The document presents five case reports that required referral from a physical therapist to a physician or specialist due to abnormal screening test results during differential diagnosis of hip versus lumbar spine pathology. Each case resulted in a new diagnosis beyond the scope of physical therapy, such as fracture or osteonecrosis of the hip. Cyriax's concepts of capsular and noncapsular patterns of joint restriction and the "Sign of the Buttock" were useful in differentiating hip from lumbar spine pathology in each patient. The clinical experience suggests these screening tests may effectively identify hip pathology, but further research is needed.

1. Differential Diagnosis of the Hip Vs. Lumbar
Spine: Five Case Reports
-
Michael). Greenwood, MS, PT'
Richard E. Erhard, DC, PT*
Dina 1.)ones, MS, PT
T
he combination of re-
cent health care policy
changes and direct ac-
cess in many states have
put increased demands
on the assessment skills of physical
therapists. Subsequently,physical
therapists must be able to identify
pathology that is beyond their scope
of practice.
Screening tests may be used to
alert physical therapists to "red flags"
indicating undiagnosed pathology.
For example, the presence of weight
loss and night pain may serve as a
quick screening test to identify poten-
tial cancer patients (2).
In patients with musculoskeletal
problems, potentially serious condi-
tions, such as fractures, necrosis, sep
tic bursitis, or severe arthritic chang-
es, should be identified and properly
medically managed before physical
therapy is initiated. Although these
conditions are generally not life
threatening, early detection of such
pathology may be essential to a favor-
able outcome.
This paper presents five case re-
ports involving the hip and lumbar
spine that required referral from the
physical therapist to either the pa-
tient's physician or a specialist be-
cause of abnormal screening test re-
sults. All of these referrals resulted in
a new diagnosis of pathology, such as
fracture, osteonecrosis, or dysplasia of
the hip, that was beyond the scope of
physical therapy. The concepts of
capsular and noncapsular patterns of
With recent health carepolicy changesand the implementationof direct access in many
states, physical therapists must be able to identify pathology that is beyond their scope of practice.
Thefive case reports presented in this series required the differential diagnosis of hip w. lumbar
spinepathology. All of the cases requireda referral from thephysical therapist to either the
patient's physician or a specialist because of abnormal screening test results. Each referral resulted
in a new diagnosis of pathology that was beyond the scope of physical therapy. Cyriax's concepts
of capsular and noncapsular patterns ofjoint restrictionand the "Sign of the Buttock" proved useful
in differentiatingbetween hip and lumbar spinepathology in each patient. Our clinical experience
indicates that utilizing thepresencehbsenceof a capsular pattern and a "Sign of the Buttock" to
screen out hip pathology in patients may be effective;however, further research is needed to
support these cbims.
Key Words:hip, lumbar spine, capsular pattern, differential diagnosis
'Physical Therapist, independent ContractingPractice, Layton, UT. At the time of this study, Mr. Greenwood
was a master's degree candidate, School of Health and RehabilitationSciences, Depamnent of Physical Ther-
apy, Universityof Pimburgh, Pimburgh, PA. Address for correspondence:552 West 1425 North, Apartment
V, Layton, UT 84041.
Assistant Professor, School of Health and RehabilitationSciences, Depamnent of Physical Therapy,
Universityof Pittsburgh, Pimburgh, PA; Head, Chiropracticand Physical Therapy Services, Comprehensive
Spine Center, Universityof Pimburgh Medical Center, Pimburgh, PA
Assistant Professor and Academic Coordinatorof Clinical Education, School of Health and Rehabilitation
Sciences, Department of Physical Therapy, Universityof Pittsburgh, Pimburgh, PA; Coordinatorof Education,
CORE Network, LLC, Pimburgh, PA; Doctoral Student, GraduateSchool of Public Health, Universityof
Pittsburgh, Pittsburgh, PA
joint restriction as described by
Cyriax (1) proved useful in each case
in differentiating hip pathology from
pain originating from the lumbar
spine.
Review of the Literature
Cyriax (1) attempted to correlate
anatomy with function to yield de-
scriptive and reproducible results,
indicating a probable source of pa-
thology. His diagnostic movement
concepts of capsular vs. noncapsular
patterns of restriction are widely used
in the assessment of peripheraljoint
pathology (1,2).
The term capsular pattern de-
scribes a specific and proportional
loss of movement at ajoint due to a
lesion of thejoint capsule or synovial
membrane (1). The most common
cause of a capsular pattern is arthritis
of ajoint (1).
