HIP Flashcards
Psoas Tendinitis Diagnosis
Psoas tendinitis can occur:
Following an acute injury
Sports related - repeated hip flexion
Associated with femoro acetabular impingement.
After total hip replacement
After hip arthroscopy
Activities that may predispose to psoas tendinitis include dancing, ballet, resistance training, cycling, rowing, running (particularly uphill), track and field, soccer, and gymnastics.
Effects young adults more commonly with a slight prevalence in females.
Psoas Tendinitis Presentation
Resisted flexion is positive→ Pain
Pain in the groin→ Hip lesions
Patients often present with complaints of an insidious onset of anterior hip or groin pain.
At presentation, patients may note pain with specific sports-related activities, such as jogging, running, or kicking. Pain with simple activities, such as putting on socks and shoes, rising from a seated position with the hips flexed for some time, walking up stairs or inclines, or brisk walking may be reported.
Psoas Tendinitis Special Tests
Flexion Abduction External Rotation (FABER) Test / Patrick’s Test (pg. 383)
Thomas Test (pg 404)
Psoas Tendinitis Imaging
Coronal T1-weighted image of the right hip in a 22-year-old female with hip pain demonstrate normal low signal at the distal iliopsoas tendon.
Psoas Tendinitis Treatment
Physical therapy is the first treatment approach. At first it is used to alleviate pain, spasm, and swelling and then it is used to return the patient to normal ROM, strength, endurance, proprioception, and activity specific to the patient’s sport. If the symptoms are resistant to physical therapy, a psoas tenotomy or lengthening can improve the painful symptoms.
Sartorius Tendinitis Diagnosis
Activities where sartorius pain can occur:
- Sitting with legs up and crossed for long periods of time (recliners, sleeping)
- Slipping or a misstep
- Sports that require planting one foot and making a sharp turn (basketball, football)
- Walking with an extended long stride
Sartorius Tendinitis Presentation
Resisted flexion is positive→ Pain
Pain in the groin→ Hip lesions
Sleeping with a pillow between ones knees seems to decrease the pain.
Sartorius Tendinitis Special Tests
Thomas Test (pg 404)
Sartorius Tendinitis Imaging
T2 weighted MRI axial view shows swelling and increased intrasubstance signal intensity in the sartorius (open arrow) and gracilis (straight solid arrow) tendons. Interstitial muscle edema and a perifascial fluid collection (*) are also noted. An associated partial tear of the medial collateral ligament is seen (curved arrow).
Sartorius Tendinitis Treatment
Physical therapy is the first treatment approach. At first it is used to alleviate pain, spasm, and swelling and then it is used to return the patient to normal ROM, strength, endurance, proprioception.
Avulsion Fracture of Greater Trochanter Diagnosis
Fractures of the greater trochanter are rare. They may be divided into those involving epiphyseal separation of adolescence and true fractures of adulthood.
Avulsion Fracture of Greater Trochanter Presentation
Resisted flexion is positive→ Pain and weakness
Resisted abduction is positive→ Pain and weakness
Lateral trochanteric pain
MOI: Forced external rotation of the leg with simultaneous contraction in the gluteus medius and minimus muscles
Avulsion Fracture of Greater Trochanter Special Tests
Single Leg Stance for 30 seconds (pg 409)
Avulsion Fracture of Greater Trochanter Imaging
AP radiograph of the pelvis showing the avulsed left greater trochanter.
CT image showing avulsion of the left greater trochanter. The trochanteric apophyseal fragment (T) is lying in a neutral position anterior to the externally rotated femur (F).
Avulsion Fracture of Greater Trochanter Treatment
ORIF is usually recommended. Following surgery NWB with crutches for 6 weeks is recommended before progressing to FWB. In adults isolated fractures of the greater trochanter have been treated both conservatively and surgically, but are most commonly treated surgically especially when displacement is involved.
Adductor Longus Tendinitis Diagnosis
Adductor tendinitis is more prevalent among athletes. Some sports where this is commonly seen include football, running, horseback riding, gymnastics, and swimming where the athlete must perform repetitive movements that change directions frequently.
Another cause is the overstretching of the adductor tendons.
Adductor Longus Tendinitis Presentation
Resisted adduction is positive→ Pain
Pain in the groin→ Hip lesions
Groin pain when palpating the adductor tendons on the pelvis, by closing the legs or abducting from the affected leg. The pain can be gradual or a sudden sharp pain.
