Lecture #15 - Bony and Articular Pathologies of the Hip

A bruise to the iliac crest (hip bone).

Muscles (like abdominal wall & gluteus medius) and the iliac crest itself can be affected.

Nerve compression causing pain in the outer thigh due to compression of the lateral femoral cutaneous nerve.

Pain may occur in the proximal distribution of the lateral femoral cutaneous nerve, which is the outer thigh.

A fracture has crepitus (a grating sound or feeling). A contusion does not.

An iliac crest contusion (hip pointer) primarily affects the muscles surrounding the iliac crest, like those in the abdominal wall and gluteus medius. It also involves the iliac crest itself.

The gluteus medius muscle is frequently affected in an iliac crest contusion due to its close proximity to the iliac crest.

Meralgia paraesthetica is a condition characterized by compression of the lateral femoral cutaneous nerve, causing pain, tingling, and numbness on the outer thigh.

Activities that increase pressure on the affected area can worsen pain from an iliac crest contusion. Examples include coughing, sneezing, and straining during bowel movements.

A key difference between an iliac crest contusion and a fracture is the presence of crepitus. If you hear or feel a grating sound or sensation, a fracture is more likely.

An iliac crest contusion, also known as a hip pointer, primarily affects the muscles surrounding the iliac crest and the bone itself. This causes pain in the area of the hip bone.

The muscles most commonly affected by a hip pointer are the abdominal wall muscles and the gluteus medius, due to their close proximity to the iliac crest.

Activities that increase pressure on the injured area, such as coughing, sneezing, and straining during bowel movements, can worsen the pain of an iliac crest contusion.

A bone fracture that occurs when a ligament or tendon tears away a piece of bone at its attachment point.

Avulsion fractures commonly occur at sites where tendons or ligaments attach to bones. Some common sites include the ASIS, AIIS, lesser trochanter, ischial tuberosity, greater tuberosity, pubis, and pubic tubercle.

Avulsion fractures are more common in children and adolescents because their bones are still growing and more susceptible to tearing away at attachment points.

Avulsion fractures occur when a sudden forceful contraction or pulling action tears a ligament or tendon away from the bone.

Avulsion fractures and tendon ruptures can have similar mechanisms of injury. In avulsion fractures, the bone tears away, while in tendon ruptures, the tendon tears completely.

Avulsion fracture pain is often sharp, constant, and worse at night. Swelling, discoloration, difficulty bearing weight, and decreased strength are also common signs.

Diagnosing avulsion fractures usually involves a physical exam, imaging tests (like X-rays), and ruling out other conditions.

Treatment for avulsion fractures typically involves rest, immobilization, and pain management. More severe cases might require surgery.

Apophysitis is an inflammation or irritation of the apophysis, which is a growth plate at the site of tendon or ligament attachment to a bone.

Apophysitis is common in growing children and adolescents, and it can cause pain and limit activity. It's important to recognize and manage it to prevent further damage.

Avulsion fractures are more frequent in children and adolescents because their bones are still growing and more susceptible to tearing away at attachment points.

Avulsion fractures happen when a sudden forceful contraction or pulling action tears a ligament or tendon away from the bone.

Apophysitis is common in active children and adolescents because repeated stress on growth plates can cause irritation and pain.

Treatment for avulsion fractures typically involves rest, immobilization, and pain management. More severe cases might require surgery.

Avulsion fractures can also occur in older adults, even though bones are less prone to break at their attachment points.

Avulsion fractures and muscle/tendon ruptures are treated similarly, often with rest, immobilization, and pain management.

An inflammatory condition affecting the growth plate where tendons or ligaments attach to a bone.

Common locations include the ASIS, AIIS, iliac crest, ischial tuberosity, greater trochanter, and pubis.

It's often linked to a rapid growth spurt, causing muscle tightness and tension at the attachment site.

Osgood-Schlatter's disease, affecting the tibial tuberosity (shin bone).

Exclusively skeletally immature athletes or individuals.

Dull, aching pain, swelling, possible deformity, limited range of motion due to pain, and point tenderness.

Individuals with very mild cases may not experience pain.

Apophysitis is gradual, while an avulsion fracture is due to a sudden injury.

Activity, especially repetitive strain on the affected area.