A capsular pattern of the hip is
defined as: gross limitation of flexion,
abduction, and internal rotation;
slight limitation of extension; and,
little or no limitation of external r e
tation (1). Because Cyriax stated that
in the early stages ofjoint involve-
ment, only internal rotation may be
painful and restricted (I), it is our
interpretation that Cyriax listed the
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2. C A S E S T U D Y
first three restrictions in an ascend-
ing order. Thus, the resultant capsu-
lar pattern of the hip would be a loss
of internal rotation more than abduc-
tion and a loss of abduction more
than flexion.
If limitations in motion are
found that do not follow a capsular
pattern, a noncapsular pattern of re-
striction is present, and the examiner
may eliminate arthritic changes from
the differentialdiagnosis. A noncap
sular pattern, however, may indicate
a variety of conditions, thus making
interpretation difficult. For example,
a noncapsular pattern could be indic-
ative of serious pathology (1) or
could represent a nonthreatening,
asymptomatic extraarticular lesion,
such as a ligamentous adhesion (1).
In patients with a noncapsular pat-
tern of restriction and strong repro-
duction of their pain during passive
hip range of motion testing, we usu-
ally recommend further testing, such
as radiographs or magnetic reso-
nance imaging. In each of the follow-
ing five case reports, the presence of
a noncapsular pattern eventually ne-
cessitated the referral of the patient
out of physical therapy.
Concerning the reliability and
validity of Cyriax's capsular and non-
capsular pattern concepts, we know
of only two studies on these subjects;
however, neither specifically studied
the hip. In a study of 88 patients with
osteoarthritis of the knee, Hayes et a1
(4) concluded that Cyriax's descrip
tion of the pattern of restriction, end-
feel, and sequence of pain and resis-
tance for the knee was not supported
by their results (10). More recently,
Pellecchia et a1 (10) examined inter-
therapist reliability of shoulder assess-
ments made using Cyriax's evaluation
techniques. The physical therapists
classified 19 of 21 cases into the same
diagnostic categories, including three
cases with a capsular pattern of re-
striction (10). The investigators con-
cluded that their study established
intertherapist reliability using Cyriax's
evaluation techniques for assessing
patients with shoulder pain (10). Nei-
ther study, however, established the
construct validity of Cyriax's tech-
niques.
The "Sign of the Buttock" is an-
other concept that was proposed by
Cyriax to identify potentially serious
pathology. The "Sign of the Buttock"
has three components (1). The first
component is a limited and painful
straight leg raise test, implicating a
structure that runs posterior to the
hipjoint or possibly in thejoint itself
(1). Next, the patient has limited and
painful passive hip flexion with the
knee bent (1). This finding indicates
that the painful structure does not
span the distance between the hip
and kneejoint (such as the sciatic
nerve or hamstrings). Lastly, a non-
capsular pattern of restriction is
present at the hip (I), indicating that
arthritic changes at thejoint are not
pathogenic.
Cyriax (1) listed eight possible
causes of a "Sign of the Buttock,"
such as osteomyelitis, neoplasm, or
sacral fracture, all of which lie be-
yond the scope of physical therapy
practice. Because there are several
possible causes of a positive "Sign of
the Buttock," we consider it a screen-
ing test for potentially serious pathol-
ogy. Screening tests generally do not
identifythe exact pathology present
but indicate that a patient may need
to be referred back to their physician
for further evaluation.
METHODS
Passive range of motion of the
hip was measured and compared with
normative values as described by Mi-
nor and Minor (9). Where applica-
ble, goniometric range of motion
measurements using standardized
measuring procedures (9) were pre-
ferred over a visual assessment of
range of motion.
The hip screening examination
started with the patient sitting on the
examination table with his/her lower
extremitiesnonweight bearing. The
patient firmly grasped the table in
such a way as to keep his/her thighs
tightly adducted. This minimized
other hip motions and provided a
reproducible starting position for re-
testing. Next, the therapist passively
internally rotated both hips simulta-
neously to the end range, or the pa-
tient's pain limit, and measured
range of motion. Sufficientoverpres-
sure was supplied when passively test-
ing range of motion so that a pain-
provoking test was not missed.
External rotation of the hip was uni-
laterally assessed in sitting.
Hip abduction was assessed with
the patient supine. The therapist pal-
pated the contralateral anterior supe-
rior iliac spine, passively abducted
the test leg until the anterior supe-
rior iliac spine being palpated began
to move, then measured the available
range of motion.
Hip flexion range of motion was
also measured in supine. Using the
tibial tubercle region as the contact
point for the therapist's hand, the
therapist passively flexed the hip and
knee until the end range, or the pa-
tient's pain limit. If a capsular pat-
tern of restriction was present, there
would be a limitation of hip flexion,
abduction, and internal rotation (1).
There would also be a slight limita-
tion of hip extension and little or no
limitation of external rotation (1).