The patient can notice swelling or lump in the adductor muscles, stiffness in the groin or inability to contract or stretch the adductors.
Adductor Longus Tendinitis Special Tests
Adductor Squeeze
- 45 degrees of hip flexion provides optimal force and adductor muscle activity
Adductor Longus Tendinitis Imaging
Altered signal is seen at the pubic attachment of adductor muscles in this Axial T2 weighted MRI.
Adductor Longus Tendinitis Treatment
Treatment for adductor tendinitis is initially RICE to aid in decreasing swelling and inflammation. Following RICE or concurrently with RICE physical therapy can be attempted where strengthening and obtaining ideal ROM can be completed.
Corticosteroid injections can be used to reduce inflammation if RICE and physical therapy are not helping.
Avulsion Fracture of Lesser Trochanter Diagnosis
Avulsion fractures of the lesser trochanter are uncommon injuries. They are mostly seen in adolescent athletes with a 2:1 male to female ratio.
They occur most often in track events like hurdling and sprinting, or games like soccer or tennis.
Most commonly seen in tennis players where rapid uncontrolled hip flexion or rotation of the torso on a fixed externally rotated femur can avulse the lesser trochanter.
Avulsion Fracture of Lesser Trochanter Presentation
Pain in the groin→ Hip lesions
The athlete will experiences a sudden, shooting pain referred to the involved tuberosity. They may lose muscular function and swelling and local tenderness may also occur.
Avulsion Fracture of Lesser Trochanter Special Tests
FABER test (Flexion Abduction External Rotation Test) (pg 383)
Avulsion Fracture of Lesser Trochanter Imaging
Frontal radiograph of the left hip demonstrates an avulsed fragment of bone (white arrow) representing the lesser trochanter of the femur. The fracture is subacute and heterotopic ossification (myositis ossificans) is forming in the soft tissues (black arrow) .
Avulsion Fracture of Lesser Trochanter Treatment
ORIF is usually recommended. Following surgery NWB with crutches for 6 weeks is recommended before progressing to FWB.
L2 Root Palsy Diagnosis
L2 root palsy can cause compression, as well as discomfort, tingling, numbness or muscle weakness that radiates to the quadriceps.
L2 root palsy can be caused by a number of conditions including:
Sciatica
Degenerative disc disease
Herniated disc
Bulging disc
Osteoarthritis
Spinal stenosis
Spondylolisthesis
L2 Root Palsy Presentation
Resisted flexion is positive→ Weakness
The L2 nerve root innervates the front of the thigh and transmits motor signals that cause the hip to flex. Because of this, L2 root palsy would affect anterior hip sensation and hip flexion strength.
L2 Root Palsy Special Tests
Begin by checking the L2 dermatome (mid anterior thigh) for sensation and then check the L2 myotome or hip flexion for muscle activity. Hip flexion is innervated by the femoral nerve.
L2 Root Palsy Imaging
Sagittal T2-weighted MRI of an L2 compression fracture. Relatively little deformity of the L2 vertebral body is shown, with less than 5° of kyphotic forward angulation. Compression fractures with little angulation often are associated with significant posterior ligamentous trauma (arrow).
L2 Root Palsy Treatment
The symptoms normally can be managed using conservative treatments such as pain medication and physical therapy. However, if chronic lower back pain persists despite weeks of conservative treatment, surgery might become an option.
L3 Root Palsy Diagnosis
L3 root palsy commonly arise from: Spondylolisthesis of the L3-L4 segment Herniation of the L3 disc Stenosis Degenerative Disc Disease Osteoarthritis
L3 Root Palsy Presentation
Resisted flexion is positive→ Weakness
The L3 nerve root innervates the medial femoral condyle and transmits motor signals that cause the knee to extend. Because of this, L3 root palsy would affect medial femoral condyle sensation and knee extension strength.
L3 Root Palsy Special Tests
Begin by checking the L3 dermatome (medial femoral condyle) for sensation and then check the L3 myotome or knee extension for muscle activity. Knee extension is innervated by the femoral nerve.
L3 Root Palsy Imaging
Lateral radiograph demonstrates an L3 spinal compression fracture. Note the downward compression of the superior endplate of the L3 (yellow arrow). The anterior portion of the L3 vertebral body has been displaced forward (white arrow).
L3 Root Palsy Treatment
Treatment of pain in the L3 segment will be dictated by the underlying diagnosis of the cause of the patient’s pain and the severity of the condition. While many injuries or ailments can be treated with physical therapy or manual manipulation, others will warrant more interventions treatment steps such as spinal injections.
