Hip, Pelvis, and Knee Conditions PDF

Hip FME2 teoría Pelvis MSP2 theory  Ankylosing spondylitis Coccygodynia PELVIS Meralgia paraesthetica Pubalgia C/O-medical records Ankylosing spondylitis Ankylosing spondylitis "Bamboo-shaped spine". Chronic form of arthritis (spondyloarthr...

Hip FME2 teoría Pelvis MSP2 theory  Ankylosing spondylitis Coccygodynia PELVIS Meralgia paraesthetica Pubalgia C/O-medical records Ankylosing spondylitis Ankylosing spondylitis "Bamboo-shaped spine". Chronic form of arthritis (spondyloarthropathy family). 80% of patients have axial symptoms. Bone involvement of the lumbar spine, mainly in the lumbopelvic spine. Infflamation=> Vertebral fusion=> Stooped posture. Different inflammatory lesions: Bone, disc, synovial joints and/or entheses. Vertebral lesions=> syndesmophytes and ankylosis.  Spondyloarthropathies classification Seronegative arthritis or peripheral spondyloarthritis: associated with Crohn's disease or ulcerative colitis: Peripheral, symmetrical and bilateral involvement of knees, ankles, elbows and wrists. Bone progression parallel to intestinal progression. Enteropathic arthritis or spondyloarthritis: Progression independent of disease or primary intestinal treatment. HLA-B27 predilection, but less than AS. Differentiated spondyloarthritis: There is peripheral arthritis, sacroiliitis and enthesitis with inflammatory low back pain, but no clear diagnostic classification can be made, or imaging tests do not help Dx. Reactive arthritis: Polyarticular, asymmetric, affects feet and peripheral joints. Most frequent symptom: pain in the hindfoot. AS incidence Most often areas affected are: Lumbopelvic joint. Lumbar region vertebrae. Areas where tendons and ligaments attach to bones, mainly at the spine. Cartilage between sternum and ribs. Hip and shoulder joints. AS: "SQUARING" Lateral projections of spinal X-rays of the same patient. A: Square shape of vertebral bodies of lumbar spine, with loss of anterior concavity (arrows). B and C: Same phenomenon, determined by syndesmophytes. Ankylosing spondylitis Unknown origin: Majority with HLA-B27 gene (prevalence 5-15%). It affects 1 of 100 people: In Spain it affects 0.26% of the population over 20 years of age (more than 100,000 Spaniards suffer from it). In Latin America the prevalence is close to 10/10,000 inhabitants. Psychological affectation: Anxiety, depression, sleep disturbances... Associated with fibromyalgia. AS: Involved factors Men, 20-40 years old. Family background. Presence of HLA-B27. Pain and stiffness at the lumbar region and hips, particularly in the morning and after periods of inactivity. Neck pain and tiredness. Over time, symptoms may worsen, improve or stop at irregular intervals. It takes 2 to 5 years for the physical alterations to appear after the first symptoms have appeared. Body map Ankylosing Spondylitis Low back and/or hip pain and stiffness. Eventually, symptoms developed at other parts of the spine. Trigger Points AS map  Low back pain at night Ankylosing Sleeping difficulties Need to get out of bed spondylitis: Improvement of pain with movement 24-hour Severe morning stiffness Pain in both heels, knees, ankles or shoulders behaviour Abdominal pain or frequent diarrhoea Pain in one eye, redness or loss of visual acuity AS: Current and past history Subacute lumbar pain begining, extending to the buttocks. Good response to NSAIDs. Fatigue Intestinal problems: Diarrhoea, intestinal inflammatory disease (Crohn's and Ulcerative Colitis). Uveitis: Inflammation of the eye and loss of vision Psoriasis AS: Special questions Rule out fracture Duration of symptoms over 3 months Cardiac problems Respiratory problems Do not confuse with low back pain! Coccygodynia Coccygodynia Coccygodynia is defined as pain in or around the coccyx that can be pointed with the finger, with undefined irradiation. Higher incidence in women (5:1). Not described prevalence: less than 1% of non- traumatic consultations for spinal complaints.  