs of ureteral pain?
Pain from costovertebral angle and radiating to the front by the inguinal canal and into the groin area
Unrelieve by changing position
What percentage of hip fractures are associated with a fall?
90%
When are women 10x more likely to have had a fracture with a fall?
Over 80
compared to those 60-69
What are exam findings that might clue you into a hip fracture?
-Leg ER and abducted when in supine
-Leg appears shortened
-Pos Log Roll Test
-Pos axial load to the LE
-Unable to perform SLR
What is the log roll test?
Passive hip IR/ER with the LE in neutral while in supine
When might a hip fracture not be treated with surgery/ORIF?
Those that are severely debilitated, unstable, uncorrectable disease, end stage of terminal illness, non-ambulatory
What type of hip fracture heals better?
Extracapsular
What are risks associated with intracapsular ORIF of the hip?
Avascular Necrosis
Impact Failure
Non Union
Mal Union
Degenerative Changes of the hip joint
What are signs or risk factors for hip stress fracture?
Increased training volume
Deep, aching pain in hip/groin region
Worse with activity, better with rest
Difficulty weightbearing
“sign of the buttock”
Decreased ROM
Empty End Feel
Non-capsular pattern
Pattellar-pubic percussion test pos
What is the difference between a fatigue stress fracture and an insufficiency stress fracture?
Fatigue generally due to an increase in activity but healthy otherwise
Insufficiency in older adults, post menopausal, RA, Renal dysfunction, after radiation, coxa vara, metabolic disorder, paget’s disease
What is the “sign of the bottock?”
A potential indicator of femoral head/neck fracture noted by:
-Limited SLR similar to hip flexion
-Trunk flexion limited to the extent of hip flexion
-painful weakness of hip extension
-Swollen Bittock
-Non capsular pattern
