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• GREEN
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• Intro:
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- Non-infectious idiopathic, inflammatory condition of the pubic symphysis & surrounding structures
- Results in groin / lower abdominal px - Multiple causes, likely related to overuse / trauma - Association w/ surgery: 1st described in pts who had undergone suprapubic surgery, remains a complication of invasive procedures around the pelvis - Can occur as an inflammatory process in athletes - Incidence of 0.5-0.8% in athletes, w/ higher incidence in distance runners & athletes in kicking sports - M>F (3:1) |
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• Aetiology (risk factors):
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- Fibular-acetabular impingement (FAI)
- Pregnancy / childbirth - High-level of athletic activity (athletic pubalgia) - Urological / gynaecological surgery - Trauma - Psoriatic arthritis - Ankylosing spondylitis |
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• Pathophysiology:
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- Stress injury affecting the peri-symphyseal pubic bones due to increased strain on the anterior pelvis
- Pubic symphysis, a non-synovial amphiarthrodial joint, has minimal motion normally due to a static ligamentous complex - Pubic symphysis is where rectus abdominis inserts & the adductor complex originates - Antagonistic actions of the rectus abdominis (elevates symphysis) & adductors (depressing the joint)create conditions osteitis pubis development through chronic tendinosis - Chronic muscle imbalance leads to abnormal forces on the pubic symphysis, causing instability, pubic bone stress reaction, & eventual hyaline cartilage degeneration - Alternative theory: osteitis results from increased compensatory motion across the joint due to limited motion elsewhere in the kinetic chain (FAI) |
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• Clinical presentation:
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- Waddling antalgic gait or crepitus
- Px localised over the symphysis & radiating outward - Anterior & medial groin px - Gradual onset - Adductor px / lower abdominal px that then localises to the pubic area - Aggravated during turning, walking, coughing, sneezing, lying on one side, & walking up or down stairs - Commonly tenderness around the pubic symphysis & pubic ramus, along w/ painful muscle spasms in the adductor region |
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• Physical examination:
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+ve palpation, Spring test of pubic symphysis, Adductor squeeze test
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• Diagnosis:
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- In early stages, plain radiographs may appear normal
- Chronic case: pubic symphysis demonstrates lytic changes, sclerosis, sub-chondral resorption, bony margin irregularities & widening - Dynamic instability of the pubic symphysis (>2mm of subluxation) can be observed on frog-leg view |
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• Complications:
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- Chronic px
- Infection - Non-union fusion - Recurrence - Scrotal / labial swelling |
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• Management:
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- Approx. 3 - 6 month recovery time (conservative care)
- RICE, NSAIDs, (steroid) injections - Surgery |
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• Ddx:
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- Athletic pubalgia
- FAI - Osteomyelitis - Adductor strain - Rectus abdominus strain - SIJ dysfunction - GU disease |
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• YELLOW
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• Intro:
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- Idiopathic & self-limiting disorder that causes temporary bone loss of the proximal femur
- Characterised by unexplained hip px - Associated w/ ↓ ROM, non-specific labs, & mostly uncertain radiographic findings |
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• Aetiology (risk factors):
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- Mainly affects the hip joint, but can also affect knee, ankle, & foot
- M>F (esp, 30-60 yrs) - Also more common in women in late stages of pregnancy (last 3 months) or who have recently given birth |
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• Pathophysiology:
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- Not clear understanding
- Blockage of small blood vessels that surround the hip - Hormonal changes - Abnormal stresses (external load & force) on the bone |
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• Clinical presentation:
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- Sudden onset of px, usually anterior thigh, groin, lateral hip, or buttocks
- Px that intensifies w/ weight bearing & may lessen w/ rest - No previous accident or injury to the hip that would trigger px - Slightly limited motion (gentle hip movement usually pxless) - Px that gradually increases over a period of weeks or months & may be disabling - Noticeable limp due to guarding |
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• Physical examination:
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- ↓ ROM (AROM feels worse)
- Severe px when wight bearing (min px w/ PROM) |
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• Diagnosis:
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X-ray:
- Early stage (first 6 weeks) of the disease may exhibit slight decrease in bone density (challenging to detect) - Several months later, may reveal significant loss of bone density, w/ femoral head nearly disappearing Nuclear medicine bone scan: - Can more clearly show changes in the bone DEXA: - Not useful in Dx of TOH |
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• Complications:
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- Fractures
- Joint collapse - Chronic px - 2° OA - Recurrence - Functional impairment |
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• Management:
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- NSAIDs
- Weight-bearing restriction - Strengthening & flexibility - Water exrcises - Mobs / drops - Proper nutrition (vitamin D & calcium) |
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• Ddx:
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- Osteoporosis
- AVN - RA - Stress fracture - Bone marrow oedema - Osteomyelitis - Hip lapral tear - Refered px from Lx disorders |
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• YELLOW
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Refer to GP if pt starts showing red flags / isn't improving
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• Intro:
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- Acute, non-specific, inflammatory process affecting joint synovium
- Common cause of hip pain in paediatric population - Benign, self-limiting process - Must differentiate TS from an acute infectious process - Most common in children 3- 10 yrs old - Incidence estimated to be 0.2%, w/ total lifetime risk of 3% - M>F (4:1) |
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• Aetiology (risk factors):
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- Preceding upper respiratory infection (URI)
- Preceding bacterial infection - Post-streptococcal toxic synovitis - Preceding trauma - Alternative theory: post-vaccine or drug-mediated hypersensitivity reactions & certain allergic predispositions |
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• Pathophysiology:
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- Pathological cascade involves non-specific inflammation targeting synovial joint lining, leading to hypertrophic changes
- Clinical Hx may reveal one or multiple risk factors |
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• Clinical presentation:
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- Acute unilateral limb disuse
- Non-specifc hip px, subtle limp, refusal to bear weight - Hx may show increased agitation or more frequent crying than baseline - Recent Hx of URI, pharyngitis, bronchitis, or otitis media (supports TS diagnosis) |
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• Physical examination:
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- Mildly ↓ ROM, especially ABduction & INternal rot.
- Pts may exhibit hip flexion, abduction, & external rotation position to alleviate intra-articular pressure - 1/3 of pts may have normal ROM - Provocative tests: +ve basic log roll or FABER test (px on ipsilateral anterior side indicates hip disorder, while px on the contralateral side around the sacroiliac joint suggests SIJ dysfunction) |
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• Diagnosis:
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Imaging:
- Radiographs: useful for excluding bony lesions unless onset of Ssx is within 3 days, no fever, child appears well, & has mildly restricted abduction w/o guarding against movement in other planes - Ultrasound: extremely accurate for detecting infra capsular effusion, doesn't help to determine the cause (used to guide hip aspiration) - MRI: useful in settings where routine aspiration is not performed to differentiate TS from septic arthritis Labs: - Complete blood cell (CBC) count - Erythrocyte sedimentation rate (ESR) - C-reactive protein measurement - Urinalysis & cultures |
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• Complications:
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-Recurrence of Ssx, in approx. 20-25% of pts (usually between 6 months)
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• Management:
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- Rest, NSAIDs, heat &/or massage
- In case of clinical concern, pt admission fro observation is considered - General improvement after 24-48 hours - Complete resolution may take 1-2 weeks (75% of pts) - If significant Ssx last for 7-10 days, consider alternative Ddx - If Ssx last longer than a month, pt may have alternative pathology |
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• Ddx:
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- Coxa magna
- Osteomyelitis - Septic arthritis - 1° or metastatic lesions - Legg-Calve-Perthes disease (LCPD) - Slipped capital femoral epiphysis (SCFE) - Others: Lyme arthritis, pyogenic sacroiliitis, & juvenile RA |
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• YELLOW
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• Intro:
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- Most common hip pathology in pre-adolescents & adolescents
- Also known as slipped upper femoral epiphysis (SUFE) |
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• Aetiology (risk factors):
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- Idiopathic w/ no Hx of trauma or injury before Ssx onset
- Associated w/ endocrine disorders such as hyper/hypothyroidism, , growth hormone deficiency, renal disorders, & Down syndrome - Hypothyroidism is most common cause of non-idiopathic SCFE - Pre-adolescent & adolescent pts (10.8/100,000) - Obesity is single most significant risk factor - M>F - Periods of rapid growth - Prior hip radiation therapy - retroversion of the acetabulum or femoral head - Average age of onset is F 11.2 & M 12.0 |
