Week 10 - physical exam of the hip

Question 1

what are the clinical entities of groin pain

Answer 1

adductor related groin pain
iliopsoas related
inguinal related
pubic related
hip related
hip joint OA

Question 2

adductor related groin pain (ACUTE)

Answer 2

 Is common is sports involving sudden change in direction.
 Presentation – acute onset, adductor longus most commonly injured muscle.
 Symptoms – groin tenderness/pain on muscle palpation, stretch or contraction.
 Clinical signs:
o Palpation – pain on muscle belly or musculotendinous junction near origin, on inferior pubic ramus.
o Adductor tenderness AND pain on resisted adduction.
o Positive tests on – resisted outer range adduction, positive squeeze test with hip neutral in long level. Passive adductor stretch
o If all three tests are positive – provide approx. 80% probability of a positive MRI in adductors.
 Can be one recurrent or chronic if not properly managed.

Question 3

adductor related groin pain (TENDINOPATHY)

Answer 3

 Presentation – graduation onset, chronic or overuse.
 Symptoms – proximal groin pain, initially pain with increased activity, may improve once warmed up, possible loss of speed and or kicking distance, if untreated, pain tends to persist during activity.
 Clinical signs:
o Pain on palpation of adductor origin
o Pain with passive hip abduction (stretch)
o Pain with resisted hip adduction (contraction)
o Positive squeeze test @ 0 degrees and 45 degrees.

Question 4

iliopsoas related groin pain - acute onset

Answer 4

 Rectus femoris acute injury with kicking and sprinting.
 Iliopsoas acute injury with change of direction in sports.
 Clinical signs:
o Iliopsoas or rectus femoris palpation
 Negative palpation = 100% probability of negative MRI.
 Positive palpation = poor probability of positive MRI.

Question 5

iliopsoas related groin pain - long standing or chronic

Answer 5

 Often related to repetitive activities and or accumulated overload in activities with excessive hip flexion (e.g., kicking, dancing).
o Iliopsoas tendinopathy
o Snapping iliopsoas tendon over iliopectineal eminence/femoral head.
o Iliopsoas bursitis.
 Presentation – groin pain, deep ache, usually unilateral.
o Pain on palpation
o Pain on resisted hip flexion and or pain on hip flexion stretching.

Question 6

snapping hip syndrome (anterior) - iliopsoas

Answer 6

Snapping hip syndrome (Anterior) – iliopsoas tendon
 Iliopsoas ‘snaps’ over iliopectineal eminence causing audible ‘clunk’.
 Presentation – ‘clunk’ anterior hip, usually no MOI or history of trauma.
o Common in young women.
 Symptoms:
o Audible ‘clunk’ – often asymptomatic – is snap felt internal or external to hip joint.
o Can be bilateral.
o Can develop pain with clunk – if painful snapping hip they may have concomitant.
o May be associated with iliopsoas bursitis.
 Clinical signs:
o Start with hip in flexion and abduction, ask patient t eccentrically lower leg into extension with guidance – see if there is a reproduction of snap.
o Or ask the patient to simply reproduce the snap.
o Palpate snap – try and change it with applied pressure over the tendon.

Question 7

inguinal related groin pain - abdominal wall

Answer 7

Inguinal related groin pain – abdominal wall
 Rectus abdominus insertion:
o Pain in the inguinal canal region AND tenderness of the inguinal canal at insertion of the rectus abdominus on pubic rami.
o No palpable inguinal hernia is present.
o Due to acute strain while lifting or overuse injury caused by excessive abdominal contractions.
o Pain aggravated by resistance testing of the abdominal muscles or on Valsalva/cough/sneeze.

 Inguinal hernia – posterior inguinal wall weakness.
o Gradual onset, poorly localise groin pain increasing with activity e.g., kicking and coughing/sneezing.
o Pain could be felt in the groin, genital area, it could be abdominal pain and they may experience urinary symptoms or bowel symptoms.
o Need to refer for medical review immediately if suspecting an inguinal hernia.
o May also involve tears in transverse Abd or external oblique fascia/aponeurosis.