Coccygodynia: Involved factors Traumatic origin. Localised trauma in the area. Sitting for extended periods on a hard or narrow surface. Other: arthritis and childbirth. OBESITY => risk factor Coccigodinia: Body map TP pelvic floor  Coccygodynia: 24-hour behaviour Pain when sitting, wich increases when leaning backwards. Pain when defecating or having sexual intercourse. Pain improves when using specific cushion. Coccygodynia: Current and past history To reduce symptoms: - Leaning forward when sitting. - Pressure-reducing cushion (also wedge-shaped). - Apply heat or ice. - Medication. If rest: disappears in a few weeks. Avoid prolonged sitting.  Discard direct or indirect trauma to the area. Problems urinating or defecating. Coccygodynia: Sexual problems. Special questions Continue using a cushion to avoid relapses. Upright sitting to avoid relapses. Meralgia paresthetica  Meralgia paresthetica Mononeuropathy of the femorocutaneous nerve (purely sensory nerve!) secondary to injury or entrapment at some point along its course, most commonly at the inguinal level. Higher incidence in population (without gender predominance) between 30 and 40 years old. Incidence rate of 4.3 per 10,000 inhabitants. Areas of mechanical conflict: Inguinal ligament Psoas, sartorius and fascia lata Obesity Meralgia paresthetica: Factors Involved Idiopathic: - Mechanical: Situations that increase abdominal pressure and situations that compress the nerve. - Metabolic: Type 2 diabetes and alcoholism. Iatrogenic: hip, lumbar spine, abdominal or obstetric and gynaecological surgery... DIFFERENTIAL DIAGNOSIS!  Body map: meralgia paresthetica Patients typically describe burning, coldness, lightning pain, deep muscle achiness, tingling, frank anesthesia, or local hair loss in the anterolateral thigh.  Hypersensitivity at the lateral and upper thigh. Tingling from groin to knee, without loss of strength. Meralgia Pain when compression in the anterior superior iliac spine. paraesthesia: Tension in the inguinal ligament. 24-hour Worsens with prolonged standing or walking, improves with sitting. behaviour Pain increases with hip extension manoeuvres and Valsalva manoeuvres or increased intra-abdominal pressure. Meralgia paraesthetica: past and present background Obesity Pregnancy Wearing very tight clothing Surgery Meralgia paresthetica: Special questions Differential diagnosis: Red flags! Metastasis at the iliac crest Lumbar disc herniation with radiculopathy Avulsion fracture of the ASIS Chronic appendicitis Spinal surgery Diabetes Do not confuse with trochanteritis Meralgia paresthetica: Prognosis 62% spontaneous remission. 90% of patients respond to conservative measures. In case of infiltration, 73% complete improvement, 20% partial improvement and 7% recurrence after more than 1 year. In case of surgery, success rate is very high. In cases of iatrogenic MP, the recovery rate during the first year is over 90%. Those caused by compression, positioning or retraction (neuropraxia) recover faster than those caused by direct injury. Pubalgia Pubalgia “Sports Hernia”, “Sportsman's Hernia”, “Sportsman's Groin”, “Gilmore's Groin”, “Athletic Pubalgia” and “Core Muscle Injury” "Pubalgia" DOESN'T EXIST: DIFFERENTIAL DIAGNOSIS! Rx NMR Anatomical Abdominal muscle group: o Rectus abdominis reminder.... o Obliques o Transverse Adductors Pubic Aponeurosis High Pubalgia Low Pubalgia=> Add med Mixed Pubalgia Pubalgia: Factors involved Young men Sports=> 5/18% 58% soccer Overload Repetitive movemtnts Postural imbalance Muscular imbalance Structural imbalance: Dysplasia, micro-traumatisms 70% adductor involvement Pubalgia: Body chart Pubalgia: 24h. behaviour Localized pain, worse with palpation Possible irradiation Increases after sports Does not increase with increased intra-abdominal pressure Improved with ice, rest, NSAIDs Relapses Pubalgia: History insidious onset Acute phase, improvement with rest and NSAIDs o Fissure, gracile disinsertion Chronic phase, constant pain and limitation o Joint overuse=> microtraumas Edema= Musc contractions= Prolonged evolution Rx RMN  Lumbar: Radiculopathy, canal stenosis, disc herniation. Pubalgia: Hip pathology Special Inguinal hernia questions Muscle rupture Urinary tract infections Adductor tendinopathy KNEE MSKP2 THEORY Knee: Clinical processes Osteoarthritis Patellar Tendinopathy Iliotibial band syndrome Patellofemoral pain syndrome C/O-Clinical records Knee Osteoarthritis  Knee Osteoarthritis Gene and proteomic pattern of inflammatory characteristics. Degenerative