S1 Root Palsy Diagnosis
Several incidents can cause S1 nerve root palsy including:
Nerve root compression
Disc herniation
Disc degeneration
Compression of the sciatic nerve
Isthmic SpondylolisthesisS1 Root Palsy Presentation
Resisted extension is positive→ Weakness
S1 Root Palsy can present with paralysis with involuntary tremors involving the ankle joint since the S1 myotome is in control of ankle plantarflexion, making it hard for one to stand on their toes or ball of the foot. Numbness and/or pain can radiate along the outside of the calf, down to the sole or outside of the foot and the toes.
S1 Root Palsy Special Tests
Begin by checking the S1 dermatome (lateral heel) for sensation and then check the S1 myotome or ankle plantarflexion for muscle activity. Ankle plantarflexion is innervated by the tibial nerve. Also one can check the S1 reflex or the achilles tendon reflex.
S1 Root Palsy Imaging
Left Sagittal View MRI: A Large “Far Lateral” Herniated Disc at L3,4 (Horizontal Arrow points to the “Black” oblong Herniated Disc “mass” extending out of the L3,4 Disc Space and pushing into the Spinal Canal). In addition, this patient has multi-level degenerative disease as indicated by the Disc Space collapse at L4,5 & L5,S1. Both levels demonstrate “Disc Bulges” (Up-curved Arrows)
S1 Root Palsy Treatment
Most cases of lumbar herniated disc symptoms resolve on their own within six weeks, so patients are often advised to start with non-surgical treatments. However, this can vary with the nature and severity of symptoms. Non-surgical treatments include, ice application, pain medications, muscle relaxants, heat therapy, and heat and ice alternations. While applying these interventions, one could attend physical therapy to aid in passive physical therapy to help reduce the patient’s pain to a more manageable level followed by active exercises to improve strength and teach the patient better ways to perform strenuous activities that may have caused the initial onset of the disc herniation. If pain is not proving to get better within 6 weeks with these interventions, surgery may become the next option.
S1, S2 Root Palsy Diagnosis
Several incidents can cause S1, S2 nerve root palsy including: Nerve root compression Disc herniation Disc degeneration Compression of the sciatic nerve Isthmic Spondylolisthesis
S1, S2 Root Palsy Presentation
Resisted flexion of knee is positive→ Weakness
S1 innervation provides the body’s ability to plantarflex the ankle while S2 allows the knee to flex. Decreased strength in these movements may be present along with pain coursing down the back of the thigh and lower leg and in the buttock region. Also bowel and bladder loss or dysfunction may be present.
S1, S2 Root Palsy Special Tests
Begin by checking the S1 dermatome (lateral heel) and the S2 dermatome (Popliteal Fossa) for sensation and then check the S1 myotome or ankle plantarflexion and the S2 myotome or knee flexion for muscle activity. Ankle plantarflexion and knee flexion are innervated by the tibial nerve. Also one can check the S1 reflex or the achilles tendon reflex.
S1, S2 Root Palsy Imaging
A midsagittal T2-weighted MRI illustrating early imaging signs of disc degeneration at L4-5 and L5-S1.
(I was unable to find an image that demonstrated S1,S2 nerve root palsy so I decided to use this image since it labels the vertebrae nicely. As mentioned above this image demonstrates early signs of disc degeneration at the L4-5 and L5-S1 areas.)
S1, S2 Root Palsy Treatment
Multiple treatments include:
Rest
Medication to reduce inflammation
Ice in acute cases to reduce inflammation
Steroidal medication to reduce inflammation in moderate to severe conditions
Physical therapy to reduce inflammation, restore joint function, improve motion, and help the return of full function
L2-L4 Root Lesion Diagnosis
It is caused by damage to the lower spine which causes compression of the L2-L4 nerve roots which exit the spine. The compression can lead to tingling, radiating pain, numbness, paraesthesia and occasional shooting pains. Radiculopathy can occur in any part of the spine, but it is most common in the lower back.
The most common causes of lumbar radiculopathy are:
A prolapsed disk
Stenosis (either of the central canal or the foramen)
Impinging or irritating a nerve root(s)
L2-L4 Root Lesion Presentation
Resisted adduction is positive→ Weakness
Symptoms of nerve root compression or damage are often initial and most prominent complaint of patients with spine disease. Principal symptoms are dermatomal pain, paresthesias, and sensory loss; selective motor loss; and bowel or bladder dysfunction when the cauda equina is involved (L2-L5, S1-S5, and the coccygeal nerve).