Question 8

pubic related groin pain (osteitis pubis)

Answer 8

 Presentation:
o Sometimes referred to as “sportsman groin.”
o May be secondary to repetitive microtrauma – training overload. Insidious gradual onset.
o Unsure of true pathophysiology.
o Involves pubic bone and pubic symphysis.
o In adolescents, pubic or adductor related groin pain could be due to apophysitis.
o Could include multiple pathologies.
 Pubic bone edema/stress reaction/periostitis pubis/ enthesopathy/adductor insertion tendinopathy.
 Consider age, type or sport and loading of the athletes with presenting symptoms.
 symptoms – symphysis pain on palpation, aggravated by exercises (twisting, turning, kicking), eases with rest, symptoms may be present during and after activity, may have over 6 weeks of longstanding pain – time of onset of symptoms is important.

Question 9

pubis related groin pain - pubic bone stress

Answer 9

 clinical signs:
o Local tenderness of pubic symphysis and on immediately adjacent bone, positive squeeze test.
 Diagnostic imaging
o Bone changes seen on X-ray, MRI, and CT.
o Bone change may be evident in early stages and degenerative changes in chronic stages.

Question 10

differentiation of groin pain

Answer 10

palpation

Question 11

hip related groin pain

Answer 11

1. Femoral acetabular impingement (FAI) syndrome
2. acetabular dysplasia and or hip instability
3. Other conditions without distinct osseous morphology (labral tear/ligamentum teres tears, chondral pathology).

Question 12

femoral acetabular impingement

Answer 12

1. Femoral acetabular impingement (FAI) syndrome – “a motion related clinical disorder of the hip with a triad of symptoms, clinical signs, and imaging findings. It represents symptomatic premature contact between the proximal femur and the acetabulum.”

 Types of morphology:
o Cam – increased bone formation at anterior surface of femur – decreased femoral head-neck offset. Associated with intra-articular head-neck offset.
o Pincer – bony growth at acetabular, generally anterior.
o Mixed – both cam and pincer present.

Question 13

cam vs pincer morphology

Answer 13

for femoral acetabular impingement

Question 14

cam vs pincer morphology

Answer 14

for femoral acetabular impingement

Cam/pincer morphology
 Can be present radiographically but be asymptomatic (10-25% of people)
 Commonly seen in young athletes – football/soccer, ballet, hockey, martial arts – hip loading in adolescents may be a risk factor for cam morphology.

Cam morphology development:
 Mainly when the proximal femoral growth plate is open.
 Rare after closure of the proximal femoral growth plate.

Question 15

clinical presentation of femoral acetabular impingement

Answer 15

Clinical presentation

 Diagnosis – clinical and imaging positive findings.
 Symptoms:
o Motion or position related hip/groin pain and/or pain in the back, buttock, or thigh – pain increased with walking, running, swatting, performing lateral/cutting movements.
o May also have clicking, catching, locking, stiffness, restricted ROM or giving way.
 Clinical signs:
o Hip impingement tests (FADIR) reproduce their pain.
o Limited hip ROM -> IR in flexion.
 Investigations:
o X ray – AP view of pelvis and Dunn view for the lateral femoral neck.
o MRI – 3D hip morphology, cartilage, ligamentum teres and labral lesions – cross sectional view.
o May be associated with previous slipped femoral epiphysis or congenital hip dysplasia.

Question 16

acetabular dysplasia and or hip instability

Answer 16

 Anatomy – fibrocartilage ring and dense CT attached to the bone acetabulum rim.
o Acetabulum labrum depends on acetabulum for stability and increased contact area of acetabulum to distribute load.
o Has a blood and nerve supply, therefore is pain sensitive.

 Presentation – most common intra-articular hip injury in athletes – 22% of athletes with hip pain.

o Anterior-superior tears are most common:

 Grade I – detachment from hyaline cartilage at acetabular rim

 Grade II – cleavage tears within substance of labrum.

o Patients with a labral tear have a 40% change they may also have chondropathy.

Question 17

acetabular labral tear

Answer 17

Acetabular labral tear
 Causes:
o Trauma – single or repetitive trauma – rotation and flexion, repetitive pivoting, hip flexion, twisting or direct trauma (fall/MVA).
o Congenital – due to acetabular or hip dysplasia.
o Capsular laxity – due to systemic connective tissue disorder or repetitive activities.
o Idiopathic – may be associated with FAI (cam or pincer morphology) syndrome.
 Symptoms – anterior groin pain, gradual onset of symptoms or related to trauma/injury, pain increases with activities.
o Ask patient is pain is intermittent, a sharp catching pain, clicking, locking, catching, giving way.
o Ask patient if they have referred pain in other areas such as buttock and/or anterior thigh.
 Diagnostic imaging
o X-ray – WB AP view and lateral hip view
o MRI and MRA most sensitive, CT scan, arthroscopy gold standard.

