BMS 150 Physmed Lecture Week 6.pdf

Orthopedic Conditions & Assessment Conditions of the Hip Dr. Albert Iarz, ND, RMT BMS 150 Lab Learning Objectives Apply the process of a focused regional exam of the hip using the OHPMNRS model Develop an illness script for each hip condition Develop a differential diagnosis for common hip condition...

Orthopedic Conditions & Assessment Conditions of the Hip Dr. Albert Iarz, ND, RMT BMS 150 Lab Learning Objectives Apply the process of a focused regional exam of the hip using the OHPMNRS model Develop an illness script for each hip condition Develop a differential diagnosis for common hip conditions and presentations Demonstrate selected orthopaedic assessments accurately and diagnostically Demonstrate basic but effective in-office treatments for common hip conditions and presentations Conditions Groin Strain Hamstring Strain Snapping Hip Acetabular Labral Tear Hip DJD Myositis Ossificans Special Tests Trendelenburg Test Yeoman Sign Sign of the Buttock Test Noble Compression Test Thomas Test Piriformis Length Test Pace Abduction Test Ely’s Test/Nachlas Test Faber’s Test Hibb’s Test Gaenslen’s Test Quadrant (Scouring) Test Functional Leg Length Discrepancy Lecture Overview Conditions Groin Strain Hamstring Strain Snapping Hip Acetabular Labral Tear Hip DJD Special Tests Resisted and Passive ROM Ortho tests to r/o other conditions Resisted and Passive ROM Ortho tests to r/o other conditions Internal: FABERE, Gaenslens, Thomas Test, Yeomans External: Obers, Obers Modified Impingement Test FABERE Resisted SLR Scour Test FABERE Lecture Overview – Special Tests Additional Special Tests Findings Hibbs Sacroiliac Joint Pathology Hip Lesion (sprain, strain, arthritis) Radicular pain – piriformis entrapment Elys Femoral nerve or root compression Quadriceps muscle contracture Nachlas SI/lumbar/knee ligament sprain, quadricep strain Radiating pain = femoral nerve pathology Nobles Compression Test Iliotibial Band Syndrome Piriformis Test Piriformis Syndrome Trendelenburg Test Weak hip abductor muscles (glute med) Sacroiliac Joint Pathology The Clinical Encounter - OHIPMNRS Observe History LO DR FICARA Inspection Palpation Motion Neurovascular Referred Pain (screening adjacent areas) Special Tests Groin Strain or Tear Definition: Stretch or tear (partial or full) of the thigh adductor muscles Order of occurrence: adductor longus (62% of cases), adductor magnus, adductor brevis, pectineus or gracillis Differential Diagnosis: 30-90% of all patients with a groin strain injury have one or more other injuries that are missed & go untreated Hernia (femoral), avulsion fracture, iliopsoas bursitis, hip OA, labral tear, low back or GI pain referral Groin Strain or Tear History: Mechanism of injury: Over stretching of adductors by forceful abduction of the thigh during activity. Often occurs in sudden change in direction while running or with quick stopping and starting. Pain: Tearing or stabbing in nature (may hear a snap or a tear) Medial thigh pain that is better with rest Groin Strain or Tear Grading Severity: Grade 1: Walking is fine Pain when changing direction and actions that require adduction Grade 2: Pain & weakness when trying to squeeze legs together Pain with groin stretch, walking and cannot run Grade 3: Full Rupture may be less painful than grade 2 Marked muscle weakness, loss of function, altered gait Groin Strain or Tear Physical: Inspection: Possible altered gait in more severe injuries. Swelling & ecchymosis may be observed Palpation: Tender to palpation over damaged tissues Defect may occasionally be palpable Motion: AROM: pain during adduction or flexion of the hip PROM: usually pain free until muscle is stretched RROM: pain and muscle weakness with resisted adduction Neurovascular: Unremarkable Could test…. distal pulses and DTRS Groin Strain or Tear Special Tests: RESISTED HIP ADDUCTION…. PAIN WITH STRETCH…… ROM usually does the trick for this condition Hamstring Strain or Tear Definition: Stretch or tear (partial or full) of the posterior thigh muscles Hamstrings: biceps femoris, semimembranosus, semitendinosus Differential Diagnosis: Not as many here… Hamstring Strain or Tear History: Mechanism of injury: Acute overstretching or repetitive strain causing disruption of muscle and fascial fibres Usually occurs at the end of activity with transition from eccentric to concentric contraction of muscle