L2-L4 Root Lesion Special Tests
Begin by checking the L2 dermatome (mid anterior thigh) for sensation and then check the L2 myotome or hip flexion for muscle activity. Hip flexion is innervated by the femoral nerve. Then check the L3 dermatome (medial femoral condyle) for sensation and the L3 myotome or knee extension for muscle activity. Knee extension is innervated by the femoral nerve. Lastly check the L4 dermatome (medial malleolus) for sensation followed by the L4 myotome for muscle activity. The L4 myotome is ankle dorsiflexion and is innervated by the deep peroneal nerve.
L2-L4 Root Lesion Imaging
Images of an 82-year-old man with right lower extremity weakness and pain, primarily in the upper leg and thigh. Electromyography suggested right L2, L3, and L4 abnormality.
A−C, Contiguous axial view T2-weighted MR images obtained at the L3–L4 level. Root compression was identified by one observer at L3–L4 on the right (arrows) but was labeled noncompressive (grade 1) by the second observer. Root compression was also correctly identified on the right by both observers at L2–L3 (grades 2 and 3).
D, Conventional myelogram shows right-sided root compression at L2–L3 (curved arrow) and L3–L4 (straight arrow), identified and assessed as grades 2 and 3 by both observers. The patient underwent right-sided keyhole decompression at L2–L3 and L3–L4. Severe root compression was surgically identified at both levels, and the patient achieved resolution of leg pain after surgical decompression.
E−H, Contiguous axial view post-myelogram CT images obtained at the L3–L4 level show slight angular distortion on the right lateral recess (arrows). The nerve roots within the canal are slightly more prominent at this level and may be somewhat edematous. Both observers labeled this lateral recess root compressive (grade 2).
L2-L4 Root Lesion Treatment
Medications are used to help with the pain and can improve your quality of life whilst healing take place. Along with medications, one can attend physical therapy to aid in decreasing inflammation and increasing lost ROM. If neither of these seems to be benefiting, one can consider injection therapy or surgery. Injection therapy and surgery are generally only used if other less invasive measures are not providing the desired results within a 6-12 weeks.
L3 Root Lesion Diagnosis
Loss of sensation in the L3 dermatome or loss of strength in the L3 myotome as compared to the non affected side may be present with this disorder. Paralysis or pain may also be present coursing down the medial side of the leg following the L3 dermatomal distribution pattern.
L3 Root Lesion Presentation
Resisted extension of knee is positive→ Weakness
Symptoms of nerve root compression or damage are often initial and most prominent complaint of patients with spine disease. Principal symptoms are dermatomal pain, paresthesias, and sensory loss; selective motor loss; and bowel or bladder dysfunction when the cauda equina is involved (L2-L5, S1-S5, and the coccygeal nerve).
L3 Root Lesion Special Tests
Begin by checking the L3 dermatome (medial femoral condyle) for sensation and then check the L3 myotome or knee extension for muscle activity. Knee extension is innervated by the femoral nerve.
L3 Root Lesion Imaging
Images of a 70-year-old man with bilateral leg pain and weakness, with reduced sensation in both upper and lower legs.
A−C, Contiguous axial view T2-weighted MR images show a trefoil-shaped canal at L2–L3 that was judged to be root compression (grade 2) on the right by one observer because of the small recess size but was judged to be noncompressive (grade 0) by the other observer (arrows).
D, Conventional myelogram shows right-sided root compression at L2–L3 (curved arrow), assessed as grades 2 and 3 by both observers. Compression at L3–L4 was also identified by both observers by using MR imaging and conventional myelography. Surgical findings revealed evidence of root compression on the right at L2–L3 as well as at L3–L4. The patient was free of leg pain at the time of postoperative discharge.
E−G, Contiguous axial post-myelogram CT images obtained at the L2–L3 level show narrowing of the right lateral recess (arrows) with a normal appearance of the left lateral recess. One observer graded the right lateral recess as abnormal (grade 2), and the second observer graded this recess as narrow but not compressive (grade 1). Observer grading in this instance was reversed between MR imaging and CT myelography. One observer graded the MR imaging findings as root compressive but graded the CT myelography findings as not compressive. The other observer graded the MR imaging findings as compressive but graded the CT myelography findings as narrow but not root compressive.
