HIP Pathologies Flashcards
Anterior Hip Pain
Common
- Synovitis
- Labral Tear
- Chndropathy
- Osteoarthritis
Less Common
- Os acetabulae
- Ligament teres tear
- Stress fracture
- Hip joint instability
- Hypermobility
- Developmental hip dysplasia
Not to be missed
- Synovial chondromatosis
- Avascular necrosis of head of femur
- Slipped capital epiphysis
- Perthes disease
- Tumour
Lateral Hip Pain
Common
- Greater trochanter pain syndrome
- Gluteus medias tears and tendinopathy
- Trochanteric bursitis
Less common
- Refered pain from lumbar spine
Not to be missed
- Fracture of neck of femur
- Nerve root compression
- Tumour
Piriformis Syndrome
Piriformis Syndrome (piriformis impingement) is a compressive neuropathy of the proximal sciatic nerve. In the majority of the population the sciatic nerve passes underneath the piriformis muscles, however for some it will piece the piriformis entirely or with branches. This predisposes those individuals to development of the syndrome as contracture or spasm will causes irritation of the sciatic nerve
Aetiology
Signs and Symptoms
Hyperlordosis
Muscle anomalies with hypertrophy
Partial or complete neural anomalies
Hip Bursitis
Dysfunctional biomechanics of the lower limb
Sacroiliac, coccygeal, groin and hip pain
Pain referral down the leg to the foot
Sometimes bilateral symptoms
Sensation of vague tingling down the leg
Changes in sensation and weakens are rear
Difficulty sitting in symptomatic side
Meralgia Parasthetica
Meralgia Parasthetica is a condition where there is entrapment or pressure of the lateral femoral cutaneous nerve as it passes under in inguinal nerve. This nerve is sensory only, so the patient experiences sensory alteration and/or burning pain on the lateral aspect of the thigh. Derived from the 2nd and 3rd lumbar nerve roots.
Aetiology
Signs and Symptoms
Trauma to the area
Wearing of tight clothing (belts, braces)
Stretching injury due to repetitive motion
Retro-peritoneal tumour or abscess, AAA, Surgery in the area
Tightness of Sartorius, Ilicus
Paraesthesia in the distribution of the nerve
Sensations of burning, tingling, numbness
Changes in posture, long sit and stand increase symptoms
Relived by rest or sitting
Lateral thigh pain
Obturator Nerve Entrapment
Obturator Nerve Entrapment is a fascial entrapment as it enters the adductor compartment through the obturator canal and under the obturator externus muscle. It is derived from the L2-L4 nerve roots and supplies hip adductor muscles. Pain is initially felt high in the adductor origin sight and then moves inferiorly towards the insertion point of the adductor.
Aetiology
Signs and Symptoms
Exercise related groin pain seen in team sports
Groin pain after exercise which can radiate into medial thigh after training
Weakness or feeling of lack of propulsion when running
Weakness of hip adduction and pain on abduction
Hip Osteoarthritis
Hip Osteoarthritis is the generation of the femoral head and acetabulum where there is decrease in articular cartilage of the joint and osteophyte formation on the femoral head. There is a strong biomechanical contribution to OA as altered gait or loading patterns due weakness or lack of stability can place extra load through the joint causing the condition to worsen or develop. Hip OA is often unilateral and cause compensatory changes to the structure of the knee, increasing the chance of OA of the knee joint.
Hip OA can be classified into concentric (medial femoral head migration) and eccentric (superior femoral head migration). Eccentric OA is considered more painful and patients deteriorate at a faster rate.
Aetiology
Signs and Symptoms
Primary
- Increased anteversion angle of the femoral neck
- Occupation
- Overweight
- Elite sport
Secondary
- Osteonecrosis
- Trauma
- Infection
- Paget’s disease
- Slipped capital epiphysis
- Perthes disease
- Femoracetabular impingements increase load on anterior superior aspects of hip and change load bearing pattern
Middle aged or older
Pain at the end of the day and eventually morning stiffness (30-60mins)
Stiffness after rest
Pain may be felt in groin, buttock, lateral thigh or medial knee
- Anterior aspect of hip with referral into groin (intra articular referral pattern)
Restriction inactivated due to pain
Pain in capsular pattern
Femoral Neck Stress Fracture
Femoral Neck Stress Fracture is a common injuring amongst runner’s dues to the compressive force the femoral neck is exposed too. Weight bearing forces (3-5 times body weight when running) form the trunk cause compressive force on the inferior aspect of the femoral neck, whereas the superior aspect is subject to tensile forces (rotational).
The blood supply to the femoral head run thoughts the femoral neck, therefore damage to this area can expose the patient avascular necrosis of the femoral head if not diagnosed initially
Aetiology
Signs and Symptoms
Dysfunctional gait and biomechanics
High training load (running)
Insufficient recovery
Gradually worsening pain of the hip, groin or thigh
Pain with initial activity and worsening as training continues
Avulsion Fractures
Avulsion Fractures are the fractures that occur where tendons and ligaments insert to the bone. These usually occur in adolescent athletes (up to 25) at the apophysis of the bone as the epiphysis is generally weaker than the musculotendon junction. Mechanism for injury is usually an explosive action e.g. sprinting or kicking a ball. The most common sites of injury include the ASIS (Sartorius), AIIS (Rectus femoris), Ischial Tuberosity (Hamstrings).