Question 18

ligamentum teres tears

Answer 18

intraarticular ligament with proprioception and stabilization role in hip joint.
- is taut in flexion, adduction and ER.
- tears common in athletes (type 1 is a partial tear, type 2 is a complete rupture, and type 3 is degenerate ligament)

MOI - forced flexion and adduction with ER or IR or twisting motions.

diagnostic imaging - MR athrography and CT arthrography.

Question 19

 Capsuloligamentous laxity (+/- hip instability)

Answer 19

 Capsuloligamentous laxity (+/- hip instability)
o Traumatic laxity +/- instability:
* Hip dislocation – fall on flexed knee and hip or form dashboard (MVA).
* Repetitive rotation movements with axial loading
* Trauma – stretching of capsule, possible labral damage/tears of ligamentum teres.
* Recurrent dislocations.
o Atraumatic instability
* In hypermobility congenital conditions, generalised ligamentous laxity, acetabular dysplasia or in athletes (gold, football).
o Symptoms
* Feeling of instability
* Pain in hip/groin region which may increase with activity.
o Clinical signs
* Decrease hip ROM +/- pain.
* Anterior hip pain with passive E + ER in prone.
* Passive accessory glides of the hip – hypermobile.

Question 20

hip related groin pain - osteoarthritis (OA)

Answer 20

 Synovial joint’s age-related response to abnormal loading from a traumatic incident or repetitive microtrauma
 OQ can affect whole joint organ – including cartilage, subchondral bone, inflammation of the synovium and synovial lining thickening.
 Leads to pain and stiffness, muscle changes and functional limitations.

 Kallgren and Lawrence scores 1-4 based on:
o Subchondral bone sclerosis
o Joint space narrowing
o Osteophytes – acetabular and femoral
o Subchondral cysts

 Femoral head superior migration, secondary to articular cartilage loss.

 MRI – the scoring hip osteoarthritis with MRI method
o Early microscopic cartilage changes
o Osteophytes
o Subchondral cysts
o Inflammation
o Muscle atrophy
o Other joint changes
o High sensitivity (95.7%) and specificity (84.8%) in detecting cartilage lesions.

Question 21

hip OA predisposing factors

Question 22

anterior pain - common conditions - Hip OA

Answer 22

 Age – increased risk in over 55-year-olds, with further increased risk in those over 65.
 Gender - women increased risk.
 Genetic predisposition.
 Ethnicity or race – lower incidence in Asian cultures than white Caucasian.
 Morphological abnormalities/developmental disorders.
 Leg length difference
 History of lower limb or hip trauma.
 Occupational factors – manual labor/physical stress work and sporting activities.
 Increased weight or obesity (BMI)

Question 23

clinical diagnosis criteria for hip OA

Answer 23

set A :
- over 50 years
- hip pain
- hip IR is greater than or equal to 15 degrees.
- pain with IR
- morning stiffness for 60min or more

Set B:
- over 50 years.
- hip pain.
- hip IR less than 15 degrees.

Question 24

OA symptoms

Answer 24

 Hip joint pain and pain anterior or posterior or lateral hip region +/- referral to thigh or knee.
 Deep “ache” or discomfort with sharp stabbing pain.
 Hip joint pain and stiffness restricted mobility.
 Stiffness in early morning eases less than 60 mins.
 Stiffness after rest, decreases with movement.
 Pain usually related with activity e.g., walking or stairs.
 Difficulty putting socks and shoes on.

Question 25

physical exam for hip OA

Answer 25

 Hip accessory glides performed anterior/posterior, lateral/medial, cephalad/caudad.
o In 20 hip flexion (because this position reduced capsule tension).
o In hip extension to assess effect of capsule tension.
o In painful hip range.
 This identifies stiffness in joint and medial/up and out migratory presentation.

Question 26

OA diagnosis - clinical prediction rule

Answer 26

Hip OA diagnosis – clinical prediction rule.
 5 main predictor variables:
1. Self-reported squatting an aggravating factor.
2. Active hip flexion causing lateral hip pain.
3. Scour test + adductor causing lateral hip or groin pain.
4. Passive IR – less than 25 degrees.
5. Active hip extension causing pain.