joint condition => progressive loss of articular cartilage => marginal bone hypertrophy => changes in the synovial membrane. Incidence: 240/100,000 people/year. OA => The most common cause of permanent disability in people over 65 y.o. More frequent in knees. It affects to the 6% worldwide, and 10% to people over 65 years old. It does not affect the whole knee, but one or two of its compartments. https://www.elsevier.es/es-revista-revista-chilena-ortopedia-traumatologia-230-articulo-osteoartritis-artrosis-rodilla-S0716454815000236  Knee OA diagnostic criteria Clinical recods Gonalgia, >50 years old, stiffness Metabolic syndrome. Physical activity has not been identified as a risk factor for its onset or progression. In 50% of patients, symptoms do not correlate with radiological alterations. OA rodilla: Body chart  Knee OA: 24 hours behaviour Beggining: o Mild pain after strenuous activity, improves with rest. Progression: o Pain increases when walking up and down stairs/ramps (down worse), squatting and walking on uneven ground. o Severe OA => Sx at rest. Greater than usual physical effort=> Pain flares up => Continuous => Swelling due to effusion. Instability, morning stiffness, pain when walking. In advanced cases, decreased mobility and deformity appear.  Knee OS: Actual and past history Previous joint injuries condition (10-15 years) => Early post-traumatic OA: o Menisectomy => greater than 30% o ACL tear Weight alterations Overuse Local trauma Infections Metabolic disorders Chondral Extracellular Matrix Involvement  Knee OA: Special questions Do not confuse with: Osteoarthrosis Rheumatoid arthritis Fibromyalgia Gout Lupus Psoriatic arthritis Reiter's disease Sjögren's Disease  Patellar tendinopathy Patellar tendinopathy "Jumper's knee" Includes tendinosis and tendinitis Overuse injury: o Pain o Thickening o Reduced function Initially=> Insidious pain and triggered by physical activity. Progression=> More persistent as the frequency and intensity of exercise increases.  Patellar tendinopathy Most common in athletes whose sports include frequent jumping and impact. However, people who do not play impact sports may suffer from it. Dysfunction of the patellar tendon => Changes at the tendon structure => Chronic localised pain for more than 6 weeks. Determining factors: Overuse, repeated trauma, overload and quadriceps dysfunction. 30-45% of injuries in athletes involved in jumping sports. Non-athletes => 8-50%, depending on the work activity. Patellar tendiopathy: Factors involved Men from 35 years of age. Biomechanical alterations=> increased risk: Excessive foot pronation, femoral anteversion, high patella or increased Q angle. Previous tendon and knee injuries. Genetics: altered tendon development and healing factors. Incorrect training. Environmental factors.  Patellar tendinopaty: Body chart Lower patella pain Pain may occur at the tibial insertion of the tendon or even on the patella.  Patellar tendinopathyy: 24 h behaviour Functional impotence=> Instability => Antalgic flexion position=> Ischios and quadriceps weakness. Pain at the anterior and inferior aspect of the knee: o Tensioning of the patellar tendon by passive stretching. o Pain when palpation. o Pain on contraction of the patellar tendon against resistance. Hypersensitivity under the patella. Stiffness, reduced joint mobility and range of motion. Localised swelling Pain at the onset of physical activity or after strenuous exercise. Pain interferes with sports or daily activities. Pain when bending the knee Stiffness, especially when jumping, bending, sitting, kneeling.  Do not confuse with: Patellar tendinopathy: Patellofemoral pain syndrome Hoffitis Special questions Traction apophysitis (osteochondrosis) Chondral injury Meniscal injury Referred pain Patellar chondropathy Infrapatellar bursitis Sinding-Larsen-Johansson Syndrome Osgood-Schlatter disease NSAID reaction Iliotibial band syndrome Iliotibial band syndrome "Runner's knee syndrome", "Iliotibial band Syndorme" Acute external knee pain Associated with repetitive knee flexion and extension in combination with a tight iliotibial band. Incidence between 1.6% and 12% in runners. Cyclists=> between 15% and 24%. ITBS=> 22% of lower limb injuries.  