Hip adduction was not assessed.
The Patrick test (6) was also uti-
lized during examination of the hip.
In supine, the examiner passively
flexed, abducted, and externally ro-
tated the hip and applied pressure to
the knee and contralateral anterior
superior iliac spine. A report of pain
that was concentrated in the sacroil-
iac region was more likely to be sac-
roiliac-related,whereas pain in the
groin or anterior hip was more indic-
ative of hip pathology (6).
If a noncapsular pattern of re-
striction was present at the hip, we
considered the magnitude of the
pain that was reproduced or exacer-
bated by the hip movements. In our
experience, the stronger and more
precisely we reproduced the patient's
pain complaint during passive hip
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3. C A S E S T U D Y
movement testing, the more we sus-
pected that the hip region may be
involved in producing the patient's
pain.
If all of the tested hip motions
were considered normal, nonprovoca-
tive with overpressure, and syrnmetri-
cal, we progressed to the examina-
tion of the lumbar spine. The lumbar
examination consisted of palpation of
pelvic landmarks (iliac crests, ante-
rior superior iliac spines, and poste-
rior superior iliac spines) and muscle
tone of the lumbar paraspinal muscu-
lature and assessment of range of
motion. Gross lumbar flexion, exten-
sion, and side bending were evalu-
ated in standing. Repeated motion
testing was performed in two of the
five case studies as deemed appropri-
ate at the time of the initial physical
therapy evaluation.
The remaining components of
the physical therapy evaluation in-
cluded lower extremity manual mus-
cle testing (8). neurological assess-
ment (sensation and tendon
reflexes), and observational gait anal-
ysis. Because of the lack of hip inter-
nal rotation associated with a capsu-
lar pattern of restriction of the hip
(I), patients with advanced hip ar-
thritis may ambulate with the in-
volved lower extremity externally ro-
tated. In our experience, as the
arthritic changes worsen, limitations
in hip extension may also become
noticeable during the stance phase of
gait.
CASE ONE
Previous History
A 73year-old female felt a "pop"
in her right hip while performing her
daily leg lifting exercises. She had
immediate buttock and right lower
extremity radiating pain. After 2
weeks of chiropractic care without
relief of symptoms, the patient went
to the emergency room were she was
evaluated by a neurosurgeon. The
neurosurgeon ordered magnetic reso-
nance imaging, which revealed the
following: severe spinal stenosis with
a complete myelographic block at
L34; posterior bulging discs at L2-3,
L34, and L45; and the desiccation
of all lumbar discs. A decompressive
laminectomy was performed 4 weeks
after the initial emergency room visit.
Physical Examination
The patient was referred to physi-
cal therapy by the neurosurgeon 1
month after her laminectomy. The
patient complained of persistent
right buttock and anterior thigh pain
that worsened with weight bearing on
the right leg. As a result, she ambu-
lated with a walker to decrease pain.
Visual observation revealed that
the patient was unable to sit erect
due to pain. To compensate, she
leaned backward approximately 45"
at the hip. Standing lumbar flexion,
extension, and left side-bending ac-
tive range of motion were minimally
limited based on visual inspection
with no increase in pain. Standing
right lumbar side bending was se-
verely limited upon visual inspection
and resulted in increased right but-
tock and right lower extremity pain.
When right lumbar side bending was
retested without weight bearing of
the right lower extremity, no pain
increase occurred.
Neuromuscular assessment re-
vealed a diminished right patella ten-
don reflex; intact lower extremity
sensation; and severe pain with all
right hip manual muscle testing at-
tempts that prohibited any accurate
strength assessment. Passive range of
motion of the right hip revealed a
noncapsular pattern of restriction
with a gross limitation of movement
in all directions, especially external
rotation. Straight leg raise of the
right lower extremity was limited to
40" [normal = 80" (a)]. When the
knee was flexed, hip flexion re-
mained limited to 45" [normal =
120" ( 9 ) ] .Based on the identification
of a noncapsular pattern of motion
restriction at the hip, the limited
straight leg raise, and the limited hip
flexion with the knee flexed, it was
determined by the physical therapist
that the patient presented with a
"Sign of the Buttockn (1).
Outcome
The neurosurgeon was immedi-
ately informed of the results of the
physical therapy evaluation, and treat-
ment was held pending the outcome
of radiographs that were ordered by
the physician. The radiology report
revealed a transcervical fracture of
the right femur with features of chro-
nicity. The neurosurgeon referred
the patient to an orthopaedic sur-
geon who performed a total hip ar-
throplasty. The patient's lower ex-
tremity pain completely resolved
following the total hip arthroplasty.
