Differential Diagnosis of a painful hip.

1. Differential Diagnosis:Clinical Practice Guidelines Evidence-based diagnosis, prognosisand intervention.

2. Physical Therapy Central

3. Bridgit A. Finley www.ptcentral.org bfinley@ptcentral.org Facebook: Physical Therapy Central Choctaw Chickasha Newcastle Norman OKC Pauls Valley Stillwater

4. 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.

5. Course Schedule EBP Resources Anatomy Biomechanics Differential Diagnosis Lecture Lab Manual Therapy Therapeutic Exercises Outcome Measures

6. Philosophy of Care Comprehensive Exam Subjective Biomechanics Feet, knees, pelvis and lumbar spine Hands on MFR, Manual Techniques One on One Exercise Specific

7. 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

8. 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

9. www.clinicallyrelevant.com Iphone app Orthopedic Clinical Tests 250 Tests Purpose Video

10. 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

11. 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

12. 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

13. +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

14. Wikipedia Sensitivity and Specificity

15. So what ?

18. Hip Joint Walking – hip supports 240% to 355% times the body weight Running – 550% times the body weight. Good foot wear is important.

19. 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.

20. Cane Aided Gait Pushing into the cane – lifts the left side of the pelvis. Lecture notes Dave Thompson, PT

21. Anatomy

22. Hip Joint Hip 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.

23. Acetabulum Angled lateral, inferiorly and anteriorly Normal is 10-15 degrees anterversion Labrum deepens the joint Covered with hyaline cartilage

24. Femur Strongest & longest bone of the body 2/3 of head covered with cartilage Fovea capitis supplies blood Head Off-set

25. Ligaments & Hip Capsule

26. Hip Capsule From acetabular rim to the base of femoral neck Thicker anterior & superiorly Joint supported by ligaments & muscles Capsule changes with O-A

27. Labrum Labrum contains free nerve endings and sensory end organs Responsible for nociceptive and proprioceptive mechanism Provide negative intra-articular pressure Deepens the socket (21%)

28. Labrum Tear in labrum = destabilizes joint Premature arthritis Reduce contact stress by increased contact area

29. Synovial Membrane Contains highly vascularized synovium Can get pinched and inflammed Hip impingement from neck of femur hitting acetabulam.

30. Hip Capsule Ligaments are weakest posteriorly Ligaments are taut in hip extension -CCP Ligaments are relaxed in hip flexion (mobilize)

31. Muscles

33. Rectus Femoris Attaches to anterior hip capsule Injury can cause capsular adhesions Limit hip extension Hip Impingment – painful with stretch

34. Anterior Hip Capsule Rectus femoris and quads can attach to the anterior hip capsule Muscle blend with hip capsule Job is to tighten capsule with contraction

35. Gluteus Medius Gluteus Medius – main hip abductor Primary stabilizer of hip and pelvis Trendelenburg sign vsgait Muscle weakness around O-A joint

36. Gluteus Maximus TFL envelops the muscles of the thigh Counteracts the backward pull of the gluteus maximums of the ITB. Hip extensors are 3 times as strong as the flexors

37. Psoas Iliopsoas bursa – present in 98% of adults. Lies under the psoas tendon Overuse and impingement syndromes

38. SLR Exercises Must have excellent core strength This is a core exercise, not psoas

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

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

41. Biomechanics

42. Ball and Socket Joint Flexion to 130-140 Extension 10-15 Abduction 30-50 Adduction 25-30 ER 30-45 IR 20-35 Rolls anterior glides posterior Rolls posterior glides anterior Rolls laterally Rolls medially Spins anteriorly and laterally Spins posteriorly and medially

43. Mobilization Flexion Extension Adduction Internal Rotation Posterior / Inferior Glide Anterior Glide Lateral Glide Lateral Glide

44. 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

45. Inclination Angle CoxaVara <100 Usually congential Causes a short leg Positive trendelenburg sign Genuvalgum Compensatory lumbar pathology

46. Inclination Angle Noraml 125 Coxa Valga >125 Causes a long leg Positive trendelengurg sign Stress on ITB and bursa Genu vara Compensatory lumbar pathology