L3 Root Lesion Treatment
Possible treatments include:
Medications to aid in reducing inflammation and pain
Physical therapy to aid in decreasing inflammation and increasing lost ROM and strength
Spinal injections and surgery only if medications and physical therapy are not obtaining the desired outcomes in a timely manner (6-12 weeks)
Fractured Sacrum Diagnosis
- Caused by injury
- Sacral fractures occur in 45% of all pelvic fractures
- Neurologic structures are at risk because of the placement of the lumbosacral plexus
- Denis Classification: (one of the many ways to classify)
- Zone 1: Fractures are lateral to the neural foramina
- Zone 2: Fracture pass through the foramina
- Zone 3: Fractures are medial to the foramen and involve the spinal canal
Fractured Sacrum Presentation
- Non-capsular pattern
- Limited ROM
- May see neurological issues
- Pain
Fractured Sacrum Special Test
+ Buttock sign
Neuro screen
Fractured Sacrum Imaging
- Transverse sacral fracture at S3
- (A) Outlet radiograph
- (B) Sagittal CT reconstruction
- (C) Coronal CT reconstruction
Fractured Sacrum Treatment
-Non-displaced fractures are treated nonsurgical
•Restricted weight-bearing
-Displaced fractures require surgery
Aseptic Necrosis Diagnosis
- Also known as avascular necrosis and osteonecrosis
- Poor blood supply to an area of bone resulting in bone death
- Causes include: trauma, damage to the blood vessels that supply bone its oxygen, abnormally thick blood, poor blood circulation to the bone, and atherosclerosis, medications
Aseptic Necrosis Presentation
-Non-capsular pattern
-Limited ROM
-May or may not have pain
•Pain can be felt in the groin, buttock, front of the thigh
-Limp with walking
-Stiffness
Aseptic Necrosis Special Tests
- Resisted movements are negative
- X-ray
Aseptic Necrosis Imaging
- X-ray (frogleg view) femoral head aseptic necrosis
- X-ray (AP view) Bilateral femoral head aseptic necrosis
Aseptic Necrosis Treatment
-Dependent of the stage of the condition
•Very early stage: nonsurgical (progression of condition still occurs)
•Early stage: surgery (core decompression)
•Later stages: surgery (joint replacement)
Gluteal Bursitis Diagnosis
-Cause: Too much repetition or high force, irritation and inflammation of the ischiogluteal bursa
•Prolonged sitting
•Repetitive running, jumping, kicking
Gluteal Bursitis Presentation
- Non-capsular pattern
- Lateral trochanteric pain
- Pain in the buttock
- Pain with activities
Gluteal Bursitis Special Tests
-Resisted movements are positive
•Resisted medial rotation + (Pain)
•Resisted lateral rotation + (Pain)
Gluteal Bursitis Imaging
- (A) MRI, T1
- (B) MRI, T2
- (C) MRI, T1
- (D) MRI, T2
Gluteal Bursitis Treatment
- Physical therapy (most patients heal well from PT)
- Medication
- Corticosteroids
- Draining of the bursa
Trochanteric Bursitis Diagnosis
-Inflammation of the bursa near the greater trochanter of the femur
-Common causes:
•Acute or chronic trauma
•Hematoma
•Arthritis
•Infection
•Tendon or muscle tear
Trochanteric Bursitis Presentation
-Non-capsular pattern
-Lateral hip pain
•Can radiate to the knee or down the lateral side of the thigh
-Pain with activity
-Pain with palpation over the greater trochanter
Trochanteric Bursitis Special Tests
-Passive external rotation +
Trochanteric Bursitis Imaging
-MRI, T2 trochanteric bursitis
Trochanteric Bursitis Treatment
-Conservative treatment
•Physical therapy
•Rest
•Ice
•NSAIDs
-Some refractory cases may need corticosteroids or surgeryRectus Femoris Tendinitis Diagnosis
-Some causes include:
•Overstretching
•Running
•Swimming
•Power walking
•Cycling
•Etc.Rectus Femoris Tendinitis Presentation
- Groin pain
- Gradual onset of pain and tenderness at the front of the hip
- Pain and stiffness may be worse after rest
- Pain with hip extension and knee flexion
- May see limited ROM and tightness
