Lx, Pelvis, Hip Flashcards
What is mechanosensitivity?
assessing the sensitivity of peripheral nerves to limb movement
What is the clinical presentation of SIJD?
Hx
- Pregnancy
- Leg length discrepancies
- Actual sprain
- Compensations due to lack of mobility elsewhere.
- Young patients
- Trauma
Pain pattern
- •Unilateral localised pain to the buttock or lower lumbar region
- •Sharp and stabbing if acute
aggravates:
relieves:
•
WHat is FAI and the clinical presentation
Femoral acetabulum impingement
pain may be felt in back buttock or groin lx or glutes
other symptoms:
- catching
- loking
- restricted ROM
*
Lumpar spine test
Slump & straight leg raise: sciatica
Flamingo: pars interarticularis
Quadrant: facet joint
Serious LB disorders
- CARDIOVASCULAR
- AAA
- Retroperitoneal haemorrhage
- NEOPLASTIC
- Metastases (breast, lung, prostate)
- Myeloma
- INFECTIVE
- Osteomyelitis
- Abscess
- Discitis
- TB
- FRACTURE
- Osteoporosis compression fracture
- NEUROLOGICAL
- Cauda equina compression
What are the serius disorders of the pelvis?
- CARDIOVASCULAR
- Buttock claudication
- NEOPLASTIC
- Metastases
- OSTEOID OSTEOMA
- INFECTIVE
- Osteomyelitis
- Septic arthritis
- Pelvic infections
- Abdominal infections
- CHILDHOOD DISORDERS
- PELVIC / GYNAECOLOGICAL DISORDERS
WHat is the management for gluteal tendinopathy?
- Decrease load by 50%
- Fitbit, pedometer
- Modify agg activities
- Lying on side
- Crossed legs
- Carrying kids, work etc
- Progressive specific load
- Exercise-based
- Make It functional if possible.
How does FAI present in a xray?
additional bone formation on the joint or femoral head
Clinical findings FAI
- Impingement tests
- FADDIR (sensitive but not specific)
- FABER
- Gait/unilateral standing
- Usually weakness in the surrounding hip musculature.
- Usually dec strength in all hip movements
- Dec functional ability = hop, side bridge, jump, single leg raise
- Muscle Tenderness
- Dec hip ROM
- Usually internal rotation with the
- patients clicking/familiar pain
Tests for Hip pathologies
Faber: hip pathology
Faddir: labral tear, OA, FAI
Hip compression: hip joint pathology
Serious disorders of the hip
- FRACTURES
- NOF and pelvis
- SPONDYLOARTHROPATHIES
- PELVIC / GYNAECOLOGICAL DISORDERS
- TUMOURS
- Testicular / prostate / ovarian
- INTRAABDOMINAL ABNORMALITIES
- INFECTIONS
- HIP JOINT
- SCFE / PERTHES / AN / OSTEOPOROSIS /
What is the mechanism of action for neurodynamic test ?
Unsensitised (e.g. non injured) nerves and neuromeningeal tissues may be moved and handled without response
Nerve pathology (compression/stretch injury): mechanosensitivity + local inflammation (which can affect small & large diameter nerves) + neuroimmune responses in DRG or dorsal horn
sensitivity to neural tissue elongation along with local tenderness over the nerve trunks are the main signs of neural tissue mechanosensitivity (Walsh, 2009, p. 184)
What are is the treatment used for LBP?
- »Most commonly mobilisation, manipulation, stretching and STM
- »Mobilisation moves joints in specific directions at different speeds to restore movement
- »Stretching improves muscle activation and function
- »STM mobilises skin and underlying muscles and connective tissues
- »Manipulation decreases pain, increases function and increases spinal mobility.
What is the management for non-specific Chronic LBP?
- Effective communication encompassing empathy, active listening,
- responsiveness, patient validation, confidence, warmth and
- friendliness = best patient outcome.
- Patient – centered education around multidimensional
- mechanisms that drive pain and disability.
- Education around beliefs, mood, stress, sleep deficits and levels
- of fatigue on pain physiology
- Promote active coping strategies for pain
- • Build patient confidence in their bodies own abilities.
- • Goal oriented behavioral changes.
Other conditions of the hip
Polymyalgia Rheumatica
Fractures
Avascular necrosis femoral head
Labral tears
Hernias
Bursitis / tendonitis
Osteitis pubis
Claudication
What is the clinical presentation of Hip OA?
Age: 60 years old but can occur much younger
Hx
- Insidious onset /
- deep ache / groin, buttock, thigh or knee /
- morning stiffness /
- better with mild activity /
- worse for excessive activity /
- +/- crepitus
What are the common diagnosis for Hip pain?
Anterior Hip
- Labral tear
- OA
- Groin
- Ligament teres sprain
- FAI
Lateral Hip pain
- Gluteal tear
- gluteal tendinopathy
Groin Pain
- Abductor
- Iliopsoas
- inguinal
- pubic
- Hip
What causes a snaping hip?
•1. ILIOPSAOS TENDONITIS / INTERNAL SNAPPING
- •Typically affects athletes
- •Painful snapping
- •Anterior groin pain
- •+/- LBPGoing from flexion to extension
- INTRA ARTICULAR SNAPPING
- •Loose bodies
- •Labral pathology
- •Iliopsoas flicking over bony prominence
- •Often snaps when you release FABERE
•.EXTERNAL SNAPPING
- ITB / Glut Max snapping over greater trochanter
Other LB conditions often missed
SIJ dysfunction
Pagets disease
Spondylolisthesis
Emdometriosis
Claudication
Depression
What are the common conditions for pelvic pain?