Aetiology
Signs and Symptoms
Rapid contraction of muscles in explosive activates e.g. jumping and sprinting
Sudden onset of pain
Occurs at a sudden change in velocity or effort
Limping
Pain with passive and active muscle testing
Pain with resisted muscle tests
Localised point tenderness
Femoral Head Avascular Necrosis (Perthe’s Disease)
Femoral Head Avascular Necrosis occurs when there is decreased blood supply to the femoral head (stress fracture or fracture of femoral neck) therefore causing cell death of osteocytes and usually resulting in the collapse of the necrotic segment. The blood supply to the femoral head comes from the medial circumflex artery, lateral circumflex artery and a branch from the obturator artery superiorly. These blood vessels are well fixated to the femoral neck therefore damage to this structure can easily change the arterial flow to the femoral head.
Aetiology
Sings and Symptoms
Femoral neck stress fracture
Femoral neck fracture
Trauma (MVA, Weight training)
Inflammatory arthritides (RA, Lupus, Gout)
AVN may present with limited signs and symptoms
Pain and limited ROM
Pain localised to groin, but also buttock, knee, GT
Pain exacerbated with activity and relived with rest
Antalgic Gait
Slipped Capital Femoral Epiphysis
Slipped Capital Femoral Epiphysis is posterior-inferior displacement of the femoral epiphysis due to weakness of the epiphyseal growth plate. It may occur in older children aged 12-15 years. It typically occurs in overweight boys who tend to be late-maturing. The slip may occur suddenly or gradually, there is associated pain that can occur in the knee and often present with limp. Slips can cause AVN of the femoral head as they affect the blood supply.
Aetiology
Sings and Symptoms
Overweight males (12-15)
Rapid growth
Femoral neck retroversion
Reduced shaft angle
Hypothyroidism
Hip discomfort with referral into the groin, medial thigh and/or knee
Pain increases with activity and decreases with rest
Severe pain on complete slippage
Mild limp
Legg-calve-perthes-disease
Legg-Calve-Perthes Disease is an idiopathic osteonecrosis of the capital femoral epiphysis of the femoral head.
Signs and Symptoms
- Hip and groin pain which may be referred to the thigh
- Mild or intermittent pain in the anterior thigh or knee
- Limp
- No history of trauma
Examination findings
Orthopaedic Tests
Decreased ROM of internal rotation and abduction
Painful gait
Atrophy of thigh muscles (disuse)
Leg length discrepancy
Short stature of the patient
AROM and PROM
Log Roll
FABER
Scoring Test
Transient Hip Synovitis
Transient Hip Synovitis is the inflammation of the inner synovium lining of the hip capsule caused by recent trauma or infection. It is the most common cause of acute hip pain in children (3-10 years).
Signs and Symptoms
- Unilateral hip or groin pain
- Medial thigh pain
- Antalgic limp
- Sometimes there is no pain
Examination findings
Orthopaedic Tests
ROM restriction in internal rotation and abduction
Pain in AROM and PROM
Tender to palpation
Low grade fever or rash
Scouring Test
FABER (Pat Fab)
Anvil
Yeomans
Gaenslens
Osteitis Pubis
Osteitis Pubis is the inflammation of the pubic symphysis and is often found in athletes.
Aetiology
Sings and Symptoms
Overuse and microtrauma injury associated with running and kicking
Repetitive adductor muscle pulls on the pubis rami creating shear force at pubic symph
Pregnancy /Childbirth
Pain localised to the pubic symph but can radiate to groin and medial thigh
Pain worse when running, kicking, COD, lying on ones die
Sensation of clicking or popping felt when stranding, rolling over in bed, walking on uneven ground
Examination findings
Orthopaedic Tests
Pain on resisted adduction
Pain on passive hip flexion and abduction
AROM and PROM (Adduction/Abduction)
Adductor muscle test
Femoral Acetaubular Impingment
Femoral Acetabular impingement is characterised by a combination of clinical, sings, symptoms, and pathology (it is not a diagnosis itself). There are three types of FAI:
- CAM lesion is reduction of femoral head-neck off set which results in additional bone at the neck of the femoral head-neck junction. Cam lesions usually occur on the anterosuperior aspect of the femoral neck. Impingement usually occurs in flexion, adduction and internal rotation.
- Aetiology = Slipped capital femoral epiphysis, Legg-Calve Perthes, Elliptical femoral head, Malunited femoral neck fractures
- Signs = Pistol grip deformity
- PINCER Impingement is bony changes in the acetabulum, these can be a deepening of the acetabulum (anteriorly) or a retroverted acetabulum. This deepening causes increased coverage of the femoral head causing pinching as the femoral head moves in the acetabulum at end ranges or flexion, internal rotation, adduction, abduction
- Aetiology = Acetabular retroversion, Coxa profunda, Protrusio acetabuli
These types may also be a mixture of both. They can cause increase stress on the acetabular labarum and articular cartilage, which may result in degeneration, labarum tears, development of OA
Examination Findings
Orthopaedic Tests
Pain on flexion and internal rotation
AROM and PROM (Flexion, adduction, internal rotation)
FADIR
Anterior and Posterior labral tear tests
Scouring Test
Craig’s Test (Retroverted acetabulum)
Acetabular Labral Tears
Acetabular Labral Tears are a tear of the fibrocartilaginous ring around the peripheral acetabulum. They can be classified as type I indicating a detachment of the labarum from the articular hyaline cartilage at the acetabular rim or type II which is a cleavage tear within the labarum itself.
Aetiology
Signs and Symptoms
Traumatic injury
Secondary to pivoting twisting motion seen in team sports
Naturally anteverted position of the acetabulum
Repeated FAI contact
Deep anterior hip pain that is sharp and stabbing
Referred pain to groin, knee, GT, or buttocks
Pain worse with activity
Clicking and snapping sensation
Examination Findings
Orthopaedics Tests
Pain in internal rotation and flexion
Snapping and clicking through ROM
AROM and PROM
Anterior and Posterior Labral Tear Test
FABER (Anterior)
FADIR (Posterior)
Scouring Test
Craig’s Test