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• Pathophysiology:
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- Uncertain mechanism
- High physiological axial load on a weak physis - Obesity increase mechanical weight & force, while endocrine / renal disorders may weaken the physis - Slippage occurs at the hypertrophic zone of physis - Epiphysis stays in the acetabulum, & metaphysis EX rots w/ anterior translation - SCFE is a Salter-Harris type I fracture |
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• Clinical presentation:
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- Atraumatic Hx
- Hip, thigh, groin, knee px - Limping & inability to WB - 4-5 months Ssx prior to Dx - Sitting w/ affected leg crossed over the other relieves px |
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• Physical examination:
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- ↓ ROM (esp. IR, FLEX, ABD)
- Drehmann sign - Trendelenburg sign - Atrophy. of surrounding muscles |
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• Diagnosis:
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- Recent studies suggest US may be more sensitive that radiographs
- X-rays: Epiphysis widening or growth plate lucency & blurring of proximal femoral metaphysis due to overlap on the displaced epiphysis |
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• Complications:
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- AVN
- Chondrolysis - FAI - Slip progression |
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• Management:
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- Mainly operative
- NSAIDs (px management) - Strengthening |
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• Ddx:
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- Septic arthritis
- Osteomyelitis - Traumatic fracture - Sprain - Strain - LCPD - Osgood Schlatter disease |
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• GREEN
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• Intro:
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- Audible or palpable snapping sensation during hip joint movement
- Affects 5-10% of the population - F>M - Common when engaging in repetitive extreme hip motions, e.g. ballet dancers (in 80%), weight lifters, soccer players, & runners Extra-articular snapping hip: - Iliotibial band moving over the greater trochanter during hip flexion, extension, & rotation - Proximal hamstring tendon rolling over the ischial tuberosity - Fascia late or anterior aspect of gluteus Maximus rolling over the greater trochanter - Psoas tendon rolling over the medial fibres of the iliac muscle - Combination of defects, e.g. thickening of both the posterior iliotibial band & anterior glute max Intra-articular snapping hip: - Iliopsoas tendon snapping over iliopectinal eminence or anterior femoral head - Parabola cysts - Partial or complete bifurcation of the iliopsoas tendon - Differentiation from intra-articular pathology: close physical exams & imaging; approx. 50% of internal snapping hip cases also have an additional intra-articular hip pathology identified |
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• Aetiology (risk factors):
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- Often caused by overuse but can also be triggered by trauma, e.g. intramuscular injection or surgical procedures
- Coxa vera after total hip arthroplasty is linked to external snapping hip syndrome - Anatomical variations: increased distance between greater trochanters, prominent greater trochanters, & narrow bi-iliac width - Iliotibial band tightness, shorter muscle or tendon lengths, muscle tightness, or inadequate muscle relaxation |
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• Pathophysiology:
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External:
- Caused by iliotibial band snapping over the greater trochanter of the femoral head - During movements like flexion, extension, & external rotation Internal: - Caused by iliopsoas tendon snapping over bony prominences - Bone prominences include the iliopectinal eminence or the anterior aspect of the femoral head |
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• Clinical presentation:
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- Prevalence of snapping hip
- Location of the snap - Timing of the snap - Age/duration of onset - Px / disability - Impact on ADLs |
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• Physical examination:
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External:
- +ve Ober's test: tight iliotibial band - FABER test: iliotibial band snapping Internal: - FABER test: iliopsoas snapping - Stinchfield test: anterior groin px - Thomas test: tight hip flexors - Iliopsoas stress test: abdominal px |
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• Diagnosis:
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- Plain radiograph (not acurate), used to rule out anatomical variations, developmental dysplasia, or other hip pathology
External: - T1 weighted axial MRI: thickened ITB or thickened anterior edge of glute max - Dynamic ultrasonography (if not visible on exam): demonstrates snapping of ITB over the greater trochanter, & can also reveal associated tendonitis, iliopsoas bursitis, or muscle tears Internal: - Magnetic resonance orthography: comprehensively identifies both the SHS & accompanying pathologies - Iliopsoas bursography - Fluoroscopy - Dynamic ultrasonography |
