Research – read your journals. CE courses – Clinical Expertise – clinical skill and formulated education
These statistics are used to describe the effectiveness of special tests in identifying specific disorders. Knowing the diagnostic accuracy of special tests is important to obtain an accurate diagnosis and maximizing treatment outcomes.Sensitivity – Most useful in ruling out a disorderFor Example the Neers Test has a sensitivity rating of 0.93 for detecting subacromial impingement. So, if the test is negative…For Example the Hawkins Kennedy Test has a specificity of 100%, a positive test results = impingementSensitivity – measures the proportion of actual positives which are correctly identified. When a highly sensitive test is negative, you can feel more assured that the patient does not have it. If it is positive you can’t be assured that they have the condition unless the test is highly specific as well.Secificity – measures the proportion of negatives which are correctly identified. When the test is positive, ccan feel better about ruling in the condition. If the test is negative, can’t be assured that they do not have the condition unless the test is sensitive.
Index measurement that combines the sensitivity and specificity values of a specific test. The LR can be used to gauge the performance of the test. Positive LR (+LR) the proportion of people who test positive and actually have the disorder.
LR are used for assessing the value of performing a diagnostic test. They use the sensitivity and specificity of the test to determine whether a test result usefully changes the probability that a condition exists.
A LR of greater than 1 indicates the test result is associated with the disease. A LR of less than 1 indicates that the result is associated with absence of the disease. Ratios close to one are of little help.
If I know that a FABER test for the hip has an .88 sensitivity for internal hip pathology ( remember it is a screening test, not highly diagnostic ) and it is negative. SnNout – I can feel confident that the pain generator that I am looking for is extra capsular.
A cane decreases the adductor moment at the right hip. It is painful with an OA hip, so body develops a trendelenburg gait.
No studies documenting any adverse effects except soreness.
In evaluation can do a quick 1 leg stand to assess strength for a quick screen.
The glut medius is weak because of the arthritic joint. Hip flexion is inhibited because of a painful joint – it causes compression. When we walk, the hip adducts, IR and with O-A can’t do that without pain.
Once I have made my diagnosis from the history, I will select special tests to r/i and r/o diagnosis
Cluster is for ruling out hip OA. SnNout 86% Hip IR is most specific finding for hip OA. Restriction of any single hip motion correlates to mild/moderate hip O-A
Gymnastics, cheerleading, golf, jumping and landing on one leg.
X-ray will show joint space narrowing, osteophytes.
3/5 of those = 68%, to 4/5 to = 91%
Pain with hip IR and Flexion Morning stiffnessIf (+) x-ray with above criteria, Sensitivity – ruling out O-A - very good for ruling out.Mild to moderate O-A LR+ 3.6 limited hip IR, FABER Sn 88% ruling out intra-articular pathologyThe reason the Child’s created a PT CPR is that the orginal one did not use any special tests that are commonly used in the clinic.
Impingement tests are positive for patients with O-AGait – secondary to weak Glut Med. b/c muscle weakness develops around an arthritic jointWhat muscles would you expect to be weak? Flexors, abductors
Goal of the Gaenslen is to apply torsion to the joint.
X-ray will detect in about 3-4 weeks. Bone scan most sensitive
Martin et al July 2006
Associated Factors: ipsilateral knee and or hip OA, Female and LBP. These people had normal hip IRSingle leg stance > 30 secondsExternal derotation test – supine with resisted ERIf not weak at Glut Medius – not likely that they have bursitisClinical Diagnosis: TTP, lateral hip pain (+) FABERTrendeleberg Sign – most accurate to predict tendon tear. No warmth, erythema or swelling.
Bird et al. MRI findings 45% of patients had glut medius tears and 55% had glut medius tendonitis, 1% had bursal distention.If a tendonopathy – how would you treat. With the two patients with bursal distention – also had glut med. Tendonopathy. Bursitis may be secondary to tears. Recently with THA, dissecting bursa and no inflammation found.
Martin JOSPT 2006
Posterior labral tears are found in the Asian populations and are associated with hyperflexion or squatting.Older than 60 – universally have labral tearsEitology – Statistically significant correlation was found with the grade of labral tear and cartilage abnormality and bone marrow edema. Due to FAI, capsular laxity and cartilage degeneration.
JOSPT July 2006
Differential Diagnosis:Clinical Practice Guidelines Evidence-based diagnosis, prognosisand intervention.