Iliotibial band syndrome The iliotibial band (ITB) consists of a dense layer of inflexible connective tissue formed by the confluence of fibres from the Tensor fascia latae, gluteus maximus and gluteus medius muscles. Origin: iliac crest and EIAS Insertion: Gerdy's tubercle (tibia) Connections with lateral patella=> Relation to patellofemoral syndrome 20º-30º knee flexion=> ITB impact against external femoral condyle Iliotibial band syndrome: Factors involved Too narrow or too wide ITB Friction of the iliotibial band against the lateral femoral condyle Compression of the adipose tissue on the BIT Weak hip abductors (Glut med!)=> hip Add and knee IR Poor foot biomechanics Dysmetria Excessive running Endurance physical activities Clothing  Iliotibial band syndrome: Body chart Pain or burning at lateral area of the knee  Iliotibial band syndrome: 24 h behaviour Onset of pain-free running, symptoms start after a certain time or distance. Pain increases when running downhill, lengthening the stride and sitting for long periods with the knee in a flexed position. Most severe cases => Pain when walking or going up and down stairs, and occasionally extending along the TFL. Symptoms disappear shortly after running, but return with the next run. Iliotibial band syndrome: Actual and past history Patellar dislocation Change in sports routine Clothing? Footwear? Improvement with NSAIDs, ice, rest or change in sports routine. Iliotibial band syndrome: Special questions Excessive varus or valgus Increased internal rotation of the tibia Pronation of the foot Lower limb dysmetria Bone tumour Not to be confused with: o Patellofemoral tendinopathy o TFL tendinopathy Patellofemoral pain syndrome  Patellofemoral pain syndrome Most common cause of dull pain around the patella and in the anterior aspect of the knee. Femur-patella mobility: oFrontal plane lateralization forces: extension and antivarus predominance. Q angle oSagittal compression forces: Holding the patella to the femur. oForces in horizontal plane: Ext subluxation and tibial RI. The patella never fully contacts the femur: o 0-90º => inf-ext contact o 90-135º => sup contact o 135º => quadriceps tendon-dependent contact  Patellofemoral pain syndrome Rubbing of patella with femur=> Cartilage inflammation=> Cartilage erosion=> Secondary osteoarthritis Patellofemoral pain syndrome Alteration of patellar tracking at the trochlear groove.: Anatomical factors: trochlear width, patellar tilt or tilt. Biomechanical factors: Femoral anteversion angle, Q angle, genu valgum, recurvatum, tibialis varus or pronation of the foot.​ Muscular factors: Weakness of the Abductor and ER muscles of the hip, extensor muscles of the knee, and lack of elasticity of the hip flexor and knee flexor-extensor muscles. Patellofemoral pain syndrome: Impact Clinical Dx, based on anamnesis and physical examination=> no complementary imaging is required. Incidence: o 33% in sportswomen and 18% in sportsmen. o In 70% of patients over 40 years of age with patellofemoral pain, osteoarthritis is present and may be associated with patellar tendinopathy. Patellofemoral pain syndrome: Factors involved Age: Adolescents and young adults. o Older people=> Arthritis. Sex: Women (10:1) (pelvic shape?). Overweight Lack of flexibility Lack of warm-up in sports routine Impact sports Increased training level Patellofemoral pain syndrome: Body chart Diffuse, retro or peripatellar location.  Patellofemoral pain syndrome:24 hours behaviour Pain and stiffness during exercise and activities where the knee is repeatedly flexed (climbing stairs, running, kneeling or squatting). Pain after sitting for a long period of time with the knees flexed. Pain related to a change in the level or intensity of activity, playing surface or equipment. Clicking or popping sounds in the knee when climbing stairs or standing up after prolonged sitting. Improvement if RICE and NSAIDs Patellofemoral pain syndrome: Actual and past history Acute onset, short-term improvement with rest and NSAIDs Worsening on resumption of sporting activity ADLs Ok at onset, very limited over time Patellofemoral pain syndrome: Special questions Not to be confused with meniscus tear or chondromalacia. Injury, trauma, dislocation or patella Fx Knee surgery Study of the footprint  Osteoarthritis HIP Hip abductor-rotator tendinosis C/O-Clinical records  "Wear and tear arthritis". Subchondral bone growth, presence of chronic synovitis. Infectious , crystal deposition or autoimmune origin. CF cartilage wear and tear=> subchondral hypertrophy => osteophytes, subchondral sclerosis and osteonecrosis => chronic synovitis. Hip Osteoarthritis Worldwide prevalence 0.85% (10.2% in Spain). Impossible to reverse: PREVENTION!  