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• Management:
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- RICE
- NSAIDs - Steroid injections - Activity modifications - Release: TFL, glute medius, glute max, & adductors - Activate: abductors - STW - SMT - Mobs / drops |
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• Ddx:
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- Acetabular labral tear
- Bursitis: greater trochanter / iliopsoas - Femoral head AVN - Hip tendonitis - Iliopsoas tendinitis - ITB syndrome - Intra-articular loose body of the hip - Synovitis |
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• GREEN
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• Intro:
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- Also known as Bernhardt Roth syndrome, lateral femoral cutaneous n. (LFCN) syndrome / neuralgia
- Associated with LFCN compression - Purely sensory nerve - Vulnerable to compression during its course from Lx-Sx plexus to inguinal ligament - Passes into subcutaneous tissue of anterior thigh, involving px & dysethesia |
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• Aetiology (risk factors):
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- Slightly more common F>M
- Common in military - Most common 40-50 yrs - Pregnant & obese pts have increased risk - 3-4 / 10,000 - Carpal tunnel syndrome associated w/ an ↑ risk of meralgia paraesthetica Spontaneous causes: - Diabetes mellitus - Lead poisoning - Alcohol abuse - Hypothyroidism Mechanical causes: - External direct pressure from tight seat belts, belts, or restrictive clothing - Increased intra-abdominal pressure from obesity, pregnancy, or tumours - Leg length discrepancy - Degenerative changes of pubic symphysis - Rare bone tumour near the iliac crest Iatrogenic causes: - Surgeries of surrounding areas |
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• Pathophysiology:
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- Derives from posterior divisions of L2/L3 spinal nerves
- Lateral psoas → under iliac fascia → crosses anterior iliacus m. → ASIS → anterior & posterior divisions pass under / through / above the inguinal ligament - Anterior: sensory to anterior thigh-knee - Posterior: sensory to lateral thigh-greater trochanter - External compression or internal pressure (obesity, pregnancy, tumours) - Surgical injury during the nerve's passage - Metabolic causes like diabetes (injury may result from swelling due to ↓ axoplasmic transport), alcohol or lead poisoning |
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• Clinical presentation:
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- Unilateral Ssx of upper lateral thigh
- Burning px, paraesthesia, hyperaesthesia - Subacute onset over days to weeks - Pts often point to or rub outer thigh (potential loss of hair from rubbing) - Ssx don't change w/ position - Aggravated by prolonged hip EX (waking, rising from seated position) - May be relieved by hip flexion (sitting) - Hx of tight clothing, trauma, weight-gain, pregnancy |
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• Physical examination:
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- Pelvic compression test (side-lying on unaffected side)
- Meralgia paraesthetica test - Sensory changes (pin-prick, light touch) |
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• Diagnosis:
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- Radiographs are not required
- May consider blood tests if metabolic etiology |
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• Complications:
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- Result from surgical transection of LFCM, leading to permanent anaesthesia (sensory loss)
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• Management:
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- Benign, self-limiting
- Often spontaneous remission - Pt reassurance & education - Reducing pressure & irritation (weight-loss) - Icing - SMT - NSAIDs - Abdominal exercises - Injection - Surgical decompression - Other: pulsed radiofrequency n, ablation, electroacupuncture, K-taping |
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• Ddx:
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- Lx radiculopathy
- Abdominal masses - Pelvic tumour - Metastasis of iliac crest - Avulsion fracture - Hip OA - Chronic appendicitis |
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• YELLOW
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• Intro:
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- Idiopathic osteonecrosis of capital femoral epiphysis of femoral head occurring in the paediatric population
- Also known as coxa plana |
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• Aetiology (risk factors):
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- Cause is unknown, possibly idiopathic or related to factors disrupting blood flow (key factor in development of LCPD) to femoral epiphysis
- Bilateral in 10%-20% cases (asymmetrical due to different stages) - Causes include: trauma (macro or repetitive micro), coagulopathy (in about 75% of pts), & steroid use - Thrombophilia is found in approx. 50% of pts - 3-12 yrs old (highest occurrence at 5-7 yo) - 1 in 1200 children <15 yo - M>F (5:1) Risk factors: Caucasian / Asian heritage, HIV, low socioeconomic status, birth weight <2.5kg, secondhand smoke exposure |
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• Pathophysiology:
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Usually 4 phases:
1. Necrosis: disruption of blood supply → infarction of femoral capital epiphysis (esp. subchondral cortical bone) → growth of ossific nucleus stops → infarcted bone softens & dies 2. Fragmentation: body reabsorbs the infarcted bone 3. Reossification: Osteoblastic activity → femoral epiphysis reestablished 4. Remodelling: new femoral head (enlarged & flattened) → reshaping occurs during growth → healing (if responding to conservative c.) takes 2-4 yrs |
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• Clinical presentation:
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- Limp of acute / insidious onset, often painless (1-3 months)
- Px (if present) localised to hip or referred to the knee, thigh, or abdomen - With progression, px typically worsens with activity - No systemic findings should be found |
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• Physical examination:
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- ↓ IR & ABD of hip
- Px on rot. referred to the anteromedial thigh &/or knee - Atrophy of thighs & buttock from px leading to disuse - Leg length discrepancy - Trendelenburg sign: weak abductors (glute med & min) - Antalgic gait (acute): short-stance phase 2° to px in the weight-bearing leg - Trendelenburg gait (chronic): downward pelvic tilt away from the affected hip during swing phase |
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• Diagnosis:
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- Labs are used to exclude other diagnoses
Imaging: - Early radiographs can be normal - Plain films are preferred - Standard A-P pelvis & frog-leg views - If in doubt or plain films are normal, DEXA scan or MRI Early findings: - Epiphyseal cartilage hypertrophy - Epiphysis appears smaller or denser - "Crescent sign" Late findings: - Mushroom head & snow cap - DEXA shows decreased perfusion of the femoral head - MRI shows marrow changes |
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• Complications:
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- Coxa magna (widening) & coxa plana (flattening)
- Damaged femoral head can result in premature physical arrest, causing leg length discrepancy - Poorly formed femoral can lead to acetabular dysplasia & hip incongruency - Hip incongruence can alter mechanics, causing labral tears - Complications like lateral hip subluxation or extrusion can result in lifelong problems - Late complication: arthritis |
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• Management:
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- Goals: px & Ssx management, restoration of ROM, & containment of femoral head in acetabulum
- Activity restriction & protective weight-bearing until ossification is complete - NSAIDs - STW - Surgery |
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• Ddx:
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- Infectious etiology including septic arthritis, osteomyelitis, pericapsular pyomyositis
- Transient synovitis - Multiple epiphyseal dysplasia (MED) - Spondyloepiphyseal dysplasia (SED) - Sickle cell disease - Gaucher disease - Hypothyroidism - Meyers dysplasia |
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• YELLOW
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• Intro:
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- Involves the cartilage ring (labrum) around the outside rim of the hip joint socket
- Labrum cushions the hip joint & acts as a rubber seal, securing the thighbone within the hip socket |
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• Aetiology (risk factors):
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- Most tears occur in anterosuperior quadrant
- Posterosuperior tears are more common in Asian population due to hyeprflexion or squatting motions - Occur between 8-72 yrs (highest incidence in 50 yrs) - F>M - 22-55% pts w/ hip/groin px have an ALT - Up to 74% of ALTs have no specific casue - Trauma & sports-related causes - Individuals attending gym 3x/week have an ↑ risk of developing ALT |
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• Pathophysiology:
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Five common mechanisms:
- Femoroacetabular impingement (FAI) - Trauma: mis-stepping, running w/ hyperextension, or EX rot - Capsular laxity: cartilage disorders (e.g. Ehlers-Danlos syndrome) or rotational laxity from excessive EX rot (ballet, hockey, gymnastics) - Hip dysplasia - Degenerative changes |
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• Clinical presentation:
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- Anterior hip / groin px
- ALT indicated by buttock px; while PLT are less common - Clicking, popping, giving way, catching, & stiffness - Dull ache often ↑ w/ activities (running, brisk walk, twisting, & climbing stairs) - Specific manoeuvres causing groin px: 1) FX, ADD, IR fro ALT 2) Passive hyper EXT, ABD, EXT rot for PLT - Functional limitations: prolonged sitting, walking, climbing stairs, running, & twisting/pivoting - Ssx can persist for long duration (average >2 yrs) - Traumatic onset associated w/ an audible pop or sensation of subluxation |
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• Physical examination:
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- FX knee gait & shortened step length on affected leg
- Anterior hip-impingement test (FAIR) or posterior impingement test - FABER test - Resisted SLR - Leg-roll test |
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• Diagnosis:
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- MR arthrogram preferred over MRI & plain radiograph
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• Complications:
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- Recurrence