CASE TWO
Previous History
A 76year-old male was referred
to physical therapy with an 1lday
history of left low back and thigh
pain. The patient reported that the
pain occurred after he had been sit-
ting for 2 hours. When he began to
rise from the chair, he felt a "stiff-
ness" in his left thigh. Once standing,
his "stiffness" became a sudden pain
in the thigh, which progressed to the
left low back. The patient rated the
pain in his low back and anterior-
medial, proximal left thigh as five out
of 10 on a scale of zero to 10 (zero
equals no pain). He also reported
occasional numbness and tingling in
his left calf and all of his toes; how-
ever, there was none present at the
time of the physical therapy evalua-
tion.
That patient reported that since
the initial onset of pain, he was un-
able to ambulate without the use of
one crutch. Other functional limita-
tions included disturbed sleep sec-
ondary to pain and increased pain
with sitting. He had not attempted
any exercise and as he was retired, he
did not have any work complications.
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4. C A S E S T U D Y
The patient's past medical history
was extensive. He had a history of
sciatica, which had been treated suc-
cessfully by one of the authors
(REE). The patient also had a right
total hip arthroplasty in 1980 and a
left total hip arthroplasty in 1981. He
had a revision of the right hip arthro-
plasty in 1993secondary to disloca-
tion and a revision of the left hip
arthroplasty secondary to a femoral
fracture 9 months prior to being seen
in the clinic for this current episode
of low back and hip pain.
The revision of the left hip 9
months ago was reinforced with wire
mesh to increase the integrity of the
repair. Following the repair, the pa-
tient was placed on bedrest for 7
weeks, then placed on crutches for
protected weight bearing until 3
months prior to our evaluation. Since
then, he had been using either a
straight cane or no assistive device
for ambulation and did not have any
complaints of pain until his current
symptoms.
Physical Examination
The patient ambulated with an
axillary crutch on his left side. His
gait was antalgic with decreased hip
extension on the left side during ter-
minal stance. When sitting, he would
not fully weight bear on the left but-
tock; instead, he reclined backward
and leaned to the right. This sitting
position resulted in only 50-60" of
left hip flexion and decreased weight
bearing on the left hip.
Neurological examination re-
vealed normal tendon reflexes and
intact light touch sensation in both
lower extremities. Girth measure-
ments of the left thigh were between
3.8 and 6.3 cm greater than the right
thigh. Both the patient and his wife
stated that the edema was new since
the time of pain onset.
Manual muscle testing (8) was
limited to the tibialis anterior and
extensor hallicus longus on the left
side because of pain complaints with
left hip and knee strength testing
attempts. Strength of the left tibialis
anterior and extensor hallicus longus
were both 4/5 (8) and symmetrical
with the right side.
The patient's active lumbar range
of motion in standing measured via
goniometry, compared with norma-
tive values (5),was as follows: flex-
ion = 35" (normal = 40-60°), exten-
sion = 20" (normal = 20-35"), left
side bending = 25", and right side
bending = 35" (normal = 15-20').
The active range of motion testing
did not change the patient's low back
pain. Lumbar extension and left side
bending referred pain to the left
groin, but the pain returned to pre-
testing levels once the patient re-
turned to the starting position. Based
on the patient's thigh edema, inabil-
ity to sit with the hip flexed to 90°,
normal neurological assessment, and
inconclusive lumbar examination, an
evaluation of the left hip was per-
formed.
Passive hip internal and external
rotation had to be tested in sitting
with the patient leaning backward
30-40" secondary to pain. Passive
internal and external hip rotation
compared with normal [45" (9)] was
as follows: internal rotation right =
10". left = 15"; external rotation
right = 45". left = 25". Passive hip
abduction was 30" bilaterally [nor-
mal = 45" (9)]. Passive hip adduc-
tion and extension were not mea-
sured.
Straight leg raise was limited to
50" bilaterally with testing on the
left side causing increased pain into
the left groin. Hip flexion with the
knee flexed revealed 90" of hip
flexion on the right but only 50" on
the left. Based on the moderately
restricted passive external rotation
of the left hip, compared with the
right, and the presence of almost
symmetrical internal rotation, the
physical therapist felt that this pa-
tient presented with a noncapsular
pattern of limitation. In addition,
the presence of the noncapsular
pattern, the limited straight leg
raise, and the limited hip flexion
with the knee flexed indicated a
positive "Sign of the Buttock" (1).
Treatment Plan
This patient presented with a
positive "Sign of the Buttockn;how-
ever, the patient's history of multiple
hip surgeries was an issue in deter-
mining the importance of this find-
ing. Because a "Sign of the Buttock"
can be associated with serious pathol-
ogy, the physical therapy evaiuation
was stopped. Because of the patient's
history of bilateral total hip arthro-
platies, radiographs of the pelvis, left
hip, and left femur were ordered by
the evaluating physical therapist, who
is also a chiropractor, to rule out
fracture and hip dislocation as possi-
ble causes of the patient's pain.