Bridgit A. Finley www.ptcentral.org email@example.com Facebook: Physical Therapy Central Choctaw Chickasha Newcastle Norman OKC Pauls Valley Stillwater
Objectives Be able to perform an algorithm based examination. Implement Evidence Based Medicine. Be able to treat patients with hip dysfunctions with manual therapy techniques. Be able to utilize outcome measures.
Philosophy of Care Comprehensive Exam Subjective Biomechanics Feet, knees, pelvis and lumbar spine Hands on MFR, Manual Techniques One on One Exercise Specific
Vision 2020 The first, best choice in musculoskeletal care. Resources APTA JOSPT Physiopedia Evidence in Motion AAOMPT PEDro Life Long Learners Autonomous Experts Take our game to the next level Specialty Certifications Manual Therapy Certifications DPT
Evidence Based Practice Integration of the best research evidence with clinical expertise and patient values. Which will ultimately lead to improved patient outcomes. Levels of Evidence Systematic Reviews Case Series Expert Opinion
Sensitivity and Specificity Sensitivity Ability to be positive when a variable is present. 0 – 1.0 Good screening exam Sn=High Sensitivity to Rule Out SnNout – sensitive test=negative=rule out Specificity Ability to be negative when a variable is absent Very specific to confirm the diagnosis Spin=High Specificity to rule in a diagnosis SpPin – specificity = positive= ruling in
Likelihood Rations The likelihood that a test result would be expected in a patient with the target disorder compared with the likelihood of the results with a patient without the disorder Good Measure of the clinical utility of a test Tells you how much a test result changes the pre-test probability of being correct
Likelihood Rations +LR The proportion of people who test positive and have the disorder. = Sensitivity / (1-Specificity) -LR The proportion of people who test negative and who do not actually have the disorder. = (1-Sensitivity)/ Specificity
+LR -LR > 10.0 < 0.1 Generate large and often conclusive shifts in probability 5.0 - 10.0 0.1 - 0.2 Generate moderate shifts in probability 2.0 - 5.0 0.2 - 0.5 Generate small, but sometimes important shifts in probability 1.0 -2.0 0.5 - 1.0 Alter probability to a small and rarely important degree
Prevalence O-A hip pain is the most common cause of hip pain in older adults.
10-27% of the population > 50 years old.
No cure but effective non-surgical treatment include: weight loss, manual therapy and exercise.
Function of the hip Support the weight of the trunk Ambulation Transmission of forces between the pelvis and lower extremities If the hip is arthritic, will stress the lumbar spine and opposite leg.
Hip Joint Walking – hip supports 240% to 355% times the body weight Running – 550% times the body weight. Good foot wear is important.
Cane Aided Gait Cane allows increased BOS, and decreased hip abductor force. Hip can stay more abduction during gait. Decreased acetabular contact pressure by 30-40 % Gluteus medius EMG activity is reduced by 45% during mid and terminal stance.
Cane Aided Gait Pushing into the cane – lifts the left side of the pelvis. Lecture notes Dave Thompson, PT
Inclination Angle Angle between femoral shaft and neck is called “inclination angle” Important influences on the hip because it changes the angle of pull of the muscles
Inclination Angle CoxaVara <100 Usually congential Causes a short leg Positive trendelenburg sign Genuvalgum Compensatory lumbar pathology
Inclination Angle Noraml 125 Coxa Valga >125 Causes a long leg Positive trendelengurg sign Stress on ITB and bursa Genu vara Compensatory lumbar pathology
Coxa Valga Changes joint reaction forces to almost parallel. Reduces the WB surface. Shortens the moment arm of the hip abductors. Increases length of LE. Increases mechanical stress on medial knee Hip Dysplasia
Femoral Anteversion Normal is 10-15 degrees Have more hip IR Femoral head more anterior in capsule May lead to labral tears, impingement and OA
Cyriax Capsular pattern – specific and proportional loss of movement Most common cause of capsular pattern is arthritis
Capsular Pattern Cyriax IR Flexion Abduction If capsular pattern of restriction; joint is arthritic. If non capsular pattern; not joint. Cyriax listed in ascending order Loss of internal rotation More than flexion More than abduction
Resting Closed Packed Flexion 30 degrees Abduction 30 degrees External Rotation 10-15 degrees Extension Adduction Internal Rotation Stable position of the joint Tighten capsule
Manual Therapy Mobilization/manipulation Manual stretching Traction Mobilization (posterior/lateral) 5 Weeks 81% had positive outcomes More effective than exercise alone Improvement Hip Harris Score
Biomechanical Forces Femoral Anteversion Pronation Tibial Internal Rotation Improper Hip Alignment Pelvis Lumbar – will lose ipsilateral rotation (left hip, left rotation)
Hip Dysplasia Displacement of femoral head in acetabulum Left hip is more often involved 80 % Females Breech birth First born
Hip Dysplasia Less degress of femoral head coverage Decreased joint surface area Normal 30-40% Angle of inclination >125 degrees Increased femoral anterversion Acetabular retroversion McCarthy & Lee found 72% of patients with dysplasia had labral tears
Dysplastic Hip Head off-set is between femoral head and shaft Off-set is decreases Femoral neck is short and thick
X-Ray Demonstrate loss of joint space, osteophytes and sclerosis. Dysplasia tears are more common in individuals with acetabular dysplasia.