Post-surgical: - DVT - Articular damage - Neuromuscular injury |
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• Management:
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- NSAIDs
- 10-12 week protocol - Reduce WB - Injection - Strengthening - SMT - Surgery |
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• Ddx:
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- Contusion (esp. over bony prominences)
- Strains - Athletic pubalgia - Osteitis pubis - Inflammatory arthritides (RA) - Piriformis syndrome - SHS - Bursitis(trochanteric, ischiogluteal, iliopsoas) - OA of femoral head - AVN - Septic arthritis - Fracture or dislocation - Tumours - Hernia (inguinal or femoral) - SCFE - LCPD - Referred px from Lx-Sx or SIJ regions |
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• YELLOW
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|
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• Intro:
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- Protrusion of intestines through a weak spot in the abdominal muscles
- Lump may disappear when pt lies down & can sometimes be manually pushed out - Coughing may cause the hernia to reappear, indicating the temporary nature |
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• Aetiology (risk factors):
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- Lifting heavy object w/o stabilising abdominal muscles
- Diarrhea or constipation - Family Hx (4x more likely) - Persistent coughing or sneezing - Obesity, poor nutrition, & smoking (weaken muscles) - Pregnancy (low risk) - Injury: most sports-related hernias occur in the groin & don't appear as a bulge (if untreated, can evolve into an inguinal hernia) - Common surgery - Peaks at 5 yo & >70 yo - M>F (9:1) |
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• Pathophysiology:
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- Congenital & acquired component
- Higher type III collagen compared to type I |
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• Clinical presentation:
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- Bulging in groin area
- Px / burning / pinching sensation in groin area - Can radiate into scrotum or down the leg - Can be aggravated by activity or coughing |
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• Physical examination:
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- Palpable bulge
- If no bulge, ask pt to cough while palpating inguinal area |
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• Diagnosis:
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- Usually used when body habits makes physical exam limited
- Ultrasound - CT scan - MRI |
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• Complications:
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- Hernia recurrence
- Chronic px |
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• Management:
|
- Monitor hernia
- Wearing a truss (supportive undergarment that holds it in place) - NSAIDs - Reduce pressure off the tissue (e.g. address breathing mechanics) - Strengthen supportive tissue (deep core) - Reduce aggravating activities - Surgery (very common) |
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• Ddx:
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- Lymphadenopathy
- Lymphoma - Metastatic neoplasm - Hydrocele - Epididymitis - Testicular torsion - Abscess - Hematoma - Femoral artery aneurysm |
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Sport hernia:
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- Weakness in the inguinal canal's posterior wall
- Nerve irritation & px occur at the tendon insertion to the bone - Expansion of the transversals fascia at its weakest point - Enlargement of the inguinal triangle results from the fascia expansion - Rectus abdominis moves upward & inward due to enlargement - Increased tension on the pubis is noted, potentially leading to tears - Bulging may compress the genital branch of the genitofemoral n. - Contribution to chronic px |
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• GREEN
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|
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• Intro:
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- Sciatica nerve entrapment at the ischial tuberosity, presenting w/ radicular px
- Piriformis m. is an EXT rot of the hip - Conditions that mimic it: Lx canal stenosis, disc inflammation, or pelvic causes |
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• Aetiology (risk factors):
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- Accounts for 0.3-6% of all cases of LBP &/or sciatica
- Annual incidence approx. 2.4 million cases - Middle aged pts - F>M (6:1) |
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• Pathophysiology:
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Function of piriformis:
- EXT rot during hip extension - Acts as a hip adductor during hip FX Issues & consequences: - Overuse, irritation, or inflammation of piriformis m. → leads to irritation of adjacent sciatica n. → sciatica n. entrapment may occur anterior to piriformis muscle or posterior to gemelli-obturator interns complex Causes of piriformis stress: - Chronic poor body posture -Acute injury resulting in sudden & strong IR of the hip |
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• Clinical presentation:
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- Chronic px in buttock & hip area
- Px when getting out of bed - Inability to sit for prolonged periods - Butt px worsened by hip movements - Ssx resembling sciatica - Difficulty differentiating radicular px due to 2° spinal stenosis vs piriformis s. - Radiating px into posterior thigh, occasionally lower leg at dermatomes L5 & S1 |