The radiology report suggested a
refracture in the left proximal femo-
ral shaft and/or subtrochanteric ar-
eas. Additional findings included
marked osteoporosis and myositis
ossificans. The patient was immedi-
ately referred back to the orthopae-
dic surgeon for reevaluation.
Outcome
Follow-up calls to the patient
were made to monitor his progress.
One week later, the patient stated
that the orthopaedic surgeon felt that
the pain originated from a muscular
tear and not a fracture, and, thus,
surgical intervention was not indi-
cated. The patient was not referred
back to physical therapy.
During a follow-up call 4 months
later, the patient stated that his pain
had been decreasing up until 2
months ago. At that time, he experi-
enced sudden and severe left hip
pain while walking which required
him to seek medical attention. Radie
graphs taken by the orthopaedic sur-
geon revealed both a femoral shaft
and component stem fracture. Revi-
sion surgery was performed 5 days
later. Four months after being seen
in the physical therapy clinic, the pa-
tient stated that although he had to
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5. C A S E S T U D Y
use a long leg brace for 6 weeks after
surgery, he was progressing well and
felt that the surgery was successful.
CASE THREE
Previous History
A 62-year-old female with a Syear
exacerbation of left low back pain
after falling down a flight of stairs
was referred to physical therapy. She
reported that the pain radiated to
the left buttock and groin with occa-
sional radiation to toes one through
three of her left foot. Additionally,
she complained of numbness in the
right lower extremity.
The patient rated her pain as
nine out of 10 on a scale from zero
to 10 (zero equals no pain). Bending,
sitting, standing, and walking greater
than 50 feet all increased her pain.
She had to stop working as a baker
1% years ago due to pain. She stated
that her sleep was interrupted two to
three times per night due to pain.
Prior to her fall 3 years ago, she
had a 30-year history of intermittent
low back pain without lower extrem-
ity symptoms. Her past medical his
tory included osteoporosis, osteoar-
thritis, and lumbar disc bulges.
Surgically,she had a hysterectomy
and a cholecystectomy. She denied
any history of diabetes, cancer, or
vascular disease. The only treatment
she had received was sustained lum-
bar traction and pain medication in
the hospital "many years ago."
Physical Examination
The patient ambulated with a
straight cane on her right side and
avoided full weight bearing on the
left lower extremity. Standing pos
tural inspection revealed a decreased
lumbar lordosis with a right lateral
shift (standing posture with shoulders
to the right and hips to the left).
Lumbar active range of motion
testing revealed a marked loss of all
motions (range = 0-15") with exten-
sion completely absent. Neurologi-
cally, light touch sensation was intact,
but the left patella tendon reflex was
diminished and the left Achilles ten-
don reflex was absent. Strength test-
ing (8) revealed a mild decrease in
all myotomes of the lower extremity
except plantar flexion, which was not
tested due to the patient's complaint
of pain.
Passive hip internal rotation
range of motion in sittingwas greater
on the left side (35") compared with
the right side (30"). Passive supine
hip abduction was 10" on the left and
30" on the right. Straight leg raise
was positive for pain and range of
motion limitation at 10" on the left
and 20" on the right. Left hip flexion
with the knee flexed elicited severe
pain at 15". On the right side, hip
flexion with the knee flexed was pain-
free, but limited to 90".
Based on the limited left hip a b
duction without limitation of internal
rotation (compared with the right
hip), it was decided that the patient
presented with a noncapsular pattern
of limitation in the left hip. It was
also noted that the patient had a pos
itive "Sign of the Buttock" due to the
presence of a noncapsular pattern of
the left hip, the limited straight leg
raise, and the limited hip flexion
with knee flexion on the left side (1).
Treatment Plan
Due to the patient's known his
tory of lumbar disc bulges, an exer-
cise was done to correct for the right
lateral shift before sending the pa-
tient back to the physician. The pa-
tient leaned her right shoulder up
against a wall with her feet together
approximately 8-10 inches from the
wall. Then in the frontal plane, she
moved her hips toward the wall. This
exercise abolished her leg pain for
approximately 30 minutes. The refer-
ring physician was notified that the
patient had a positive "Sign of the
Buttock" but had responded well to
the initial treatment and that we
would like to continue physical ther-
apy on a trial basis. The patient was
treated in physical therapy for six
visits. Treatment consisted of the lat-
eral shift correcting exercise, prone
positioning on a table with hips
shifted to the right, postural instruc-
tion, and a home exercise program
consisting of the same exercises.
