Differential Diagnosis Of The Hip2010

Differential Diagnosis:Clinical Practice GuidelinesEvidence-based diagnosis, prognosisand intervention.

Bridgit A. Finleywww.ptcentral.orgbfinley@ptcentral.orgFacebook: Physical Therapy CentralChoctaw Chickasha Newcastle Norman OKC Pauls Valley Stillwater

ObjectivesBe 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.

Course ScheduleEBPResourcesAnatomyBiomechanicsDifferential DiagnosisLectureLabManual TherapyTherapeutic ExercisesOutcome Measures

Philosophy of CareComprehensive ExamSubjectiveBiomechanicsFeet, knees, pelvis and lumbar spineHands onMFR, Manual Techniques One on One ExerciseSpecific

Vision 2020 The first, best choice in musculoskeletal care.ResourcesAPTAJOSPTPhysiopediaEvidence in MotionAAOMPTPEDroLife Long LearnersAutonomous ExpertsTake our game to the next levelSpecialty CertificationsManual Therapy CertificationsDPT

Evidence Based PracticeIntegration of the best research evidence with clinical expertise and patient values.Which will ultimately lead to improved patient outcomes.Levels of EvidenceSystematic ReviewsCase SeriesExpert Opinion

www.clinicallyrelevant.comIphone appOrthopedic Clinical Tests250 TestsPurposeVideo

Sensitivity and SpecificitySensitivityAbility to be positive when a variable is present.0 – 1.0 Good screening examSn=High Sensitivity to Rule OutSnNout – sensitive test=negative=rule outSpecificityAbility to be negative when a variable is absentVery specific to confirm the diagnosisSpin=High Specificity to rule in a diagnosisSpPin – specificity = positive= ruling in

Likelihood RationsThe 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 disorderGood Measure of the clinical utility of a testTells you how much a test result changes the pre-test probability of being correct

Likelihood Rations+LRThe proportion of people who test positive and have the disorder.= Sensitivity / (1-Specificity)-LRThe 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

WikipediaSensitivity and Specificity

PrevalenceO-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 hipSupport the weight of the trunkAmbulationTransmission of forces between the pelvis and lower extremitiesIf the hip is arthritic, will stress the lumbar spine and opposite leg.

Hip JointWalking – hip supports 240% to 355% times the body weightRunning – 550% times the body weight.Good foot wear is important.

Cane Aided GaitCane 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 GaitPushing into the cane – lifts the left side of the pelvis.Lecture notes Dave Thompson, PT

Hip JointHip is a ball and socket synovial joint and is the largest weight bearing joint in the body.Unlike the shoulder, the hip has a tight fit and sacrifices movement for stability.

AcetabulumAngled lateral, inferiorly and anteriorlyNormal is 10-15 degrees anterversionLabrum deepens the jointCovered with hyaline cartilage

FemurStrongest & longest bone of the body2/3 of head covered with cartilageFovea capitis supplies bloodHead Off-set

Hip CapsuleFrom acetabular rim to the base of femoral neckThicker anterior & superiorlyJoint supported by ligaments & musclesCapsule changes with O-A

LabrumLabrum contains free nerve endings and sensory end organsResponsible for nociceptive and proprioceptive mechanismProvide negative intra-articular pressureDeepens the socket (21%)

LabrumTear in labrum = destabilizes jointPremature arthritisReduce contact stress by increased contact area

Synovial MembraneContains highly vascularized synoviumCan get pinched and inflammedHip impingement from neck of femur hitting acetabulam.