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• Physical examination:
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- Mild-moderate tenderness around sciatica notch
- FAIR test - Limited SLR - No neurological deficits - Sometimes limp when walking - Shortened & EXT rot leg when supine (splayfoot) |
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• Diagnosis:
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- US
- MRI - CT - EMG |
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• Complications:
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Related to surgery:
- Nerve injury (sciatica) - Infection - Bleeding |
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• Management:
|
- Diagnosis of exclusion
- NSAIDs - Muscle relaxants - Injections - Mobs - SMT - STW - Stretching - Surgery |
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• Ddx:
|
- Lx canal stenosis
- Disc inflammation - Hamstring injury - Lx-Sx facet syndrome - Lx radiculopathy - Spondylolisthesis / spondylosis - SIJ dysfunction - Inferior gluteal artery aneurysm - Tumour - Arteriovenous malformation |
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• GREEN
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|
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• Intro:
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- Hip px due to mechanical impingement from abnormal hip morphology
- Involves proximal femur &/or acetabulum - Soft tissue damage in the FA joint results from extreme hip rotation or repetitive abnormal contact between bony prominences - Degenerative changes & OA may develop in the long-term of this abnormal contact |
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• Aetiology (risk factors):
|
- Still under investigation
- Genetic factors may contribute to abnormal hip pathology - ↑ incidence in young athletes (males) due to cam deformity formation - Can occur in pts w/ a Hx of SCFE or LCPD -SCFE can cause a residual deformity even after surgical fixation, leading to an impingement - High prevalence in asymptomatic pts - Increased awareness → higher Dx rate throughout every. age |
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• Pathophysiology:
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- FAI syndrome is associated w/ 3 hip joint morphology variations: cam, pincer, & a combination
- Cam: flattening or convexity of femoral head-neck junction, common in young athletic men - Pincer: "overcoverage" of moral head by acetabulum, more common in women - Isolated cam or pincer morphology insufficient for FAI syndrome Dx - Combination: often associated w/ SCFE (85% of pts) - Cam & pincer morphologies can damage articular cartilage & labrum due to impingement, causing FAI Ssx Other factors contributing to FAI: - Weakness of deep hip muscles compromising stability, leading to increased joint loading - Repeated loading of labrum causing up regulation of nociceptive receptors |
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• Clinical presentation:
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- Gradual onset of hip px, worsened by hip FX & IR
- Activities like high-intensity sports, squatting, driving, & prolonged sitting aggravate - Acute hip px warrants workup for other potential causes Key inquiries: trauma, infection, SCFE, LCPD, hip dysplasia, osteonecrosis, sporting activities, & other hip pathologies - Groin & anterolateral hip px, radiating to thigh, often with a "C sign" gesture indicating px location Associated complaints: clicking, popping, & catching, suggesting a possible labral injury |
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• Physical examination:
|
- Trendelenburg air or abductor lurch suggests abductor muscle weakness or insufficiency
- ↓ ROM, especially FX & IR - FABER test: often +ve due to impingement-related labrum tear - +ve FAIR & posterior impingement test - +ve IROP test |
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• Diagnosis:
|
- X-ray initially
- CT or MR arthrogram for better appreciation of morphology of the hip / associated cartilage & labral lesions |
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• Complications:
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- Associated w/ surgery
Major: - Femoral neck fracture: risk increases w/ excess reaction of a cam lesion - Abdominal compartment syndrome:during hip arthroscopy - Other: PE, deep joint infection, AVN, postoperative complication Minor: - Hematoma - DVT - Numbness & discomfort of lateral thigh - Temporary perineal numbness - Dyspareunia - Superficial infection - Heterotopic ossification |
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• Management:
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- Adaptation of ADLs to a safe ROM
- Strengthening - SMT / hip distraction - Strengthening - NSAIDs - Steroid injections - Surgery |
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• Ddx:
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- Trochanteric bursitis
- Athletic pubalgia - Snapping hip syndrome - Flexor muscle strain - Hip subluxation - Soft tissue tumour - Femoral neck stres fracture - Septic arthritis - Osteomyelitis - Soft tissue infection - Osteonecrosis - Lx radiculopathy - Inguinal hernia - Hip OA |
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- Hypertonic iliopsoas
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- Starts w/ a muscular imbalance
- Most likely due to sedentary lifestyle - Creates new muscular strains, ligamentous & capsular sprains & fascial tension |