47. 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

48. 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

49. Cyriax Capsular pattern – specific and proportional loss of movement Most common cause of capsular pattern is arthritis

50. 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

51. Noncapsular Restrictions Fractures Osteomiylitis Labral tears Cancer Bursitis Capsular Irritation Synovitis Impingement

52. 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

53. 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

54. Biomechanical Forces Femoral Anteversion Pronation Tibial Internal Rotation Improper Hip Alignment Pelvis Lumbar – will lose ipsilateral rotation (left hip, left rotation)

55. Hip Dysplasia Displacement of femoral head in acetabulum Left hip is more often involved 80 % Females Breech birth First born

56. 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

57. Dysplastic Hip Head off-set is between femoral head and shaft Off-set is decreases Femoral neck is short and thick

58. X-Ray Demonstrate loss of joint space, osteophytes and sclerosis. Dysplasia tears are more common in individuals with acetabular dysplasia.

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

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

61. Evaluation of the Hip

62. Diagnosis Bony Osteoarthritis Capsule/ Ligaments Labral tear or Impingement Muscle / Tendon “itis” Muscle tear

63. 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

64. 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

65. 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

66. Differential Diagnosis From the history, form a working diagnosis Use cluster’s test to rule in and rule out

67. Osteoarthritis Most common cause of hip pain Usually >50 yo, but can occur at any age. Will have capsular pattern of restriction X-ray

68. 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)

69. Functional Limitations Walking Stair climibing Putting on shoes Shaving legs/foot care

70. 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

71. Risk Factors Age Developmental Disorders Dysplasa Previous hip injuries Trauma Labral Tears

72. 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

73. Differential Diagnoses Lumbar Referred Pain Stress Fracture Bursitis Labral Tear

74. 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

75. 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

76. Special Tests Trendelenburg Gait MMT FABER’s Test Scour Test Empty and painful end-feel Spasm with early stage O-A

77. 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

78. SI Joint Pain provocation test Thigh thrust Gaenslen’s video Sacral thrust

79. 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

80. Femoral Neck Stress Fracture Pain with extreme ROM Pain with WB Positive Hop Test – 70% accurate Positive FABER/scour Positive Fulcrum

81. 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

82. Greater Trochanteric Bursitis Pain Lateral thigh/gluteal area Pseudoradiculopathy Aggravating Lying on affected side Prolonged stand/walk Stair

83. 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.

84. GT Bursitis

85. Anatomy

86. 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

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

88. 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

89. 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

90. 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.

91. 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.

92. Examination

93. Differential Diagnosis One of the most common referral patterns to the hip and thigh is lumbar spine Hip pain can refer to knee and below Must clear the SI joint and Lumbar spine

94. Standing Exam Gait Lumbar AROM Posture Atrophy Weight bearing Leg Length Laxity Test Balance Step Ups Single Leg Stand Gluteus medius strength

95. Gait Hip extension 15-20 degrees Pelvic Rotation Side bending Observe as walk into clinic Pain with WB – think articular

96. Lumbar AROM Flexion Extension SB Does the movement reproduce “their” pain

97. Posture Atrophy & WB Leg Length Laxity

98. Step up Balance Trendelenburg’s Sign Gluteus Medius Tear

99. Sitting Examination Sit to stand Muscle Reflex Sensory ROM – hip ER/IR Quick cursory screen

100. Sit to Stand Loss of flexion, adduction and internal rotation Compensate by loading non-painful leg

101. Muscle Test Hip Flexion ER IR Hamstrings Quads Normal except for Flexion

102. Neurological Sensation Reflexes Should all be normal If not, evaluate lumbar spine Disc Nerve root compression Stenosis

103. ROM Loss of hip IR first sign of internal hip pathology: arthritis, effusion, labral pathology impingement

104. Fulcrum Test (+) if reproduce pain at femoral shaft Testing for stress fractures along femoral shaft

105. Supine Examination Hip ROM – active & passive Sign of the Buttock FABER Test Thomas test McCarthy (Labral) test Active SLR Scour test Trochanteric /PsoasBursitis SI – thigh thrust