Outcome
The patient was only able to at-
tend two physical therapy sessions
per week for 3 weeks due to family
health issues. These health issues
made it difficult for her to comply
with her home exercise program. She
reported that when she attended
therapy her leg pain would abolish
for 30 minutes or more, but then the
pain would return. Her home exer-
cise program consisted of the same
exercises that were done in the clinic;
however, she reported that she did
not get the relief from her home ex-
ercises that she did in the clinic.
During the third week of therapy,
the referring physician was notified
that the patient's improvements
could not be maintained. The physi-
cian ordered a bone scan, which re-
vealed a chip fracture of the left ace-
tabulum that did not appear acute.
Physical therapy was stopped, but no
other medical intervention was un-
dertaken. Follow-up telephone calls
indicated that the patient's family
health issues continued to interfere
with medical intervention, and that
her symptoms were essentially the
same.
CASE FOUR
Previous History
A 54year-old white male pre-
sented with complaints of low back
pain that radiated from the right but-
tock to the right anterior and poste-
rior knee and left knee pain, but no
left thigh pain. His mechanism of
injury occurred while lifting a patient
at work, when he slipped but did not
fall. The patient complained that
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6. C A S E S T U D Y
. - -
walking increased his pain, while sit-
ting relieved his symptoms.
The patient was evaluated by an
orthopaedic physician and referred
to physical therapy with a diagnosis
of spinal stenosis at levels L34,L45,
and W 1 . The patient's past medical
history was significant for a 21-year
history of asthma that had required
corticosteroid treatment for the last
3-4 years.
First Physical Therapy Examination
and Treatment
Manual palpation and inspection
of the pelvis in standing revealed a
right posterior innominate rotation
that was corrected with manipulation.
Active lumbar flexion, extension, and
left side bending in standing were all
limited. The patient experienced in-
creased pain with extension, de-
creased pain with left side bending,
and no change in pain with right
side bending. Repeated extension in
standing increased the patient's low
back and right lower extremity pain.
Neuromuscular assessment was found
to be within normal limits.
Based on the above findings, the
physical therapist determined the
physical therapy diagnosis to be spi-
nal stenosis and a right posterior in-
nominate rotation. Treatment con-
sisted of manipulation to correct the
posterior rotation, pelvic traction,
pool therapy for deweighting and to
improve ambulation, and a home
exercise program using repeated
lumbar flexion (based on diagnosis
of spinal stenosis),but the patient
only gained short-term relief of symp
toms with these interventions.
Second PhysicalTherapy Examination
and Treatment
One and one-half years later, the
patient was referred to physical ther-
apy due to recurring symptoms. The
patient reported an increase in low
back and right lower extremity pain,
possibly related to his work require-
ments that included transferring pa-
tients. According to the patient, he
had been placed in a &week work
hardening program that aggravated
his symptoms. During the work hard-
ening program, the patient noticed
bilateral edema below the knees that
was worse on the right. The patient
stated that a treadmill test had been
performed to differentiate between
vascular and neurogenic claudication
by comparing results using a level vs.
an inclined grade. According to the
patient, the treadmill test results were
inconclusive and could not specify
the etiology of his pain.
The patient rated his low back
and right lower extremity pain as
eight out of 10 on a scale from zero
to 10 (zero equals no pain). The
physical examination revealed man-
ual muscle testing (8) strength
grades of 4/5 for bilateral extensor
hallicus longi, peroneus longus and
brevis, hamstrings, and quadriceps
femoris. Iliopsoas strength on the
right was 3/5 and 4/5 on the left
(8).
Active lumbar range of motion
was assessed via visual inspection in
standing. All movements were a p
proximately 75% of normal range,
except for extension which was 50%
of normal range. All movements in-
creased pain in the right thigh and
anterior lower leg.
Passive hip range of motion was
as follows: internal rotation left =
14". right = 5"; external rotation
left = 31°, right = 12"; abduction
left = 36", right = 18"; and exten-
sion left = 12",right = 5" [normal
extension = 10" (9)]. Left hip flex-
ion with the knee flexed was 100" on
the left and 88" on the right.
Because all passive movements of
the right hip were markedly limited,
it was felt that the patient presented
with a noncapsular pattern of restric-
tion of the right hip. The long-term
corticosteroid use plus the presence
of marked range of motion restric-
tions at the right hip were deciding
factors in the physical therapist/chi-
ropractor ordering radiographs of
the right hip. The radiology report
revealed pronounced degenerative
changes consistentwith osteonecrotic
bone collapse. It was deemed that
these changes were serious enough to
be the etiology of this patient's pain.