Hip CapsuleLigaments are weakest posteriorlyLigaments are taut in hip extension -CCPLigaments are relaxed in hip flexion (mobilize)

Rectus FemorisAttaches to anterior hip capsuleInjury can cause capsular adhesionsLimit hip extensionHip Impingment – painful with stretch

Anterior Hip CapsuleRectus femoris and quads can attach to the anterior hip capsuleMuscle blend with hip capsuleJob is to tighten capsule with contraction

Gluteus MediusGluteus Medius – main hip abductorPrimary stabilizer of hip and pelvisTrendelenburg sign vsgaitMuscle weakness around O-A joint

Gluteus MaximusTFL envelops the muscles of the thighCounteracts the backward pull of the gluteus maximums of the ITB.Hip extensors are 3 times as strong as the flexors

PsoasIliopsoas bursa – present in 98% of adults.Lies under the psoas tendonOveruse and impingement syndromes

SLR ExercisesMust have excellent core strengthThis is a core exercise, not psoas

Hip External RotatorsHip capsule is cut and the ER are retracted so that the joint can be exposed.Hip Scope – no muscles cut and hip capsule intact.

AdductorsTight adductors will create a functional short leg.Increase stress on the hip joint.Inhibit glut medius.

Ball and Socket JointFlexion to 130-140Extension 10-15Abduction 30-50Adduction 25-30ER 30-45IR 20-35Rolls anterior glides posteriorRolls posterior glides anteriorRolls laterallyRolls mediallySpins anteriorly and laterallySpins posteriorly and medially

MobilizationFlexionExtensionAdductionInternal RotationPosterior / Inferior GlideAnterior GlideLateral GlideLateral Glide

Inclination AngleAngle 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 AngleCoxaVara <100Usually congentialCauses a short legPositive trendelenburg signGenuvalgumCompensatory lumbar pathology

Inclination AngleNoraml 125Coxa Valga >125Causes a long legPositive trendelengurg signStress on ITB and bursaGenu varaCompensatory lumbar pathology

Coxa ValgaChanges 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 kneeHip Dysplasia

Femoral AnteversionNormal is 10-15 degreesHave more hip IRFemoral head more anterior in capsuleMay lead to labral tears, impingement and OA

CyriaxCapsular pattern – specific and proportional loss of movementMost common cause of capsular pattern is arthritis

Capsular PatternCyriaxIRFlexionAbductionIf capsular pattern of restriction; joint is arthritic.If non capsular pattern; not joint.Cyriax listed in ascending orderLoss of internal rotationMore than flexionMore than abduction

Noncapsular RestrictionsFracturesOsteomiylitisLabral tearsCancerBursitisCapsular IrritationSynovitisImpingement

Resting Closed PackedFlexion 30 degreesAbduction 30 degreesExternal Rotation 10-15 degreesExtensionAdductionInternal RotationStable position of the jointTighten capsule

Manual TherapyMobilization/manipulationManual stretchingTractionMobilization (posterior/lateral)5 Weeks81% had positive outcomesMore effective than exercise aloneImprovement Hip Harris Score

Biomechanical ForcesFemoral AnteversionPronationTibial Internal RotationImproper Hip AlignmentPelvis Lumbar – will lose ipsilateral rotation (left hip, left rotation)

Hip DysplasiaDisplacement of femoral head in acetabulumLeft hip is more often involved80 % FemalesBreech birthFirst born

Hip DysplasiaLess degress of femoral head coverageDecreased joint surface areaNormal 30-40%Angle of inclination >125 degreesIncreased femoral anterversionAcetabular retroversionMcCarthy & Lee found 72% of patients with dysplasia had labral tears

Dysplastic HipHead off-set is between femoral head and shaftOff-set is decreasesFemoral neck is short and thick

X-RayDemonstrate loss of joint space, osteophytes and sclerosis.Dysplasiatears are more common in individuals with acetabular dysplasia.

Glut Medius controls Adductor MomentHip Abductor function in closed chain is to maintain a level pelvis.

