Osteitis Pubis
• GREEN |
• Intro: |
- 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) |
• Aetiology (risk factors): |
- Fibular-acetabular impingement (FAI)
- Pregnancy / childbirth
- High-level of athletic activity (athletic pubalgia)
- Urological / gynaecological surgery
- Trauma
- Psoriatic arthritis
- Ankylosing spondylitis |
• Pathophysiology: |
- 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) |
• Clinical presentation: |
- 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 |
• Physical examination: |
+ve palpation, Spring test of pubic symphysis, Adductor squeeze test |
• Diagnosis: |
- 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 |
• Complications: |
- Chronic px
- Infection
- Non-union fusion
- Recurrence
- Scrotal / labial swelling |
• Management: |
- Approx. 3 - 6 month recovery time (conservative care)
- RICE, NSAIDs, (steroid) injections
- Surgery |
• Ddx: |
- Athletic pubalgia
- FAI
- Osteomyelitis
- Adductor strain
- Rectus abdominus strain
- SIJ dysfunction
- GU disease |
Transient Osteoporosis of the Hip (TOH)
• YELLOW |
• Intro: |
- 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 |
• Aetiology (risk factors): |
- 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 |
• Pathophysiology: |
- Not clear understanding
- Blockage of small blood vessels that surround the hip
- Hormonal changes
- Abnormal stresses (external load & force) on the bone |
• Clinical presentation: |
- 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 |
• Physical examination: |
- ↓ ROM (AROM feels worse)
- Severe px when wight bearing (min px w/ PROM) |
• Diagnosis: |
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 |
• Complications: |
- Fractures
- Joint collapse
- Chronic px
- 2° OA
- Recurrence
- Functional impairment |
• Management: |
- NSAIDs
- Weight-bearing restriction
- Strengthening & flexibility
- Water exrcises
- Mobs / drops
- Proper nutrition (vitamin D & calcium) |
• Ddx: |
- Osteoporosis
- AVN
- RA
- Stress fracture
- Bone marrow oedema
- Osteomyelitis
- Hip lapral tear
- Refered px from Lx disorders |
Transient Synovitis (TS)
• YELLOW |
Refer to GP if pt starts showing red flags / isn't improving |
• Intro: |
- 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) |
• Aetiology (risk factors): |
- 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 |
• Pathophysiology: |
- Pathological cascade involves non-specific inflammation targeting synovial joint lining, leading to hypertrophic changes
- Clinical Hx may reveal one or multiple risk factors |
• Clinical presentation: |
- 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) |
• Physical examination: |
- 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) |
• Diagnosis: |
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 |
• Complications: |
-Recurrence of Ssx, in approx. 20-25% of pts (usually between 6 months) |
• Management: |
- 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 |
• Ddx: |
- 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 |
Slipped Upper Femoral Epiphysis (SUFE)
• YELLOW |
• Intro: |
- Most common hip pathology in pre-adolescents & adolescents
- Also known as slipped upper femoral epiphysis (SUFE) |
• Aetiology (risk factors): |
- 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 |
• Pathophysiology: |
- 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 |
• Clinical presentation: |
- 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 |
• Physical examination: |
- ↓ ROM (esp. IR, FLEX, ABD)
- Drehmann sign
- Trendelenburg sign
- Atrophy. of surrounding muscles |
• Diagnosis: |
- 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 |
• Complications: |
- AVN
- Chondrolysis
- FAI
- Slip progression |
• Management: |
- Mainly operative
- NSAIDs (px management)
- Strengthening |
• Ddx: |
- Septic arthritis
- Osteomyelitis
- Traumatic fracture
- Sprain
- Strain
- LCPD
- Osgood Schlatter disease |
Snapping Hip / Coxa Saltans
• GREEN |
• Intro: |
- 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 |
• Aetiology (risk factors): |
- 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 |
• Pathophysiology: |
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 |
• Clinical presentation: |
- Prevalence of snapping hip
- Location of the snap
- Timing of the snap
- Age/duration of onset
- Px / disability
- Impact on ADLs |
• Physical examination: |
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 |
• Diagnosis: |
- 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 |
• Management: |
- RICE
- NSAIDs
- Steroid injections
- Activity modifications
- Release: TFL, glute medius, glute max, & adductors
- Activate: abductors
- STW
- SMT
- Mobs / drops |
• Ddx: |
- Acetabular labral tear
- Bursitis: greater trochanter / iliopsoas
- Femoral head AVN
- Hip tendonitis
- Iliopsoas tendinitis
- ITB syndrome
- Intra-articular loose body of the hip
- Synovitis |
Meralgia Paraesthetica
• GREEN |
• Intro: |
- 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 |
• Aetiology (risk factors): |
- 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 |
• Pathophysiology: |
- 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 |
• Clinical presentation: |
- 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 |
• Physical examination: |
- Pelvic compression test (side-lying on unaffected side)
- Meralgia paraesthetica test
- Sensory changes (pin-prick, light touch) |
• Diagnosis: |
- Radiographs are not required
- May consider blood tests if metabolic etiology |
• Complications: |
- Result from surgical transection of LFCM, leading to permanent anaesthesia (sensory loss) |
• Management: |
- 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 |
• Ddx: |
- Lx radiculopathy
- Abdominal masses
- Pelvic tumour
- Metastasis of iliac crest
- Avulsion fracture
- Hip OA
- Chronic appendicitis |
Legg-Calve-Perthes Disease (LCPD)
• YELLOW |
• Intro: |
- Idiopathic osteonecrosis of capital femoral epiphysis of femoral head occurring in the paediatric population
- Also known as coxa plana |
• Aetiology (risk factors): |