Outcome
The referring physician was im-
mediately contacted, and he subse-
quently referred the patient to an
orthopaedic surgeon. The surgeon
recommended a right total hip ar-
throplasty, but, as of the latest fol-
low-up telephone call, the patient
had refused such intervention.
CASE FIVE
Previous History
A 37-year-old white female was
referred to physical therapy with the
insidious onset of low back pain 2
years ago. She reported that the pain
had been worsening over the last sev-
eral months. The pain had started as
a "constant ache" in the lumbar re-
gion and had progressed into the left
lower extremity in the 6 months
prior to her physical therapy evalua-
tion.
The patient reported that her
pain was slightly better in the morn-
ing and worsened in severity as the
day progressed. In addition to lifting
and bending difficulties,she reported
weakness and numbness in her left
lower extremity during walking with
occasional "buckling" of the knee.
Nonsteroidal anti-inflammatorymedi-
cations had previously helped control
her pain, but their effectiveness
ceased in the months prior to her
physical therapy evaluation. One ex-
ception was, while awaiting further
medical consultation, she had been
instructed to take aspirin and found
that it provided a dramatic decrease
in her pain.
This patient's past medical his-
tory was unremarkable. She had pre-
viously received 6 weeks of chiroprac-
tic care approximately 1%years ago
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7. that included modalities and re-
peated spinal manipulations without
relief of symptoms. Lumbar radio-
graphs and magnetic resonance imag-
ing revealed a slight rotoscoliosis, but
otherwise were considered normal.
Pelvic magnetic resonance imaging
revealed mild arthritic changes in
both hips, with the left more involved
than the right. Additionally, in-
creased joint fluid was noted, but
there was no evidence of avascular
necrosis or focal bone abnormality.
A bone scan showed only "an 'S' type
scoliosis of the thoracolumbar spine
with no other focal lesions identi-
fied."
Physical Examination
The patient rated her pain as six
out of 10 on a scale of zero to 10
(zero equals no pain). Her pain was
located primarily in the lumbar re-
gion. The patient ambulated with
decreased stance time on the left
lower extremity. Manual muscle test-
ing (8) revealed strength grades of
4/5 for left hip flexion and 4/5 for
left hip abduction. Passive hip range
of motion assessed via goniometry
was within normal limits bilaterally,
except for the following: left hip ab-
duction = 36", left straight leg
raise = 70°, and supine left hip flex-
ion with the knee flexed = 90" sec-
ondary to complaints of pain.
The patient's active lumbar range
of motion in standing based on visual
inspection was as follows: flexion =
75%. extension = 60%. left side
bending = 75%, and right side bend-
ing = 80%. Pain with lumbar range
of motion was located in either the
left groin, right lumbar area, or cen-
tral lumbar area. The patient also
had a positive left femoral nerve
stretch test (3) in prone lying as indi-
cated by the complaint of left lumbar
pain when the left knee was flexed
greater than 130" with the hip ex-
tended.
Palpation was remarkable for in-
creased pain in the bilateral inguinal
regions. Lumbar spring testing was
positive for pain at L2-3 and L5S1.
The left gluteal region appeared
slightly atrophied upon visual inspec-
tion.
Assessment at this point indicated
a possible L 3 radiculopathy or left
hip pathology. The left hip was impli-
cated because of the pain pattern,
weakness, and pain with passive hip
flexion past 90". The physical thera-
pist/chiropractor decided that bilat-
eral hip radiographs should be taken
as none had been done to this point.
The radiology report suggested bilat-
eral hip dysplasia with greater in-
volvement of the left hip.
Outcome
The refemng physician was im-
mediately contacted, and he subse-
quently referred the patient to an
orthopaedic hip specialist, who ad-
vised that the patient undergo a left
hip hemiarthroplasty. The patient
elected to have the procedure done
and at 8 weeks follow-up reported
that her low back pain had subsided.
She rated her overall improvement at
80-90% at that time.
DISCUSSION
Cyriax's capsular pattern con-
cepts proved useful in each of the
previous case reports. We chose cases
with noncapsular patterns of limita-
tion that were dramatic in nature for
this series. Patients with capsular pat-
terns caused by arthritis, however, are
much more clinically common than
the cases we have presented here.
Patients with arthritic hip pain may
have pain referral patterns in the low
back and/or lower extremity and
may respond well to physical therapy
intervention.
We acknowledge that the con-
cepts of capsular and noncapsular
patterns are not without difficulty or
fault. The starting positions to mea-
sure passive range of motion are
poorly defined by Cyriax at some
joints, such as the hip, or defined in
ways dissimilar to those described by
other current references (9). This
may be problematic because two dif-
ferent starting positions for the same
movement could result in two differ-
ent range of motion measurements
and possibly a discrepancy in deter-
mining whether or not a capsular
pattern exists. For example, shoulder
external rotation measured in supine
at 0" of glenohumeral abduction may
be less than that measured at 90" of
glenohumeral abduction.