Trendelenburg GaitHave patient stand on one leg and assess if the pelvis drops.(+) Trendelenburg Sign

DiagnosisBonyOsteoarthritisCapsule/ LigamentsLabral tear or ImpingementMuscle / Tendon“itis”Muscle tear

Subjective HistoryPossibly the single most important part of the examinationestablishes your interest in the patientestablishes the relationship uncovers information not available from the objective examinationsestimated to make up about 70% of the diagnosis

Summarybe focused on the patient’s problemsmaintain control of the interviewbe systematic in your interview methodfollow up answers but do not get side trackedtake as long as you needbe professionalbe analytical

Causes of hip pain in adultsOsteoarthritisOther arthritides:RAPsoriaticAnkylosingSpondylitisHip FracturePaget’s diseaseAvascular necrosisReferred painMalignancyInfectionPainful soft tissueTrochanteric bursitisSnapping hip; ilio-psoas tendonTorn acetabular labrumMuscle strain

Differential DiagnosisFrom the history, form a working diagnosisUse cluster’s test to rule in and rule out

OsteoarthritisMost common cause of hip painUsually >50 yo, but can occur at any age.Will have capsular pattern of restrictionX-ray

Subjective HistoryDJD (>50 yo)Usually no specific mechanism of injuryGroin pain; behind greater trochanter, anterior thigh to kneeStiffness in the morning (1 hour)Capsular pattern for loss of ROMIncreased pain with WB (limp)

Functional LimitationsWalkingStair climibingPutting on shoesShaving legs/foot care

Osteoarthritis – Physiopedia Eric WilsonDiagnostic Cluster Hip PainIR >15 DegreesPain with IRMorning stiffness < 60 minutesAges 50 or olderDiagnostic ClusterHip IR < 15 degreesHip Flexion < 115 degreesStiffness < 60 minutesPain in the hip

Risk FactorsAgeDevelopmental DisordersDysplasaPrevious hip injuriesTraumaLabral Tears

Diagnosis Hip O-AMade with certainty on the basis of history and physical exam.X-ray is definitive CPR – Child’s et al.Hip Guidelines – CibuklaPhysiopedia

Differential DiagnosesLumbar Referred PainStress FractureBursitisLabral Tear

CPR for Hip OsteoarthritisSelf 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 RheumatologyHip O-A if had hip pain plusHip IR < 15 degrees - painfulHip Flexion < 115 degrees> 50 yoMorning Stiffness < 60 minutesSensitivity 86%Specificity 75% LR + 3.44LR – 0.19

Special TestsTrendelenburg GaitMMTFABER’s TestScour TestEmpty and painful end-feelSpasm with early stage O-A

Lumbar SpineMay have radicular pain into the buttock, groin and/or thighSpine AROM/PROM will produce the referred pain.Must reproduce the pain with the examination

SI JointPain provocation testThigh thrustGaenslen’svideoSacral thrust

Hip FractureElderly osteoporotic womenFall followed by inability to WBNon-displaced fx, can WB but have increasing painMay need surgical stabilizationOveruseFemaleGroin/thigh painOccur 2 weeks after initiation in activityAmenorrhea

Femoral Neck Stress FracturePain with extreme ROMPain with WBPositive Hop Test – 70% accuratePositive FABER/scourPositive Fulcrum

Iliopsoas BursitisPresent in hip flexion : ER & IR for reliefPain with passive hip extensionPain with resisted hip flexionBursa tender to palpation(+) Snapping Hip & Supine Heel Raise< 30 yo

Greater Trochanteric BursitisPainLateral thigh/gluteal areaPseudoradiculopathyAggravatingLying on affected sideProlonged stand/walkStair

Greater Trochanter Pain SyndromeNo warmth, redness or swellingSilva et al, Bird et al.Concur that a bursitis is not the common cause of lateral hip pain.Glut Medius insertion tendonopathyHighest incidence is fourth – six decade of life.