- muscular strains - abductors (groin pain)
- Referred pain from the lumbar spine
- Hip OA
- SIJ dysfunction
- Tendinopathy
- Piriformis syndrome
What are the neurodynamic tests for the lower limb?
Slump: sciatic N.
passive leg raise: sciatic
Prone knee bend: femoral N.
What is the management of a vertebral dysfunction?
- keep moving
- educate the patient - return to normal activities, stay active
- reassure
- physical therapy
- relative rest
- post-acute phase exercises
- heat
What are the referral pain patterns from the hip?
WHat structures can cause groin pain?
Adductor related
- Most common type of groin pain
- Pain on palpation of adductors and
- resisted adduction
Iliopsoas related
- • Pain on palpation of the iliopsoas AND pain on active resisted/stretch of hip flexors
Inguinal related
- • Pain with palp of inguinal canal AND worse with cough/sneeze/abdominal active resisted
Pubic related
- Least common type of groin pain
- Pain on palp pub symph/pubic bone
- Pain on active and passive thomas test
What are the x-ray vies of the lumbar spine
Standard Views
- •AP Lumbopelvic •Lateral Lumbosacral
- Additional Views
- Posterior Oblique (Right & Left) – Image Pars for #
- AP or Lateral Lumbosacral Spot •
Flexion/Extension views, Sidebending views
What is the treatment for FAI ?
Treatment
- Conservative management
- Strength and movement retraining
- Especially in early stages
Surgical Intervention
- If failed conservative measures
- High predisposition to OA in future.
What is the clinical presentation and treatment for a labral tear
Clinical Examination
- FADIR
- FABER
- Thomas Test
- Clicking, catching, locking
• Treatment
•Conservative management first
- Focus on unloading damaged labrum usually anteriorly and superiorly
- Reduce hip repetitive movement.
- Increase neuromotor control in the deep
- stabilising musculature of the hip
• Surgery
More test for SIJ
Active straight leg raise
trendelenburg:
What is the grading in hamstring strain?
- •GRADE 1
- •Mild pain with walking
- •Definite pain with running
- •Pain on stretch
- •GRADE 2
- •Pain and weakness of resisted knee flexion
- •Pain and weakness resisted Hip extension
- •Altered gait
- •Inability to run
- •GRADE 3
- •Full rupture
- •Less pain
- •Marked muscle weakness / lost function / altered gait
Clinical presentation back pain with radiculopathy?
Cause: OA and Disc
Pain location: unilateral or Bilat.
relieved with movement
Tests for SIJ instability
Gapping: anterior lig.
Thomas test, Thigh thrust, sacral compression: Posterior SIJ lig.
Other pelvic conditions often missed
Polymyalgia Rheumatica
Fractures
Avascular necrosis femoral head
Labral tears
Hernias
Bursitis / tendonitis
Osteitis pubis
Claudication
What’s the clinical presentation of a facet sprain?
Adult > 40
Quality: dull ache and sharp with movement
Aggravating: Extension (walking/ prolonged standing)
Relieving: Flexion - sitting - decreasing the load
Onset: suddenly - insidious
Risk factors: Pregnancy, obesity, Hx of LB injury,
WHat are the x-ray vies of the hip?
Standard Views
- • AP
- • AP Spot
- • Frogleg
Other:
- • Lateral
What is the clinical presentation of gluteal tendinopathy?
In history
- Pain walking upstairs/hills
- Pain on walking/first standing that eases after a couple of steps
- Pain in lying on the effective side.
- Pain position can be variable + referral is common.
On examination
- • Palpation
- • If it’s not tender over the tendon/bursae.
- Single leg loading – hip hitch/drop • Trendelenber
- FADER/FABER/Obers can all help with the clinical picture.
- Strength testing – resisted abduction
WHat is the clinical presentation of a hamstring strain?
- •1. Occurs in activities where the hamstrings can be stretched eccentrically at high speed. (sprinters, soccer, football, dancers, hurdlers)
- Occurs with acute overstretching
- Occurs with repetitive strain causing disruption of mm fibres
- Any age Especially (16-25 year olds)
•Risk Factors
- •Prior injury
- •Failure to warm up
- •Quick stops and direction changes
- •Weak Glutes / adductors
- •Quadricep dominance
- •Poor Rehabilitation
History
- Sudden onset post thigh pain
- May hear a “pop”
- Usually, the end or beginning of the activity
- Pain sitting or walking uphill /stairs
- Decreased pain with rest ice (acute) heat (chronic)
- Often prior to history
What are the red flags for LBP?
- •>50 or <20 Drug/alcohol abuse
- •History of cancer Use of anticoagulants
- •Increased temperature Use of corticosteroids
- •Constant pain No improvement > 1/12
- •Unexplained weight loss ssx Cauda equina
- •Symptoms in other systems (eg breast l ump)
- •Significant trauma
- •Features of spondyloarthropathy
- •Neurological deficit
- Drug/ alcohol
- coagulants/ corticosteroids
- Cauda equina
- No improvement 1/12
hat do you use an ultrasound of the hip for?
Gluteal tendinopathy
Troch/glute bursitis
Gluteal tear
What are the causes of hip pain?
Extraarticular
- Greater Trochanteric Pain Syndrome (GTPS)
- Glutealtendinopathy
- Trochbursitis
- Deep Gluteal Syndrome
Intraarticular
- FAI
- – Cam
- – Pincer
- – Mixed
- Non-FAI
- – Labral tear
- – Osteonecrosis
- – Acetabular dysplasia
