Week 7 - Hip/SIJ/Lx differentiation Flashcards
what is included in the interview
• Body chart – Area, quality and type of symptoms • Current and past history • Behaviour of Symptoms – Aggravating v Easing factors – 24hr pattern • Special Questions
Lx as the source of pain
• Any innervated structure can produce local and referred pain:
– Varied distribution that does not follow a definitive pain map = somatic pain
– Can refer as far as the ankle, but typically not below the knee.
– Upper lumbar vs lower lumbar intracapsular (McCall et al 1979)
– Central pain may be less suggestive of z-joint as the source (Schwarzer et al 1994)
• Injury to the nerve roots:
– Evokes radicular pain into the lower limb resembles
dermatomal distribution= radicularpain
– Considered when LBP projects below knee
Lx as the location of pain
• SIJ and hip can refer into the Lx region, though rarely:
• E.g. Sembrano and Polly (2008)
– 85% from the Lx spine
– 14.5% from the SIJ
– 12.5% from the hip joint
• Also consider visceral and non- MSK sources of referral into the Lx (e.g. kidney, gall bladder)
SIJ as the source of pain
• Fortin et al (1994)
• MostcommonlyoverPSISextendingcaudallyandlaterally
• Slipman et al (2000)
• 94%reportedbuttockpain
• 72%reportedlowerlumbar(belowiliaccrest) • 14%reportedgroinpain
• 6%reportedupperlumbarpain
• Fukui et al (2002) • 100%overPSIS
• 68.7%medialbuttock
• 37.5%overGtrochandlatthigh • 31.2%posteriorthigh
• 9.3%inthegroin
Key points:
Composite drawings of pain maps from Dreyfuss et al (2004)
• Variable; commonly localised PSIS and rarely past the knee or above L4/L5
• Unilateral:bilateral pain = 4:1 (Vleeming et al 1990)
Hip joint as a source of pain
• Lesher et al (2008)
– 71% reported buttock pain
– 57% reported thigh pain
– 55% reported groin pain
– Only 2% reported knee pain (?)
– No patient reported lower lumbar spine referral
Key points:
• Potentially refer within the L3 dermatome or sclerotome.
• Similar referral patterns to the Lx and SIJ studies, but very rarely refers into the lower lumbar region.
• Most commonly presents as groin and/or buttock pain.
Paraesthesia and anaesthesia
• More suggestive of Lx involvement (i.e. radiculopathy)
• Also consider local peripheral nerve entrapments
– e.g. meralgia paraesthetica - sensory changes only (does not cross thigh midline), worse standing/walking etc.
• SIJ dysfunction has been associated with neural symptoms (? Linked to Lx changes or inc. mechanosensitivity of the sciatic nerve)
clicking, giving way or catching
• May be useful in terms of location aggs/eases & other symptoms etc.
• Examples…
– Acetabular labral tear – sharp catch pain with hip flexion/rotation associated with a deep click
– Segmental Lx instability – ‘feeling of giving way’ or catching through range during F/E
– SIJ hypermobility – clicking sensation in groin with unilateral LL loading
Low back pain stats
- ~ 70-80% will experience an episode of back pain in their life and ~ 5-20% during a single year (Rubin, 2007)
- ~ 30% will have a reoccurrence within 6 months (Cassidy et al., 2005)
- ~ 80% of these episodes will be mild (Cassidy et al., 2005)
- In the majority of LBP cases the source will be in the Lx
SIJ as the source of LBP
~ 15% (13-30%) of people with (?chronic) back pain have SIJ as the pain generator (Foley et al 2006)
• ~ 50% of people with SIJ pain there was a history of trauma (Foley et al., 2006)
• ~ 20% of pregnant women develop pain attributable to the SIJ (Vleeming et al., 2007)
Hx questions related to Lx
Mechanism of Injury:
• What was the position of the lumbar spine and how does this influence the loading pattern and predispose to certain patterns of injury?
• What other forces were involved e.g. internal (↑ IAP – valsalva, cough, sneeze) or external (blunt trauma)?
• Sustained vs cumulative loading
Consider a gradual onset of symptoms:
• Degenerative, spondyloarthropathies (e.g. scheuermann’s), non- mechanical
Consider the time of day:
• IVD demonstrate higher water content in the morning (? more susceptible to compressive injury)
Consider the progression of symptoms after MOI:
• Initially ok then gradual build up after the initial event – .e.g. Lx radiculopathy
Is the CHx suggestive of loading/injury to the Lx?
Hx questioning related to SIJ
• May be of gradual or sudden onset
• Sudden onset most commonly associated with trauma (~50%)
– Fall onto buttock (consider forces thru Lx)
– Missed step/stairs or missed kick
– Lift and twist with unilateral loading of LL
• Gradual onset
– Athletes:
• Repeated unilateral and torsional loading e.g. kicking, throwing sports, figure skating
– Pregnancy related pelvic pain ~20% (Vleeming et al (2008)
– Spondyloarthropathies (e.g. ankylosing spondylitis)
– Stress fractures rare but possible
Is the CHx suggestive of loading/injury to the SIJ?
Hx questioning Hip jt
Sudden onset due to trauma:
– Sudden compressive loading of hip joint e.g. fall onto knee or hip, or sudden take-off
– Twisting on planted foot
– Hyperextension + ER
Gradual onset due to repetitive microtrauma:
– Chronic labral injury - running, repeated hip flexion/add (e.g. running, kicking, tackles)
– Femoral neck stress fractures – fatigue loadingIs the CHx suggestive of loading/injury to the hip?
consider past Hx
Recall high recurrency rates of LBP and risk of chronicity
Consider congenital abnormalities (e.g. CHD, Perthe’s)
Consider previous surgery (e.g. laminectomy or SCFE repair)
Consider previous pregnancy and birth history
Consider previous injuries
– E.g. recurrent ankle injury may alter running biomechanics and contribute to lateral hip pain
– E.g. old pubic rami fracture may contribute to SIJ dysfunction
lumbar spine agg factors
Increase IAP e.g. cough/sneeze
Bending forward or lifting Prolonged sitting
Rising from a chair
Uphills > down hills
lumbar spine eas factors
Lying prone or contralateral sidelying
Standing/walking (short periods)