- 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 |
• Pathophysiology: |
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 |
• Clinical presentation: |
- 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 |
• Physical examination: |
- ↓ 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 |
• Diagnosis: |
- 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 |
• Complications: |
- 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 |
• Management: |
- 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 |
• Ddx: |
- 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 |
Acetabular Labral Tear (A/PLT) / Loose Body
• YELLOW |
• Intro: |
- 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 |
• Aetiology (risk factors): |
- 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 |
• Pathophysiology: |
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 |
• Clinical presentation: |
- 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 |
• Physical examination: |
- 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 |
• Diagnosis: |
- MR arthrogram preferred over MRI & plain radiograph |
• Complications: |
- Recurrence
Post-surgical:
- DVT
- Articular damage
- Neuromuscular injury |
• Management: |
- NSAIDs
- 10-12 week protocol
- Reduce WB
- Injection
- Strengthening
- SMT
- Surgery |
• Ddx: |
- 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 |
Hernias (sports & inguinal)
• YELLOW |
• Intro: |
- 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 |
• Aetiology (risk factors): |
- 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) |
• Pathophysiology: |
- Congenital & acquired component
- Higher type III collagen compared to type I |
• Clinical presentation: |
- 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 |
• Physical examination: |
- Palpable bulge
- If no bulge, ask pt to cough while palpating inguinal area |
• Diagnosis: |
- Usually used when body habits makes physical exam limited
- Ultrasound
- CT scan
- MRI |
• Complications: |
- Hernia recurrence
- Chronic px |
• 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) |
• Ddx: |
- Lymphadenopathy
- Lymphoma
- Metastatic neoplasm
- Hydrocele
- Epididymitis
- Testicular torsion
- Abscess
- Hematoma
- Femoral artery aneurysm |
Sport hernia: |
- 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 |
Piriformis Syndrome
• GREEN |
• Intro: |
- 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 |
• Aetiology (risk factors): |
- 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) |
• Pathophysiology: |
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 |
• Clinical presentation: |
- 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 |
• Physical examination: |
- Mild-moderate tenderness around sciatica notch
- FAIR test
- Limited SLR
- No neurological deficits
- Sometimes limp when walking
- Shortened & EXT rot leg when supine (splayfoot) |
• Diagnosis: |
- US
- MRI
- CT
- EMG |
• Complications: |
Related to surgery:
- Nerve injury (sciatica)
- Infection
- Bleeding |
• Management: |
- Diagnosis of exclusion
- NSAIDs
- Muscle relaxants
- Injections
- Mobs
- SMT
- STW
- Stretching
- Surgery |
• 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 |
Femoroacetabular Impingement (FAI)
• GREEN |
• Intro: |
- 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 |
• 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 |
• Pathophysiology: |
- 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 |
• Clinical presentation: |
- 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 |
• 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 |
• Diagnosis: |
- X-ray initially
- CT or MR arthrogram for better appreciation of morphology of the hip / associated cartilage & labral lesions |
• Complications: |
- 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 |
• Management: |
- Adaptation of ADLs to a safe ROM
- Strengthening
- SMT / hip distraction
- Strengthening
- NSAIDs
- Steroid injections
- Surgery |
• Ddx: |
- 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 |
Disordered Hip Complex
- Hypertonic iliopsoas |
- Starts w/ a muscular imbalance
- Most likely due to sedentary lifestyle
- Creates new muscular strains, ligamentous & capsular sprains & fascial tension |
- 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 |
- Hip & groin px
- Possible referral into anterior-medial thigh
- LBP |
- Modified Thomas test |
- Passive stretching
- TrPs
- SMT
- STW
- PIR
- Muscle relaxers |
Capsulitis of the Hip
• Intro: |
- Also known as: adhesive capsulitis & 'frozen hip'
- Non-specific & painful ROM limitations |
• Aetiology (risk factors): |
- 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 |
• Pathophysiology: |
- 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 |
• Clinical presentation: |
- Non-specific px
- Nocturnal px or px exacerbated by weight bearing may occur
- Progression of Ssx |
• Physical examination: |
- ↓ 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 |
• Diagnosis: |
- 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 |
• Management: |
- SMT
- Pressure dilation
- NSAIDs
- Exercise program
- Steroid injections
- Surgery |
Congenital Dislocation of the Hip (CDH)
• YELLOW |
• Intro: |
- 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 |
• Aetiology (risk factors): |
- 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 |
• Pathophysiology: |
- 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 |
• Clinical presentation: |
- Mild hip instability
- Limited ABD in infants
- Asymmetric gait in toddlers
- Hip px in adolescence
- OA in adults |
• Physical examination: |
- Trendelenburg gait (abductor insufficiency)
- Lx lordosis
- Leg length discrepancies |
• Diagnosis: |
- US
- X-ray |
• Complications: |
Failure to identify & treat:
- Functional disability
- Hip px
- Accelerated OA |
• Management: |
- Pavlik harness
- Adolescent / adult hip preservation surgery |
• Ddx: |
- Proximal femoral focal deficiency
- Femoral neck fracture
- Coxa vara
- Residual effects of infective arthritis |
|
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