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- Psoas pulls femur into FX & EXT rot
- Hip joint I spilled anterior & superiorly - Considerable increase in intracapsular pressure of the hip joint - Directly related to degenerative changes in the hip - Limits pelvic sway |
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- Hip & groin px
- Possible referral into anterior-medial thigh - LBP |
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- Modified Thomas test
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- Passive stretching
- TrPs - SMT - STW - PIR - Muscle relaxers |
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• Intro:
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- Also known as: adhesive capsulitis & 'frozen hip'
- Non-specific & painful ROM limitations |
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• Aetiology (risk factors):
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- May appear as 1° condition, develops w/o underlying cause
- May occur as 2° entity, superimposed on underlying joint pathology - Commonly affects middle-aged females, suggesting potential hormonal or demographic influence - Unknown triggers: initiate inflammatory response leading to a frozen hip - Nocturnal or weight-bearing aggravation |
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• Pathophysiology:
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- Often begins w/ synovial membrane inflammation
- Over time, inflammatory process may lead to fibrosis of the joint Stages of frozen hip: 1 & 2 represent acute AC, where px is typically the 1° Ssx 3 & 4 represent chronic AC, characterised by ROM limitations as the 1° Ssx |
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• Clinical presentation:
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- Non-specific px
- Nocturnal px or px exacerbated by weight bearing may occur - Progression of Ssx |
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• Physical examination:
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- ↓ ROM
- Muscle weakness due to px & stiffness: flexors, extensors, abductors, & adductors - Potential instability or laxity of joints - Soft tissue palpation: potential tenderness, swelling, or warmth - Gait alterations or compensatory movements - Sensory & motor function in LL (nerve or vascular compromise) Special test: - Thomas test - Ober's test - FABER test - Provocative manoeuvres |
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• Diagnosis:
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- Challenging to Dx due to limited value in standard diagnostic tests & imaging techniques
- Differentiate from Arthrofibrosis: AC is distinct from arthrofibrosis (knee, elbow, shoulder), & the initial inflammatory phase in AC progresses to capsular fibrosis AC can lead to arthrofibrosis |
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• Management:
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- SMT
- Pressure dilation - NSAIDs - Exercise program - Steroid injections - Surgery |
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• YELLOW
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• Intro:
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- Also known as developmental dysplasia of the hip (DDH)
- Caused by abnormal hip development & can manifest in infancy or early childhood - Multifactorial cause, involving genetic, environmental, & mechanical factors |
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• Aetiology (risk factors):
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- F>M (4:1)
- Breech position in the last trimester (most significant risk) - Family Hx - swaddling in the adducted & extended position - Postmaturity (prematurity isn't associated w/ ↑ risk) - 69.5 / 1000, but most are self-limiting in approx. 6-8. weeks - Leaving 4.8 / 1000, which need further treatment |
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• Pathophysiology:
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- Under-coverage of femoral head due to disrupted contact can lead to abnormal development
- Swaddling in an extreme position hinders proper hip development - Acetabulum continues to grow up to age 5 - Prolonged maligned contact causes chronic changes like capsule hypertrophy, ligament teres hypertrophy, & thickened acetabular edge |
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• Clinical presentation:
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- Mild hip instability
- Limited ABD in infants - Asymmetric gait in toddlers - Hip px in adolescence - OA in adults |
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• Physical examination:
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- Trendelenburg gait (abductor insufficiency)
- Lx lordosis - Leg length discrepancies |
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• Diagnosis:
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- US
- X-ray |
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• Complications:
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Failure to identify & treat:
- Functional disability - Hip px - Accelerated OA |
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• Management:
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- Pavlik harness
- Adolescent / adult hip preservation surgery |
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• Ddx:
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- Proximal femoral focal deficiency
- Femoral neck fracture - Coxa vara - Residual effects of infective arthritis |
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