Muscle StrainPROM will be pain freeMay have pain with stretchPainful AROM – when specific muscle is usedMost common is Glut MediusNon capsular pattern of loss ROM

MalignancyMets to the pelvis or proximal femur will produce hip pain. Primary bone tumor are very rare.Hx of CA

Labral Tear75% of tears are not associated with any injury or cause.Insidious on-set that increases in intensityAge range 20-40FemaleAnterior hip painUsually normal x-ray

Subjective HistoryCommon complaint of pain, clicking, locking, catching, instability, giving way.Anterior groin pain 96-100% of casesLocking 58% of casesPredisposing factor: CoxaValga 87%MOI – hip ER + extension

LabrumInner 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 DiagnosisHip Impingement20-40 yoFemaleCaused by muscle imbalances/biomechanicsTight posterior hip capsulePostural adaptationsPinching of anterior structuresFemoral neck against acetabular rim.

Differential DiagnosisOne of the most common referral patterns to the hip and thigh is lumbar spine Hip pain can refer to knee and belowMust clear the SI joint and Lumbar spine

Standing ExamGaitLumbar AROMPostureAtrophyWeight bearingLeg LengthLaxity TestBalanceStep UpsSingle Leg StandGluteus medius strength

GaitHip extension15-20 degreesPelvicRotationSide bendingObserve as walk into clinicPain with WB – think articular

Lumbar AROMFlexionExtensionSBDoes the movement reproduce “their” pain

PostureAtrophy & WBLeg Length Laxity

Step up BalanceTrendelenburg’s SignGluteus Medius Tear

Sitting ExaminationSit to standMuscleReflexSensoryROM – hip ER/IR Quick cursory screen

Sit to StandLoss of flexion, adduction and internal rotationCompensate by loading non-painful leg

Muscle TestHipFlexionERIRHamstringsQuadsNormal except for Flexion

NeurologicalSensationReflexesShould all be normalIf not, evaluate lumbar spineDiscNerve root compressionStenosis

ROMLoss of hip IR first sign of internal hip pathology:arthritis,effusion, labral pathologyimpingement

Fulcrum Test(+) if reproduce pain at femoral shaftTesting for stress fractures along femoral shaft

Supine ExaminationHip ROM – active & passiveSign of the ButtockFABER TestThomas testMcCarthy (Labral) test Active SLRScour testTrochanteric /PsoasBursitisSI – thigh thrust

Hip ROMWatch for compensation at the pelvis.AROMPROMCapsular pattern?End-feel?Pain?

Sign of the ButtockScreening TestIdentify serious pathologyLimited and painful SLRLimited and painful hip and knee flexion Non-capsular pattern of restriction(osteomyelitis, neoplasm or fracture)Screening tests do not identify the exact pathology presentRead journal article

Sign of the ButtockLimited and painful SLRLimited and painful hip and knee flexion Non-capsular pattern of restrictionStrong reproduction of pain with PROM

FABERScreening test for hip and SI jointPassively flex, abd., and ER hipOverpressurePain at groinPain at SI

Thomas TestPositive testThigh off the tableTight iliopsoas and rectus femoris muscle (knee flexion)

Scour TestMove the leg into flexion, abduction-adduction and IR.Compression(+) Hip Pain

Log Roll TestUsed to assess labral pathologyMaximally IR & EREliciting a click or popping sensationAlso assess capsular laxity

McCarthy testAnterior labrum – full flexion, lateral rotation and abduction.Medical rotation, adduction and extension.(+) reproduce pain, popping or catching.

Active SLRPatient flexes hip to 30 degrees with knee straight against resistance.(+) reproduce groin pain.(-) if reproduces lumbar spine pain.

Impingement testFlex knee 90 degrees – apply flexion, adduction, internal rotation and overpressure.(+) test – pain that is reproduced in the groinPain with IR = anterior labrumPain with ER + Abd= posterior labrum

Bursa Special TestWill pinch the trachanteric bursa with hip adduction and IRWill pinch the psoas bursa with hip flexion and ER

Lateral Hip ExaminationOber testDesigned 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 BursitisIliopsoas BursitisSubjective HistoryAnterior Hip PainWorse with hip extensionOveruseMay complain of snappingObjective ExamPain with passive hip extensionResisted hip flexionTTP(+) Snapping Hip Maneuver(+) Supine Heel Raise

MMTTest strength of AbductorsIsolate glut mediusWill be weak (inhibited) with arthritic joint

Hip RotationPROM of left hipLoss of IR > loss of hip EREnd-feel usually empty and painful for OA hip.

