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Conditions of the hip

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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