OA: Clasification Primary: Fingers, spine, hips and knees. Secondary: Following joint injury or inflammation, or as a result of another condition affecting the cartilage (haemochromatosis). Hip OA: Factors Involved Female sex=> Hormones Advanced age (3.5-5.6% over 50 y.o., 80% over 75 y.o.) Obesity. Joint lesions. Repeated stress on the joint. Genetic factors (50-65%). Bone and/or cartilage deformities. Muscle weakness. Metabolic diseases. Nutritional factors Body map Hip OA Localised pain in hips and buttocks Referred pain in groin, leg and knee  Hip OA: 24-hour behaviour Dull pain at the groin or radiating to the leg (xternal aspect), knee or buttocks. Morning stiffness. Trouble walking. Pain, stiffness and swelling, worsens with strenuous activity and sedentary lifestyle. Instability. Dysmetry. Hip OA: Current and past history Progression: -First episodes short and self-healing. -Over the years the episodes last longer, are more frequent and more intense. Painkillers & NSAIDs => not always improve. Variable evolution, with the usual presence of a "constant background pain" that flares up according to activity. Previous predisposing factors. Special questions Not to confused with: o Arthrosis o Rheumatoid arthritis o Toxic synovitis o Labral tear o Osteonecrosis o Beware of localised trauma o Beware for osteoporosis Tendinosis of hip abductor-rotator tendons Hip abductor Hip rotator muscles muscles Obturatus internus Gluteus medius Obturator externus Gluteus minimus Gemellus superioris Tensor fasciae latae Inferior gemellus Quadratus femoris Piriformis Tendinosis or tendonitis?  Tendinosis or tendonitis? TENDINOSIS TENDONITIS Result of injury or overuse. Intratendinous degenerative condition: Imbalance between tendon tissue damage and selfrepair. Inflammatory damage Compression and friction=> Degeneration=> Common cause: Unstructured and weakened tendon=> - Age High risk of spotaneous rupture. - Sports This condition usually develops gradually and can affect any tendon in the body, although it Systemic diseases (Rheumatoid arthritis is most common in the supraspinatus tendon. or diabetes) Tendinosis or tendonitis? Ultrasound classification of tendinosis Grade 1 Tendon thickening less than 50% thickening Grade 2 Greater than 50% thickening Homogeneous fibrillar pattern Initial myxoid degeneration Grade 3 Greater than 50% thickening Fibrillar micro-rupture Intratendinous cystic degeneration Grade 4 Greater than 50% thickening Fibrillar rupture/ultrasound pattern alteration Intratendinous cystic degeneration/fibrosis Microcalcifications Hip abductor-rotator tendinosis: Factors involved Men. Obesity. Oral contraceptives in women. Frequent in impact athletes. Errors using sports equipment. Injured connective tissue. Overuse or misuse. Increased myotendinous tension. Previous tendonitis.  Body Chart Hip abductor- rotator tendinosis Localised pain at greater trochanter Secondary pain at the groin and buttocks  Chronic and persistent pain in the affected area, varies according to movement and may reach the knee. Improves with rest. Stiffness. Pain on pressure, localised in the greater trochanter. Pain when running, going down slopes or stairs and even Hip abductor-rotator when walking. Also when standing for long periods. tendinosis: Associated muscle weakness. Limitation of movement. 24-hour behaviour Patient reports feeling contact of the tendon with other structures. Usually no inflammation. These symptoms usually worsen with activity Tendinosis: Current and past history Previous tendon injury Direct trauma Muscle atrophy Constant and repetitive overloaded movements Poorly performed sporting practices Hip Tendinosis: Special Questions Localised trauma Sports practice Footwear Job Metabolic dysfunctions Physical disorders Previous tendinitis