Hip Pain Flashcards
Mr T, 67 year old man with painful R hip
PHx: IHD, HTN, obesity, severe GN 20 years ago
SHx: lives with wife in double storey house, recently retired from sales, enjoys lawn bowls and caravan travelling
What associated symptoms would you ask about?
How would you assess severity?
Associated Sx: stiffness, clicking/grating, limping, leg weakness (sensation of giving way), limb numbness/paraesthesia
Assessing Sx severity/impact: PADL/DADL/CADL limitations e.g. walking distance/mobility, sleep disturbance, analgesia/NSAID use
What structures refer pain to the buttock, groin, anterior thigh and lateral pelvis?
Buttock: lumbosacral spine, hip joint
Groin: hip joint, lumbosacral spine, SI joint
Anterior thigh: hip joint
Lateral pelvis: gluteal muscles, trochanteric bursa
What nerves innervate the hip joint?
Femoral and obturator nerves (both L2-L4)
Superior gluteal nerve, and nerve to quadratus femoris (both L4-S1)
Mr T, 67 year old man with painful R hip
Rx: metoprolol 50mg bd, candesartan 16mg mane, aspirin 100mg mane, simvastatin 20mg
Mr T’s pain has been present for 18/12, gradually getting worse, in groin and anterior thigh
Exacerbated by a recent caravan trip to the Kimberleys
Avoiding going up and down the stairs at home; painful when putting on his socks
Taking paracetamol SR regularly for 3/12, no NSAIDs (increases risk of CV mortality)
What site and type of pathology do you think is the likely cause of Mr T’s pain? Why?
Site: local - bone/joint, soft tissue, or referred - spine, SI joint
Pathology: #, arthritis, bursitis, tendinopathy, but want to exclude infection or tumour
Risk factors for secondary OA
Hx of trauma
Other pre-existing joint disease e.g. gout, inflammatory arthritis, childhood developmental disorders
Avascular necrosis from previous steroid use
Give 3 examples of childhood developmental disorders which may predispose to secondary OA
Congenital hip dysplasia
Perthes
Slipped femoral epiphysis
Describe the steps in the screening rheumatological examination
- Look: while standing, look for wasting (of quads, hamstrings) and abnormalities of alignment (e.g. pelvic tilt, lumbar hyperlordosis, flexed hip posture)
- Look: observe gait (e.g. antalgic - short leg or pain)
- Feel: whilst lying, feel greater trochanter/gluteal region for tenderness
- Move: flexion and extension (Thomas test), IR, ER, abduction, adduction
- Special tests: leg length, Trendelenburg test, spine examination
Describe the GALS system of a screening MSK examination
G: gait appearance and movement (look for asymmetry and joint deformity)
A: arms appearance and movement
L: legs appearance and movement
S: spine appearance and movement
How is apparent leg length vs true leg length measured?
Apparent: from umbilicus to medial malleolus
True: from ASIS to medial malleolus
What does a positive Trendelenburg test indicate?
Inability to control posture; suggests proximal muscle weakness
Describe 4 common abnormalities of posture, comparing to normal posture
Normal spinal alignment: 3 normal curvatures (cervical, thoracic, lumbar)
Scoliosis: sideways curvature of thoracic spine
Sway-back
Flat-back
Kyphosis lordosis posture: curvature of thoracic spine
How do you make a Dx of OA?
Hx: stiffness
O/E: limited ROM esp IR and ER
Ix: no blood test for OA Dx but perform tests to exclude other arthritides (e.g. RA, septic arthritis) IF clinically indicated
Imaging: XR
What findings are expected on XR in OA?
Loss of joint space
Sclerosis
Osteophytes
Subchondral cysts
Describe the epidemiology of OA in Australia
Up to 1.2 million Australians have symptoms of OA (13% classified as disabled or handicapped(
Affects >50% of people >75
Significant problem for >10% of adults still in the workforce
Patients experience a decline in mobility and ability to perform daily activities; this is associated with peripheral weakness and CV deconditioning
What factors contribute to OA patients’ decline in mobility and ADLs as a result of their pain?
Peripheral weakness
CV deconditioning
What are the treatment goals in OA?
Relieve pain
Improve mobility
What kind of therapy best achieves the treatment goals of OA: rest or exercise?
Exercise; rest relieves pain but leads to muscle deconditioning/weakness
Describe non-operative Mx for OA
Exercise
Physiotherapy
How does exercise improve symptoms of OA?
Strengthening muscular support around joints
Helps with weight reduction and promotes endurance
Describe the efficacy of weight reduction as a treatment for OA
10% weight reduction as effective on hip scores as THR
How can pain and inflammation be reduced for the exercising OA patient?
Apply local heat before
Apply cold packs after
Focus on non-weight bearing exercises (e.g. swimming, water aerobics, cycling)
How can physiotherapists assist the OA patient?
Can provide support devices useful for reducing weight bearing on the joints (e.g. splints, canes, walkers and braces)
Longer term, these devices are generally used only in patients for whom surgical management is not appropriate, usually due to severe medical co-morbidities (not the case for Mr MT)
What are the 4 mainstays of pharmaceutical therapy for OA?