Apophysitis is most common at the ASIS, AIIS, iliac crest, ischial tuberosity, greater trochanter, and pubis.

It often occurs due to rapid growth spurts, causing muscle tightness and tension at the attachment site.

The most well-known type of apophysitis, affecting the tibial tuberosity (shin bone).

Dull, aching pain, swelling, possible deformity, limited range of motion due to pain, and point tenderness.

Individuals with very mild cases may not experience pain.

Apophysitis is gradual, while an avulsion fracture is due to a sudden injury.

Activity, especially repetitive strain on the affected area, can worsen symptoms.

The pain is often described as dull and aching, localized to the affected area but may spread due to inflammation.

Apophysitis predominantly affects skeletally immature athletes because their bones are growing rapidly and under high stress.

Inflammation at the pubic symphysis and surrounding muscle attachments, typically characterized by chronic pain.

Osteitis pubis can occur in females, particularly associated with childbirth due to the stress and changes in the pelvic region.

While adductor strain is an acute injury, osteitis pubis is chronic and involves inflammation at the pubic symphysis.

Unlike the acute sprain, osteitis pubis is a chronic inflammatory condition involving the pubic symphysis.

People with osteitis pubis often experience limited hip rotation, particularly with isometric adduction and trunk flexion.

A chronic inflammatory condition affecting the pubic symphysis (the joint connecting the two halves of the pelvis) and surrounding muscle attachments.

It affects skeletally mature individuals, often athletes involved in sports requiring repetitive kicking, pivoting, or forceful hip movements.

Pain and tenderness at the pubic bone, limited hip rotation, pain with certain movements (like hip adduction, trunk flexion, core work, and standing on one leg).

Adductor strain is a sudden, acute injury to the inner thigh muscles, while Osteitis Pubis is a chronic, gradual inflammation of the pubic joint.

A pubic symphysis sprain is a sudden, acute injury to the pubic joint, while Osteitis Pubis is a chronic inflammation of the pubic joint and surrounding tissues.

Pain and tenderness at the pubic bone, limited hip rotation, pain with hip adduction, trunk flexion, core work, and single-leg stance.

Stress fractures in the femoral neck are common in endurance athletes, especially females due to the female athlete triad and those with a lean body type.

Pain from a femoral neck stress fracture is a deep ache that worsens with increased activity and persists even after activity.

The pain is often worse at night because bone healing and remodeling are most active during rest (sleep).

Femoral neck stress fractures are difficult to diagnose because the bone is deep within muscle and tissue.

Range of motion (ROM) is limited and painful with a femoral neck stress fracture, especially at the end ranges of motion.

To diagnose a femoral neck stress fracture, consider three key factors: 1. Duration of the problem, 2. Training intensity, and 3. Presence of a persistent tendinopathy.

A positive active straight leg raise test can indicate a stress fracture because it stresses the bone and surrounding tissue.

A fulcrum is a pivot point, a fixed point around which something moves, like a seesaw.

Joint play refers to the movement of bones within a joint. Superior glide in the hip means the femur moves upwards within the acetabulum.

Pain from a femoral neck stress fracture is a deep ache that worsens with increased activity and persists even after activity.

The pain is often worse at night because bone healing and remodeling are most active during rest (sleep).

Femoral neck stress fractures are difficult to diagnose because the bone is deep within muscle and tissue.

To diagnose a femoral neck stress fracture, consider three key factors: 1. Duration of the problem, 2. Training intensity, and 3. Presence of a persistent tendinopathy.

A positive active straight leg raise test can indicate a stress fracture because it stresses the bone and surrounding tissue.

A fulcrum is a pivot point, a fixed point around which something moves, like a seesaw.

A tiny crack in the neck of the femur, often found in endurance athletes, especially women, with a lean build due to repetitive stress.

A deep, aching pain worsens with activity and lingers even after stopping exercise.

Pain is often worse at night because bone healing and remodeling are most active during rest, making stress fractures more sensitive.

Because the bone is deep within muscle and tissue, making it difficult to diagnose.

End ranges of motion are limited and painful due to the fracture's location near the hip joint.

1. How long has the athlete had the problem? 2. What is their training intensity? 3. Do they have a tendinopathy that isn't healing?