Glut Medius controls Adductor Moment Hip Abductor function in closed chain is to maintain a level pelvis.
Trendelenburg Gait Have patient stand on one leg and assess if the pelvis drops. (+) Trendelenburg Sign
Subjective History Possibly the single most important part of the examination establishes your interest in the patient establishes the relationship uncovers information not available from the objective examinations estimated to make up about 70% of the diagnosis
Summary be focused on the patient’s problems maintain control of the interview be systematic in your interview method follow up answers but do not get side tracked take as long as you need be professional be analytical
Causes of hip pain in adults Osteoarthritis Other arthritides: RA Psoriatic AnkylosingSpondylitis Hip Fracture Paget’s disease Avascular necrosis Referred pain Malignancy Infection Painful soft tissue Trochanteric bursitis Snapping hip; ilio-psoas tendon Torn acetabular labrum Muscle strain
Differential Diagnosis From the history, form a working diagnosis Use cluster’s test to rule in and rule out
Osteoarthritis Most common cause of hip pain Usually >50 yo, but can occur at any age. Will have capsular pattern of restriction X-ray
Subjective History DJD (>50 yo) Usually no specific mechanism of injury Groin pain; behind greater trochanter, anterior thigh to knee Stiffness in the morning (1 hour) Capsular pattern for loss of ROM Increased pain with WB (limp)
Functional Limitations Walking Stair climibing Putting on shoes Shaving legs/foot care
Osteoarthritis – Physiopedia Eric Wilson Diagnostic Cluster Hip Pain IR >15 Degrees Pain with IR Morning stiffness < 60 minutes Ages 50 or older Diagnostic Cluster Hip IR < 15 degrees Hip Flexion < 115 degrees Stiffness < 60 minutes Pain in the hip
Risk Factors Age Developmental Disorders Dysplasa Previous hip injuries Trauma Labral Tears
Diagnosis Hip O-A Made with certainty on the basis of history and physical exam. X-ray is definitive CPR – Child’s et al. Hip Guidelines – Cibukla Physiopedia
CPR for Hip Osteoarthritis Self report squatting as an aggravating factor. Scour test with adduction causing groin/lateral pain. Active hip flexion causing groin/lateral hip pain. Active hip extension (walking) causing groin/lateral pain. Passive hip IR < 15 degrees
American College of Rheumatology Hip O-A if had hip pain plus Hip IR < 15 degrees - painful Hip Flexion < 115 degrees > 50 yo Morning Stiffness < 60 minutes Sensitivity 86% Specificity 75% LR + 3.44 LR – 0.19
Special Tests Trendelenburg Gait MMT FABER’s Test Scour Test Empty and painful end-feel Spasm with early stage O-A
Lumbar Spine May have radicular pain into the buttock, groin and/or thigh Spine AROM/PROM will produce the referred pain. Must reproduce the pain with the examination
SI Joint Pain provocation test Thigh thrust Gaenslen’s video Sacral thrust
Hip Fracture Elderly osteoporotic women Fall followed by inability to WB Non-displaced fx, can WB but have increasing pain May need surgical stabilization Overuse Female Groin/thigh pain Occur 2 weeks after initiation in activity Amenorrhea
Femoral Neck Stress Fracture Pain with extreme ROM Pain with WB Positive Hop Test – 70% accurate Positive FABER/scour Positive Fulcrum
Iliopsoas Bursitis Present in hip flexion : ER & IR for relief Pain with passive hip extension Pain with resisted hip flexion Bursa tender to palpation (+) Snapping Hip & Supine Heel Raise < 30 yo
Greater Trochanteric Bursitis Pain Lateral thigh/gluteal area Pseudoradiculopathy Aggravating Lying on affected side Prolonged stand/walk Stair
Greater Trochanter Pain Syndrome No warmth, redness or swelling Silva et al, Bird et al. Concur that a bursitis is not the common cause of lateral hip pain. Glut Medius insertion tendonopathy Highest incidence is fourth – six decade of life.