106. Hip ROM Watch for compensation at the pelvis. AROM PROM Capsular pattern? End-feel? Pain?

107. ROM

108. 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

109. 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

110. FABER Screening test for hip and SI joint Passively flex, abd., and ER hip Overpressure Pain at groin Pain at SI

111. Thomas Test Positive test Thigh off the table Tight iliopsoas and rectus femoris muscle (knee flexion)

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

113. Log Roll Test Used to assess labral pathology Maximally IR & ER Eliciting a click or popping sensation Also assess capsular laxity

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

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

116. 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

117. Bursa Special Test Will pinch the trachanteric bursa with hip adduction and IR Will pinch the psoas bursa with hip flexion and ER

118. 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.

119. 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

120. MMT Test strength of Abductors Isolate glut medius Will be weak (inhibited) with arthritic joint

121. Hip Rotation PROM of left hip Loss of IR > loss of hip ER End-feel usually empty and painful for OA hip.

122. Hip Special Tests Martin et al JOSPT July 2006 Intra-articular Tests FABER Test Scour Test Resisted SLR Log Roll Test Distraction FAI

123. 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

124. Hip Arthroscopy

125. Complication Rates .05 and 5% Most often related to distraction, procedures > 1 hour Sciatic, femoral, peroneal or pudendalneuropraxia Avascularnecrosis Fracture

126. Candidates Mechanical symptoms – catching, locking, clicking Failed to respond to conservative therapy Extent of articular cartilage has the most direct relationship to surgical outcomes

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

128. Harris Hip Score Scores on 10 different variables Pain ROM Gait ADLs Score range from 0 “worst” to 100 “best”. Harris Hip Score

129. Non-musculoskeletal Causes Retrocecal Appendicitis Hernia Renal Ureteral Regis University

130. Treatment

131. Rehabilitation Protocol Individualized Modify per patient status Per Physician Age Health Status Control pain and swelling Surgical Procedure Change WB and precautions

132. Rehabilitation Goals Control edema/effusion Muscle Balance Joint Capsule & Motion Biomechanics Balance & Proprioception

133. Patient Goals Normal gait Stairs Squat Put on shoes and sox Shave legs/clip toenails

134. Exercise Therapy Flexibility ROM – improve function Strengthening Normalize gait will decrease impact loads Cardiovascular Endurance 60-80% for 15-30 minutes

135. Muscle Imbalances Tightness Psoas Adductors Quadratus Lumborum TFL Piriformis Release Weakness Glut Maximus Glut Medius Quads Hip ER Core Muslces Abs Errectorspinae

136. FACILITATED MUSCLES Iliopsoas Rectus Femoris TFL QL Hip Adductors Piriformis Hamstring Lumbar Erector Spinae

137. Treatment Modalities MFR/ Massage PROM- watch precautions Balance MET / Mobilization/Manual Stretching Cardiovascular Core Stabilization

138. Manual Therapy MFR ITB Piriformis Psoas Psoas release

139. Hip PROM Watch for compensation at the pelvis. Capsular pattern? End-feel? Pain?

140. MET – manual stretching Soft tissue and capsular tightness Have not moved hip though this motion in years

141. Gait Hip extension 15-20 degrees Pelvic Rotation Side bending

142. Muscle Energy Technique Hamstrings Psoas Lumbar Spine

143. Week 4-5 (-) Trendelenburg Sign Initiate Hip PRE Neutral alignment lumbar spine Full PROM

144. Treatment Myofascial Release Psoas Posterior Hip Capsule PROM/Jt. Mobilization Core Stabilization Proprioception Balance

145. Mobilization Leg traction – inferior glide Distraction – inferior or caudal glide. Mobilization with movement Belt MET to restore IR/ER or hip flexion

146. Joint Mobilization

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

148. Therapeutic Exercise Strengthen the glutes Do not strengthen the hip flexors

149. S.E.R.F. Strap Pulls the hip into ER JOSPT September 2008 Vol 38, N 9 50% self report decrease pain Decreases hip impingement

150. Questions & Answers

151. Conclusion