Furthermore, Cyriax did not ad-
dress whether the capsular pattern
concept applied tojoints that have
undergone surgery. Because scar tis-
sue is less flexible in most cases than
the tissue it replaces, this could alter
movement restrictions at ajoint or
make accurate comparison to the
contralateraljoint inconclusive.
Cyriax also acknowledged that the
anatomy of the capsule may not fully
explain a capsular pattern. One ex-
ample of this is when a capsular pat-
tern develops within a few hours of a
severe knee sprain (1).
Moreover, controversy exists re-
garding the exact definition of a c a p
sular pattern ofjoint restriction. For
example, Kaltenborn's description of
a hip capsular pattern included loss
of hip extension as second only to
internal rotation loss (7), whereas
Cyriax listed hip extension loss as
slight, after greater limitations of flex-
ion, abduction, and internal rotation.
Cyriax also stated that the pain
referral pattern of the hip was nor-
mally in the third and fourth lumbar
dermatomes because these were the
levels from which the hip developed
(1). Thus, pain can be referred from
the groin, down the anterior thigh
and into the anterior leg and ankle.
Occasionally, the upper inner but-
tock at the posterior superior iliac
spine region will also receive referred
pain from the hip (1). Although
Cyriax's description of the pain refer-
ral pattern of the hip has not been
validated, the presence of such a der-
matomal pain pattern should warrant
further investigation of the hip as the
potential source of pathology, espe-
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8. cially when accompanied by motion
loss at the hip.
The fifth case in this series serves
to illustrate that such a pain referral
pattern may exist. The patient in the
fifth case reported that her pain
started as a "constant ache" in the
lumbar spine region and then, al-
most 1% years later, it progressed
down the leg. The definitive diagno
sis was hip dysplasia which required a
hip hemiarthroplasty procedure.
Three of the cases (cases 1, 2,
and 3) included a positive "Sign of
the Buttock," potentially implicating
pathologies that are beyond the
scope of physical therapy practice.
The first two cases were both related
to a partial or complete fracture of
the femur. Cyriax did not, however,
list femoral fracture as one of the
potential causes of a "Sign of the But-
tock."
The third case could be argued
as a false positive "Sign of the But-
tock" because the patient had multi-
ple issues, including osteoporosis,
lumbar disc bulges, and questionable
compliance with her home exercises,
that may have interfered with her
therapy. The reason that we included
this case was that when a "Sign of the
Buttock" was found, follow-up radio
graphs revealed a chip fracture of
acetabulum that was consistent with,
but not included in, Cyriax's list of
possible causes.
Finally, cases4 and 5 illustrate the
importance of the presence of a non-
capsular pattern of restriction in the
absence of a positive "Sign of the But-
tock" because both of the cases proved
to be surgical candidates. Thus, the
presence of a noncapsular pattern
alone may be sufficient enough to war-
rant further investigation.
Despite the aforementioned diffi-
culties, our clinical experience indi-
cates that utilizing the presence/ab
sence of a capsular pattern and a
"Sign of the Buttock" to rule out hip
pathology may be effective; however,
further research is needed to support
these claims. Although studies by
Hayes et a1 (4) and Pellecchia et a1
(10) addressed Cyriax's concepts in
the knee and shoulder respectively,
no studies to date have examined
these concepts in the hip. The five
case reports have served as examples
of successful applications of these
screening principles to clinical situa-
tions. Hopefully, future research at-
tention will address the reliability,
validity, specificity,and sensitivity of
Cyriax's evaluation procedures.
CONCLUSION
The five case reports presented
in this series required the differential
diagnosis of the hip vs. lumbar spine
pathology. Cyriax's concepts of capsu-
lar vs. noncapsular patterns and the
"Sign of the Buttock" were screening
tools that may have saved unneces-
sary patient visits, guided us in our
decision to refer these patients for
further medical care, and ultimately
resulted in a new diagnosis for each
patient. These screening tools may be
performed quickly in the clinic and
could be included in all lumbar ex-
aminations; however, further research
is needed to establish the reliability,
validity, specificity,and sensitivity of
these tests. JOSPT
ACKNOWLEDGMENTS
Gratitude is expressed to Brian
Hagen, MS. PT, Vince Whalen, MS,
PT, OCS, Patricia Nowakowski, MS,
PT, and Nick Martin, PT, for their
valuable contribution to these case
reports.
C A S E S T U D Y
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