Muscle Strain PROM will be pain free May have pain with stretch Painful AROM – when specific muscle is used Most common is Glut Medius Non capsular pattern of loss ROM
Malignancy Mets to the pelvis or proximal femur will produce hip pain. Primary bone tumor are very rare. Hx of CA
Labral Tear 75% of tears are not associated with any injury or cause. Insidious on-set that increases in intensity Age range 20-40 Female Anterior hip pain Usually normal x-ray
Subjective History Common complaint of pain, clicking, locking, catching, instability, giving way. Anterior groin pain 96-100% of cases Locking 58% of cases Predisposing factor: CoxaValga 87% MOI – hip ER + extension
Labrum Inner 2/3 is avascular, only outer 1/3 potential to heal. Labrum is innervated, potential for pain generator. Tears can be degenerative, dysplastic, traumatic and idiopathic. Most labral tears are anterior-superior.
Differential Diagnosis Hip Impingement 20-40 yo Female Caused by muscle imbalances/biomechanics Tight posterior hip capsule Postural adaptations Pinching of anterior structures Femoral neck against acetabular rim.
Sign of the Buttock Screening Test Identify serious pathology Limited and painful SLR Limited and painful hip and knee flexion Non-capsular pattern of restriction (osteomyelitis, neoplasm or fracture) Screening tests do not identify the exact pathology present Read journal article
Sign of the Buttock Limited and painful SLR Limited and painful hip and knee flexion Non-capsular pattern of restriction Strong reproduction of pain with PROM
FABER Screening test for hip and SI joint Passively flex, abd., and ER hip Overpressure Pain at groin Pain at SI
Thomas Test Positive test Thigh off the table Tight iliopsoas and rectus femoris muscle (knee flexion)
Scour Test Move the leg into flexion, abduction-adduction and IR. Compression (+) Hip Pain
Log Roll Test Used to assess labral pathology Maximally IR & ER Eliciting a click or popping sensation Also assess capsular laxity
McCarthy test Anterior labrum – full flexion, lateral rotation and abduction. Medical rotation, adduction and extension. (+) reproduce pain, popping or catching.
Active SLR Patient flexes hip to 30 degrees with knee straight against resistance. (+) reproduce groin pain. (-) if reproduces lumbar spine pain.
Impingement test Flex knee 90 degrees – apply flexion, adduction, internal rotation and overpressure. (+) test – pain that is reproduced in the groin Pain with IR = anterior labrum Pain with ER + Abd= posterior labrum
Bursa Special Test Will pinch the trachanteric bursa with hip adduction and IR Will pinch the psoas bursa with hip flexion and ER
Lateral Hip Examination Ober test Designed to elicit tightness in the ITB and tensor fascia lata. Patient placed side lying with the hip extended and abducted with the knee flexed. Positive test if the leg does not adduct to midline.
Psoas Bursitis Iliopsoas Bursitis Subjective History Anterior Hip Pain Worse with hip extension Overuse May complain of snapping Objective Exam Pain with passive hip extension Resisted hip flexion TTP (+) Snapping Hip Maneuver (+) Supine Heel Raise
MMT Test strength of Abductors Isolate glut medius Will be weak (inhibited) with arthritic joint
Hip Rotation PROM of left hip Loss of IR > loss of hip ER End-feel usually empty and painful for OA hip.
Hip Special Tests Martin et al JOSPT July 2006 Intra-articular Tests FABER Test Scour Test Resisted SLR Log Roll Test Distraction FAI
Hip Arthroscopy Labral tears Chondral lesions 90% tears are anterior Occur with twisting motion Lead to early OA Indications Loose bodies Labral tear Chondral flap tears