 If patient has 3/5 predictor variables – likelihood of having hip OA is 68% (positive likelihood ratio = 5.2)
 If patient has 4/5 predictor variables – likelihood of having hip OA is 91% (positive likelihood ratio = 5.3).

Question 27

hip related groin pains (other)

Answer 27

• stress fracture of neck of femur or acetabulum
• stress fracture of pelvis or pubic ramus
• nerve entrapment - Obturator nerve 0 entrapped in the fascia as entering adductor longus, brevis and pectineus compartment OR Ilioinguinal nerve – entrapped under ilioinguinal ligament – groin pain radiating to genitalia region.
• other conditions causing groin pain not to be missed: o Orthopaedic, neurological rheumatological, urological, gastrointestinal, dermatological, oncological and surgical.
  o Lumbar spine referral.

Question 28

GTPS (1)

Answer 28

 Umbrella term for conditions causing lateral hip pain:
o Glut med/min tendinopathies or tears.
o Trochanteric bursitis -tendinopathies of the gluteal tendons and bursa.
 Prevalence – 10-25% of the population in 40–60-year-old.
o More common in females – a lower neck shaft angle is a risk factor for, and adiposity is associated with GTPS in women.
 Pathology
o Compressive loading of the gluteal tendons and bursa between greater trochanter and ITB with repetitive activities.
o Compression loads – tendon and bursa thickening.
o Thickened tendons develop reduced capacity for tensile loading, leading got tears under less loading.

Question 29

GTPS - clinical signs and symptoms

Answer 29

 Symptoms:
o Lateral hip pain, ache, intermittent, persistent or unrelating.
o Pain lying on affected site, sitting with legs crossed, prolonged standing on one leg, decreased physical exercise.

 Clinical signs
o Lateral hip tender on palpation, over the greater trochanter
o Plus- pain with at least one of the following:
 Pain EOR hip adb/add or hip IR/ER
 Positive FABER
 Active resisted abduction in adducted position
 Pain with sustained single leg stance
 Positive resisted external de-rotation
 Positive Ober’s test.

Question 30

GTPS - gluteal tendinopathy

Answer 30

GTPS: Gluteal tendinopathy
 Presentation:
o Females more than males.
o Insidious onset pain usually.
o Pain may be associated with training loads or physical activity sudden changes.
o May be acute onset, after an incident such as a fall.

 Symptoms:
o Pain and tenderness over greater trochanter
o Pain may radiate down lateral thigh.
o Pain may be worse at night.
o Pain to sleep on affected side.
o Pain with prolonged single leg stance or stairs.

 Clinical signs:
o Pain provocative tests
o *Tender on palpation over greater trochanter
o *Sustained single leg stance

 Patient reported outcome measure.
o VISA – G questionnaire

 Investigations:
o MRI – gold standard
o US.

Question 31

GTPS - snapping hip syndrome (lateral)

Answer 31

 Common in younger, active people.
 Pathology – gluteus max anterior fibres and ITB and move over the greater trochanter from posterior to anterior as the hip moved from extension to flexion causing a snapping.
o May be associated with pain and inflammation.
 Symptoms:
o Audible snap during repetitive flexion, extension, and abduction +/- pain.
o Snap increases with repetitive hip F/E.
 Clinical signs:
o Patient can usually reproduce their symptoms in:
 In side-lying with the ITB on stretch – ask patient to actively flex and extend their hip.
 Manual compression to the band proximal to greater trochanter or external rotation of hip may relieve snap.
 Trochanteric bursitis could also be present.

Question 32

posterior pain - buttock pain

Answer 32

 Common in younger, active people.
 Pathology – gluteus max anterior fibres and ITB and move over the greater trochanter from posterior to anterior as the hip moved from extension to flexion causing a snapping.
o May be associated with pain and inflammation.

 Symptoms:
o Audible snap during repetitive flexion, extension, and abduction +/- pain.
o Snap increases with repetitive hip F/E.

 Clinical signs:
o Patient can usually reproduce their symptoms in:
 In side-lying with the ITB on stretch – ask patient to actively flex and extend their hip.
 Manual compression to the band proximal to greater trochanter or external rotation of hip may relieve snap.
 Trochanteric bursitis could also be present.

Piriformis
 Piriformis syndrome and sciatic nerve entrapment
o In short posterior rotators.
 Ischiogluteal bursa
o Between hamstring tendon and origin on the ischial tuberosity.
o Usually affected in conjunction with proximal hamstring tendinopathy.