Indicates a potential stress fracture because it stresses the bone and surrounding tissues in the hip area.

A pivot point or fixed point around which something moves.

An abnormal or irregular shape of either the femoral head or the acetabulum (hip socket) that restricts normal hip movement.

There are three types of FAI: Cam (abnormal femoral head), Pincer (abnormal acetabulum), Mix (combination of both).

Mixed FAI, where both the femoral head and acetabulum have abnormalities, is the most complex and often causes more significant problems.

FAI can be both congenital (present at birth) and developmental (occurring over time due to factors like posture or activity).

Any individual with persistent groin pain should be evaluated for FAI, as early diagnosis can help prevent further complications.

Imaging studies like x-rays or MRIs are necessary to confirm the presence of FAI and determine the specific type.

FAI is characterized by insidious onset (gradual pain) that worsens with activity or prolonged sitting and a pinching sensation with hip movement.

The specific movements that cause pain with FAI are dependent on the location and type of bone overgrowth (cam or pincer).

FAI can present like other hip problems, such as stress fractures, tendinopathy, osteoarthritis, or labral tears.

Pelvic anterior rotation/tilting is a key predictor of early onset FAI, while a posterior pelvic tilt can lead to FAI, but with less of an early onset.

Mixed FAI, where both the femoral head and acetabulum are abnormal, is the most complex and often leads to more severe problems.

FAI can be both. Some people are born with it (congenital), while others develop it over time (developmental) due to factors like posture or activity.

Anyone with persistent groin pain should be evaluated for FAI, as early diagnosis can help prevent further complications.

Imaging studies like x-rays or MRIs are necessary to confirm the presence of FAI and determine the specific type.

FAI can cause gradual onset pain (insidious onset) worsened by activity or prolonged sitting, and a pinching sensation during hip movement.

FAI can resemble other problems like stress fractures, tendinopathy (tendon problems), osteoarthritis, or labral tears.

Pelvic anterior rotation/tilting is a significant predictor of early-onset FAI, while a posterior pelvic tilt can also lead to FAI but with a less pronounced early onset.

Yes, it's possible for someone to have FAI without experiencing any symptoms. However, even asymptomatic FAI can have an impact on other parts of the body, such as the knees, SI joint, and lower back.

Pelvic anterior rotation/tilting is a key predictor of early onset FAI, while a posterior pelvic tilt can also lead to FAI, but with a less pronounced early onset.

OA is a degenerative joint disease causing cartilage loss in the hip joint, leading to pain, stiffness, and decreased range of motion.

Risk factors for OA include: older age, female sex, excess weight, high or low activity levels, and family history.

Anteversion, Retroversion, Coxa vara, and Coxa valga, abnormalities in hip bone alignment, can put extra stress on the joint.

Decreased hip internal rotation (IR) is a primary symptom.

FAI occurs when the hip joint's bones (femoral head or acetabulum) have an abnormal shape, causing a pinching sensation during movement due to bone rubbing against bone.

Crepitus (grating sound), clicking, and grinding noises during hip movement are common.

OA is a widespread degeneration of the whole hip joint, while FAI involves a localized bone contact issue.

All these conditions involve bone-on-bone contact leading to increased bone growth, narrowing joint space, and decreased ROM, strength.

Yes, OA tends to develop earlier in the hip joint compared to other joints.

Imaging studies like X-rays or MRIs are often needed to determine the precise cause of hip pain.

A condition where cartilage in the hip joint wears down, causing pain, stiffness, and decreased range of motion.

The main risk factors are: age, sex (females), weight (excess), activity level (too much or too little), and family history.

Decreased internal rotation (IR) of the hip, often accompanied by decreased flexion.

Common sensations include crepitus (grating), clicking, and grinding during movement.

OA is a more widespread joint condition, while FAI is a localized issue, often due to a 'bump' of bone.

The body tries to repair the damage by laying down more bone, but this worsens the problem in the long run.

OA occurs earliest in the hip joint.

FAI causes sudden, sharp bone-on-bone feeling limiting movement, while OA restriction is more gradual.

Imaging studies like X-rays or MRIs are needed to confirm the presence of OA or FAI.