Rectus Femoris Tendinitis Special Tests
-Resisted movements are positive
•Resisted flexion is + (Pain)
•Resisted extension of the knee is + (Pain)
Rectus Femoris Tendinitis Imaging
-MRI, T2, “bull’s-eye” sign
Rectus Femoris Tendinitis Treatment
-Physical therapy
•US, laser, massage, rehab program
-Rest
-Ice
-Anti-inflammatory medicationObturator Hernia Diagnosis
- Rare type of hernia of the pelvic floor
- Pelvic or abdomen contents protrude through obturator foramen
- More common in women
Obturator Hernia Presentation
- Pain in the medial thigh
- Bowel obstruction
Obturator Hernia Special Tests
-Resisted movements are positive
•Resisted flexion is + (Pain)
-Howship-Romberg sign
Obturator Hernia Imaging
CT
Obturator Hernia Treatment
-Surgery and repair of the hernia orifice
Avulsion Fracture of ASIS Diagnosis
-Occurs in young athletes
-Causes include:
•Trauma
•Sudden or forceful contraction of Sartorius and TFL
•Can occur during hip extension
-Often a pop or a snap is reported
Avulsion Fracture of ASIS Presentation
- Groin pain
- Weakness with hip flexion and knee extension
- Can result in a limp
Avulsion Fracture of ASIS Special Tests
-Resisted movements are positive
•Resisted flexion is + (Pain and weakness)
Avulsion Fracture of ASIS Imaging
-Reconstructed 3D CT scan
Avulsion Fracture of ASIS Treatment
-Nonsurgical:
•Rest
•Crutches for protected weight bearing
•Early ROM and stretching
-Surgical: ORIF of the avulsion fracture (displacement >3cm)
Iliac Apophysitis Diagnosis
- Mechanical overloading injury at the tendon insertion site
- Normally in younger individuals
- In runners this can happen when there is a simultaneous contraction of the abdominal musculature, gluteus medius, and TFL. Excessive arm swing and trunk rotation while running or even a sudden change in direction.
Iliac Apophysitis Presentation
- Tenderness with palpation of iliac crest
- Sudden onset of pain
- Swelling
- Weakness
Iliac Apophysitis Special Tests
-Resisted movements are positive
•Resisted abduction is + (Pain and weakness)
Iliac Apophysitis Imaging
-X-ray (AP view) Iliac Apophysitis
Iliac Apophysitis Treatment
-Several conservative phases:
•1: Rest and protection
•2: Gentle stretching
•3: Progressive resistive exercises
•4: Long term flexibility and strengthening program
-Surgery is rare
Hamstring Syndrome Diagnosis
-Also known as hamstring tendinosis
•Stress, small tears, thickening
-Semimembranosus tendon mostly affected
-Sometimes biceps femoris
-Usually develops as overuseHamstring Syndrome Presentation
- Pain in the buttock
- Pain at and with palpation at the ischial tuberosity
- Sitting is uncomfortable or painful
- Side differences in forward bending
Hamstring Syndrome Special Tests
-Resisted movements are positive
•Resisted flexion of the knee is + (Pain)
-Puranen-Orava test +
-SLR +
Hamstring Syndrome Imaging
- MRI, T1
- First image is normal
- Second image is hamstring syndrome
Hamstring Syndrome Treatment
-Conservative:
•Rest
•Avoid long sitting
•Avoid over stretching
•Mobility exercises of hip
•Muscle strengthening
•Massage
•NSAIDs
•Corticosteroid injections
-SurgeryRheumatoid-type Arthritis Diagnosis
-Autoimmune disease where the body attacks the synovium of both sides of the body
-Cause is unknown but possibilities include:
•Genetics
•Environmental factors
•Hormones
Rheumatoid-type Arthritis Presentation
-Symptoms: (can come on gradually or suddenly)
•Pain
•Stiffness
•Swelling
-Can lead to:
•Hip joint damage
•Loss of function
•Limited ROM
•DisabilityRheumatoid-type Arthritis Special Tests
Capsular Pattern
Rheumatoid-type Arthritis Imaging
-X-ray RA of bilateral hips
Rheumatoid-type Arthritis Treatment
- DMARDs
- NSAIDs
- Corticosteroids
- Exercise
- Surgery
Monoarticular Steroid Sensitive Arthritis
Presentation- patient will complain of joint pain, aggravated by activity.