Analgesics
NSAIDs
Glucosamine and chondroitin
Intra-articular corticosteroid injection
What analgesics are commonly used to manage OA?
Paracetamol
Tramadol
Codeine
?other opiates
List 4 possible complications of NSAIDs
Nausea
Abdo pain
Diarrhoea
Gastritis and ulcers +/- GI bleeding (esp if on anti-platelets or anti-coags)
What kinds of NSAIDs can be used in the Mx of OA?
Non-selective
COX-2
?role of topical therapies (NSAID creams)
What is the evidence supporting use of glucosamine and chondroitin in OA?
Can relieve symptoms of pain and stiffness for some people with OA
Initial research demonstrated only a minor benefit in relieving pain for those with the most severe OA, and in most patients there was no benefit greater than that from placebo pills
When in the course of OA is intra-articular corticosteroid injection most useful?
Generally most effective early in the natural Hx of OA when inflammation is a major contributor to pain, before joint damage is the most significant component
How does the efficacy of corticosteroid injections for OA vary across the different types available?
Several types, all equally effective
Describe the degree and duration of benefit afforded by corticosteroid injection for OA
Very variable
What about hyaluronic acid analogues for Mx of OA? What are they, how do they work and are they commonly used?
Very viscous products; when injected into joints they can temporarily reduce pain and improve mobility
Not of established benefit so their use is not supported by the PBS
What is the major indication for THR in OA?
Disabling pain with failed non-operative treatment:
Severe degenerative changes and failure of non-op treatment for 3-6/12
Severe disabling pain (painful hip joint at rest and at night)
Severely deformed hip, decreased ROM and function, impaired ADLs
What are the goals of hip arthroplasty?
Relieve pain
Correct deformity
Restore ROM and ADLs
Describe the typical THR procedure
1) Incision over hip
2) Exposure and cutting of femoral neck, removal of femoral head
3) Reaming of acetabulum
4) Placement of acetabular cup and screw
5) Reaming of femoral canal, placement of femoral prostheses
6) Closure
What are the major issues for OA patients pre-operatively?
Medical optimisation
Informed consent
Assessing need for post-op rehabilitation
Mr T, 67 year old man with painful R hip
PHx: IHD, HTN, obesity, severe GN 20 years ago
Preadmission assessment?
FBE UEC Coagulation screen (INR, APTT) Group and hold MSU, MRSA screen of nose and perineum ECG indicated because of known IHD Resident r/v of medical problems: assessing for recent angina, adequacy of BP control, Sx of HF Anaesthetic r/v
Mr T, 67 year old man with painful R hip
PHx: IHD, HTN, obesity, severe GN 20 years ago
Rx: metoprolol 50mg bd, candesartan 16mg mane, aspirin 100mg mane, simvastatin 20mg
What anaesthetic options are indicated in this patient, given his Rx Hx? Should any of these Rx be withheld? Why/why not?
Neuraxial anaesthesia (epidural, spinal) is contraindicated while on clopidogrel, warfarin and dabigatran (variable withholding period for each) BUT no problems with aspirin Patient should continue aspirin through peri-operative period (risks of myocardial ischaemia/infarction without aspirin is greater than the risks associated with bleeding)
What is the effect of NSAID use on peri-operative transfusion requirements?
Increased transfusion requirements
What issues must be discussed when obtaining informed consent for any procedure?
1) Dx and natural Hx of patient’s condition, expected clinical course if surgery not performed
2) Recommended treatment and alternative treatment
3) Explanation of procedure
4) Risks and complications (general specific)
5) Give patient opportunity to ask questions
What are the potential intra-op, early post-op and late post-op complications of THR?
Intra-op: injury to neurovascular structures
Early post-op: haematoma, infection, would dehiscence
Late post-op (3-6 months): dislocation, leg length discrepancy, #, loosening (aseptic vs septic), heterotopic ossification
When is in-patient rehabilitation indicated post-THR?
Medical complications, multiple comorbidities, pre-existing functional impairment (e.g. arthritis in other joints, stroke)
Post-op weight bearing restrictions (with complicated surgery, uncemented implants, intra-op fractures, revision arthroplasty)
Persistent pain, decreased ROM
Poor social support, poor home environment set-up (stairs, difficult access)
What are the different degrees of body weight which can be recommended to be supported through the affected limb post-THR?
Non-WB: 0%
Toe-touch WB:
What are the post-op issues for a THR?
Wound Mx (no wound discharge prior to discharge) Pain Mx Rehabilitation Hip precautions Anti-coags Complications FU
How is pain managed post-THR?
Regional pain relief
Systemic (simple e.g. paracetamol + opiate - initially parenteral via patient controlled analgesia (PCA), then oral slow release to avoid peaks and troughs)
Should Abx be given post-arthroplasty?
Yes; give cephazolin 1g 8hrly (3 doses)
Should any Ix be performed post-THR?
XR of pelvis AP and hip lat view
What should physios focus on with a post-THR patient?
Bed exercises, standing, transfers
Breathing exercises to prevent atelectasis and hypostatic pneumonia
Hip precautions