Hip Special TestsMartin et alJOSPT July 2006Intra-articular TestsFABER TestScour TestResisted SLRLog Roll TestDistractionFAI

Hip ArthroscopyLabral tearsChondral lesions90% tears are anteriorOccur with twisting motionLead to early OA IndicationsLoose bodiesLabral tearChondral flap tears

Complication Rates.05 and 5%Most often related to distraction, procedures > 1 hourSciatic, femoral, peroneal or pudendalneuropraxiaAvascularnecrosisFracture

CandidatesMechanical symptoms – catching, locking, clickingFailed to respond to conservative therapyExtent of articular cartilage has the most direct relationship to surgical outcomes

Lower Extremity Function ScaleOrdinal Scale 0 “extreme difficulty” to 4 “no difficulty”Patient rate ability to perform 20 different activities0 to 80 scale, 80 no limitations.Minimum detectable change 9 scale points

Harris Hip ScoreScores on 10 different variablesPainROMGaitADLsScore range from 0 “worst” to 100 “best”.Harris Hip Score

Non-musculoskeletal CausesRetrocecal AppendicitisHerniaRenalUreteralRegis University

Rehabilitation ProtocolIndividualizedModify per patient statusPer PhysicianAgeHealth StatusControl pain and swellingSurgical ProcedureChange WB and precautions

Rehabilitation GoalsControl edema/effusionMuscle BalanceJoint Capsule & MotionBiomechanicsBalance & Proprioception

Patient GoalsNormal gaitStairsSquatPut on shoes and soxShave legs/clip toenails

Exercise TherapyFlexibilityROM – improve functionStrengtheningNormalize gait will decrease impact loadsCardiovascularEndurance 60-80% for 15-30 minutes

Muscle ImbalancesTightnessPsoasAdductorsQuadratus LumborumTFLPiriformisReleaseWeaknessGlut MaximusGlut MediusQuadsHip ERCore MuslcesAbsErrectorspinae

FACILITATED MUSCLESIliopsoasRectus FemorisTFLQLHip AdductorsPiriformisHamstringLumbar Erector Spinae

TreatmentModalitiesMFR/ MassagePROM- watch precautionsBalanceMET / Mobilization/Manual StretchingCardiovascularCore Stabilization

Manual TherapyMFRITBPiriformisPsoasPsoas release

Hip PROMWatch for compensation at the pelvis.Capsular pattern?End-feel?Pain?

MET – manual stretchingSoft tissue and capsular tightnessHave not moved hip though this motion in years

GaitHip extension15-20 degreesPelvicRotationSide bending

Muscle Energy TechniqueHamstringsPsoasLumbar Spine

Week 4-5(-) Trendelenburg SignInitiate Hip PRENeutral alignment lumbar spineFull PROM

TreatmentMyofascial ReleasePsoasPosterior Hip CapsulePROM/Jt. MobilizationCore StabilizationProprioceptionBalance

MobilizationLeg traction – inferior glideDistraction – inferior or caudal glide.Mobilization with movementBeltMET to restore IR/ER or hip flexion

ProprioceptionArthritic hips lose input secondary to loss of articular cartilage.THR – no input from the hip joint. Must retrain neuromuscular system.Balance activities.

Therapeutic ExerciseStrengthen the glutesDo not strengthen the hip flexors

S.E.R.F. StrapPulls the hip into ERJOSPT September 2008 Vol 38, N 950% self report decrease painDecreases hip impingement

Differential Diagnosis Of The Hip2010

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