Diagnosis- can be initial manifestation many joint disorders. The first step is to rule out surrounding tissue and confirm the pain in the joint. Crystals from gout or psudo gout are the most common cause. One must examine joint fluid for leukocyte/uric acid or use light microscopy to identify crystals
Special Tests- Capsular Pattern
Imaging- X-rays
Treatment- NSAIDS, corticosteroids, exercise, surgery
Septic Arthritis(aka infectious)
Presentation- Rapid intense pain, joint swelling, the presence of extra-articular symptoms and usually the triad of Fever, Pain, and Imapired ROM
Diagnosis- Arthrocentesis = look at synovial fluid for luekocyte cell count and infection from bacteria.
Special Tests- Capsular Pattern
Imaging- X-rays to look fr joint damage
Treatment- Powerful antibiotics, drain infected fluid, corticosteroids, NSAIDs for pain
Tuberculosis Arthritis
Presentation- Can affect LE joints, wrists, and spine, causing decreased ROM, excessive sweating, low fever, joint swelling, muscle atrophy and spasms, numbness/tingling below affect level of spine, weight loss, and it starts slow.
Diagnosis- Caused by bacteria known as Myobacterium tuberculosis, few people who have TB will get this, affects one joint typically.
Special Tests- Capsular Pattern
Imaging- Chest X-ray, CT of spine, joint x-ray
Treatment- Cure the infection with drugs that fight the TB bacteria: Isnaizid, Rifampin, Pyrazinamide, and ethambutol to name a few.
Haemarthrosis
Presentation- Joint pain and inflammation leading to a decrease in PROM/AROM, pain/tenderness upon palpation, bruising around joint, and a tingling sensation may be present.
Diagnosis- Bleeding into joint following injury, but main occurs in patients with a predisposition to hemorrhage (taking warfarin) and is associated with TKA patients, but definitive diagnosis requires joint aspiration.
Special Tests- Capsular Pattern
Imaging- MRI
Treatment- depends on cause, can do synovectomy, menisectomy, osteotomy, ablation, joint replacement, give clotting agents, or Physical Therapy
Crystal Synovitis (aka pseudogout)
Presentation: older adults, asymptomatic, can present as acute or chronic inflammatory arthritis, WBC raised, polyarticular, crystal form within aricular tissues, and commonly affects the knees wrists and hips. Due to this it can be misdx as carpal tunnel syndrome.
Diagnosis: Two elements, radiology and joint fluid analysis- X-ray/CT/MRI show calcific mass within joint capsule while arthrocentesis tests for cyrstals with H&E stain.
Special Test: Capsular Pattern
Imaging: H&E Stain applicable?
Treatment: aspiration of synovial fluid, NSAID’s, corticosteroids either injection or orally, pulsed US, and possibly total joint replacement
Beginning Arthrosis
Presentation: develops slowly with early stages casuing cartilage erosion that can go unnoticed for a long time because it is a non-inflammatory disease that does not present until it is too late, and the patient is in the early stages of arthritis. The pain is typically monoarticular, worse during movement, and stiff in general, but not accompanied by swelling. The patient may begin to notice loss of ROM and bony outgrowths may be felt with palpation. Essentially early arthritis.
Diagnosis: Mechanical stress on articular cartilage causing wear and tear. Typically related to age, obesity, genetics, hormonal imabalances, and work.
Special Tests: Capsular Pattern
Imaging: X-Ray = degredation of cartilage and possible narrowing of joint space, but that would be arthritis.
Treatment: Manage pain and reduce stress on joints. Modalities, NSAID’s, Cortisone, chronic = mobs, and hot therapies.
Hamstring Tendonitis
Presentation Diagnosis Special Tests Imaging Treatment
Pain in the groin: referred from Aneurysms
Diagnosis
Abdominal Aortic Aneurysms are areas of the Aorta at the level of the abdomen that are swollen or bulging out due to weak walls. The cause is unknown, but risk factors include: High BP, Smoking, and Vascular Infection,
Pain in the groin: referred from Aneurysms
Presentation
Most aneurysms have no symptoms unless they rupture. If this does occur you can experience: Sudden pain in the abdomen or back that can move into your pelvis legs or buttocks, increased HR, shock or loss of consciousness, sweaty or clammy skin.
Pain in the groin: referred from Aneurysms
Special Tests
CT scan of the abdomen abdominal ultrasound chest X-ray abdominal MRI study Palpation of a pulsing mass
Pain in the groin: referred from Aneurysms
Imaging
This is a CT scan of an abdominal aortic aneurysm
Pain in the groin: referred from Aneurysms
Treatment
Option 1: The doctor will monitor the aneurysm regularly and continue to assess the situation. This is done normally if the aneurysm is small.