Four hip conditions that increase the risk of developing osteoarthritis: anteversion, retroversion, coxa vara, and coxa valga.

Femoral Acetabular Impingement (FAI) can also present with decreased hip internal rotation, but to a lesser extent than osteoarthritis.

Osteoarthritis pain is most aggravating early in the morning and at night because the joint hasn't moved much, making it stiff.

Three abnormal sensations commonly experienced with FAI: crepitus (grating), clicking, and grinding.

Osteoarthritis is associated with stiffness and weakness in the hip joint.

Imaging studies, like X-rays, are ultimately necessary to distinguish between osteoarthritis (OA) and femoral acetabular impingement (FAI).

All accessory movements of the hip are reduced in individuals with osteoarthritis (OA).

A tear in the labrum, a ring of cartilage that helps to stabilize the hip joint.

1. Clicking
2. Catching
3. Popping
4. Instability

The movements restricted depend on the location of the labral tear.

Moving from FLEX to EXT (flexion to extension) of the hip.

The end-feel of a labral tear is cartilaginous (soft), while the end-feel of osteoarthritis is bone-to-bone (hard).

1. Structural pathologies
2. Degeneration
3. Postural/ mechanical dysfunction

An abnormal or irregular shape of either the femoral head or the acetabulum (hip socket) that restricts normal hip movement.

1. Cam (abnormal femoral head)
2. Pincer (abnormal acetabulum)
3. Mixed (combination of both)

Mixed FAI, where both the femoral head and acetabulum have abnormalities, is the most complex and often causes more significant problems.

Insidious onset (gradual pain) that worsens with activity or prolonged sitting and a pinching sensation with hip movement.

A labral tear in the hip is similar to a labral tear in the shoulder, both involving the rim of cartilage in a joint.

Hip dislocations and subluxations are rare compared to shoulder dislocations, due to the hip's greater stability.

Labral tears in the hip are more likely to be caused by an acute injury, a sudden event.

A labral tear in the hip usually causes pain with a clicking, catching, popping, and a feeling of instability.

Active and Passive Range of Motion (AROM, PROM) will be decreased with a labral tear, but it's not a reliable way to diagnose.

A labral tear will have a cartilaginous or soft end feel during joint tests, unlike bone-to-bone in other conditions.

The anterior part of the labrum, the front edge of the cartilage, is most often injured in a labral tear.

A feeling of instability happens when something in the joint (like a torn labrum) disrupts the smooth movement of bones, causing receptors to overreact.

Hip pain can come from various conditions: osteoarthritis, femoroacetabular impingement (FAI), or a labral tear.

Certain structural conditions can increase the risk of a labral tear, including anterversion, retroversion, coxa vara, and coxa valga.

Labral tears are more likely to result from an acute injury, rather than a chronic condition.

Hip dislocations frequently involve a labral tear due to the forceful nature of the injury, disrupting the surrounding structures.

Hip labral tears often manifest with clicking, catching, popping, and a feeling of instability.

Labral tears can restrict range of motion in the hip, particularly when moving from flexion to extension.

Movement limitations alone are not a definitive diagnosis for a labral tear.

During physical examination tests, a cartilaginous end feel suggests a labral tear, while bone-to-bone end feel indicates conditions like osteoarthritis or FAI.

Internal joint pathologies, including osteoarthritis, FAI, and labral tears, can cause a feeling of instability.

The anterior labrum is the most commonly injured portion in hip labral tears.

Most hip sprains occur when the trunk rotates while the leg is fixed, leading to a forced overstretch of the hip joint.

Activities that involve running and cutting movements, such as in sports, are often difficult with a hip sprain.

Hip extension and rotation are usually painful with a hip sprain, indicating the ligaments involved.

Hip sprains usually involve deeper structures, making it harder to see swelling.

Doctors may test joint play to assess the degree of ligament injury and stability.

The most common mechanisms of injury for hip sprains are forced overstretching of the hip joint and trunk rotation of a fixed limb.

Running and cutting movements are typically most aggravated by a hip sprain due to the stress placed on the hip joint.

Hip extension and rotation are the movements most commonly affected by hip sprains, leading to increased pain during these motions.

Hip sprains typically involve deeper structures, making them more difficult to see and assess visually.