Option 2: Endovascular Surgery is less invasive and uses a graft to repair weak walls of the aorta.
Option 3: Open Abdominal Surgery is done with the aneurysm is large or fast growing or if it has already ruptured.
Pain in the groin: referred from Genitalia
Diagnosis
Orchitis is inflammation of the testicles due to a virus or bacteria. It can present in both testicles, but is more common to occur in only one. A common cause of this is the mumps.
Pain in the groin: referred from Genitalia
Presentation
Pain in the testicles or groin is normally the primary sign, but you can also have: tenderness in the scrotum, painful urination, painful, ejaculation, a swollen scrotum, blood in the semen, abnormal discharge, an enlarged prostate, swollen lymph nodes in the groin,
a fever
Pain in the groin: referred from Genitalia
Special Tests
A doctor may ask questions about past medical history as well as doing a physical to rule out other diagnosis. A ultrasound can also be performed.
Pain in the groin: referred from Genitalia
Imaging
This is an Ultrasound of Orchitis in the left testicle.
Pain in the groin: referred from Genitalia
Treatment
Bacterial Orchitis can be treated with antibiotics and anti-inflammatory drugs.
Viral Orchitis has no cure, but will go away on its own over time.
You can manage symptoms with ice, elevation, and pain relievers.
Pain in the groin: referred from Urinary Tract
Diagnosis
A UTI is caused by the growth of bacteria in any part of the urinary system. This occurs most commonly in the bladder.
Pain in the groin: referred from Urinary Tract
Presentation
Chills and shaking or night sweats Small amount of urine, even though you have urge to go Side, back or groin pain (sometimes severe abdominal pain) Fatigue and general ill feeling Flushed, warm, or reddened skin Mental status changes or confusion (particularly in the elderly) Frequent and urgent urination Painful or difficult urination Discomfort above the pubic bone Blood in the urine Cloudy or foul smelling urine Nausea and/or vomiting Fever above 101° Fahrenheit
Pain in the groin: referred from Urinary Tract
Special Tests
A urinalysis is the best test with a urine culture used to specify which antibiotic is best.
Pain in the groin: referred from Urinary Tract
Imaging
Imaging is only done to see if the anatomy predisposes someone to getting UTI’s.
CT scan of the abdomen
Intravenous pyelogram (IVP) Kidney scan
Kidney ultrasound
Voiding cystourethrogram
Pain in the groin: referred from Urinary Tract
Treatment
Antibiotics are used to treat UTI’s.
Pain relievers and heating pads can improve symptoms. Drinking plenty of water and avoiding alcohol, caffeine and smoking can improve recovery.
Pain in the groin: referred from Rectus Abdominus
Diagnosis
A Desmoid Tumor is a fibrous neoplasm that can occur in the abdominal wall as well as over the rest of the body. It occurs more commonly involving genetics, but can still occur rarely in random cases.
Pain in the groin: referred from Rectus Abdominus
Presentation
Internal Desmoid Tumors on the abdominal wall can cause severe pain, rupture of intestines, compression of the kidneys or ureters or rectal bleeding. They look or feel like firm lumps under the skin if they are superficial enough to notice at all.
Pain in the groin: referred from Rectus Abdominus
Special Tests
A biopsy is needed to confirm a tumor although an Ultrasound is usually first used to identify the tumor. An MRI or CT can later be used to determine if the tumor is attached to surrounding tissue.
Pain in the groin: referred from Rectus Abdominus
Imaging
Ultrasounds are used to Identify Desmoid Tumors, but MRI and CT can be used for further exam if the tumor is free floating or not. This image is a CT with contrast.
Pain in the groin: referred from Rectus Abdominus
Treatment
Radiation or Chemotherapy are commonly used along with surgery to remove the tumors and to try to prevent recurrence. A multi-disciplinary team is usually needed for best outcomes.
Sacroiliac Joint Strain
Diagnosis
Sacroiliac Joint dysfunction can come from the joint being either hyper or hypo mobile. Dysfunction can occur because of muscle surrounding the SI joint being to active or by being weak.
Sacroiliac Joint Strain
Presentation
SI joint dysfunction can commonly be mistaken for many other diagnosis. It presents with pain in the lower back, hip, groin buttock and sciatic region. It is typically worse with standing or walking or other physical activity of the hip.