i.e. sprinting, kicking, hurdles Pain : Sudden posterior thigh pain Patient may hear a “popping” sound Hamstring Strain or Tear Grading Severity: Grade 1: Mild pain with walking Definite pain with running or full stretch of muscle Grade 2: Pain & weakness resisted knee flexion or hip extension Grade 3: Full Rupture may be less painful than grade 2 Marked muscle weakness, loss of function, altered gait Hamstring Strain or Tear Physical: Inspection: Possible antalgic gait Severe injuries may show ecchymosis Palpation: Tenderness to palpation of affected fibres. Local myospasm and tightness Hamstring Strain or Tear Physical: Motion: AROM & PROM: pain with any motion that stretches the damaged fibres (hip flexion) RROM: pain with resisted knee flexion, in severe injuries, the patient is unable to generate force. Neurovascular: What nerve might be impacted with a tight hamstring? Hamstring Strain or Tear Special Tests: RESISTED KNEE FLEXION PAIN WITH STRETCH…… ROM usually does the trick for this condition Remember the Straight Leg Raise? Snapping Hip Definition: Hip syndrome that is characterized by a repeatable audible or palpable ‘snap’ or ‘click’ that occurs in or around the hip during motion Differential Diagnosis: Local bursitis (may coexist) Hip arthritis Adductor strain Tendinopathy (iliopsoas, TFL, glute max) Labral Tear Snapping Hip 3 Categories: External (most common): Includes causes like the ITB, glute med/max or TFL snapping over the greater trochanter OR Proximal hamstring over the ischial tuberosity Snapping Hip 3 Categories: Internal: Iliopsoas tendon snapping over the femoral head, iliopectineal eminence of lesser trochanter OR Possibly the iliofemoral ligaments moving over the anterior hip capsule Snapping Hip 3 Categories: Intra-articular: Labral tears, fracture fragments or loose bodies, idiopathic hip instability & crepitus secondary to cartilage degeneration Snapping Hip History: Repeatable audible or palpable ‘snap’ or ‘click’ that may be painful or painless. Pain: dull, achy Worse with activity and better with rest Location: Lateral = ITB, TFL, glute max Anterior & deep = iliopsoas Snapping Hip Physical: Inspection: Observe gait and reproduction of snapping Flexed knee in heel-strike & midstance phases of gait indicate iliopsoas External snapping = ITB, TFL, glute max Palpation: Can often palpated or hear ’snapping’ with motion External = tenderness over proximal lateral thigh Internal = tenderness over iliopsoas tendon with anterior pelvic tilt Snapping Hip Physical: Motion: External: PROM: pt side-lying, can often reproduce hip snapping with passive internal and external rotation of the hip Internal: AROM: Snapping may be reproduced with pt starting with hip flexed ~80* then moving into extension or abduction with external rotation Neurovascular: Unremarkable Snapping Hip (External) Special Tests: OBERS (+) Trochanteric Pain -> suggestive of a coexisting trochanteric bursitis (+) Hip pain -> suggestive of hip pathology OBERS MODIFIED (learned with the knee) Ruling out other pain generators in the area - otherwise ROM does the trick for reproducing the snapping. Snapping Hip (Internal) Special Tests: PATRICKS (FABERE) (+) Pain or inability to perform motion -> hip joint pathology, severe arthritis, sprain/strain, fracture, tight hip adductors https://www.physiotutors.com/wiki/patricks-test/ Snapping Hip (Internal) Special Tests: THOMAS TEST (+) Elevation of the straight leg -> hip contracture, tight iliopsoas or rectus femoris https://www.physiotutors.com/wiki/thomas-test/ Snapping Hip (Internal) Special Tests: YEOMANS (+) Muscle tightness of the extender hip -> iliopsoas or rectus femoris contracture Also tests for SI or anterior thigh pain https://www.physiotutors.com/wiki/yeoman-test/ Snapping Hip (Internal) Special Tests: GAENSLENS (+) Elevation of extended hip -> iliopsoas contracture Also tests for SI or anterior thigh pain https://www.physiotutors.com/wiki/gaenslens-test/ Acetabular Labral Tear Definition: Tearing or detachment of the fibrocartilaginous acetabular labrum Differential Diagnosis: Avascular necrosis (AVN) Hip DJD Groin Strain (may coexist) Hernia Testicular pathology Acetabular Labral Tear History: Mechanism of injury: Trauma (acute or repetitive) - trips, falls, twisting, OA Congenital hip dysplasia, degeneration, capsular laxity or instability Pain: Groin pain is the most common in 90% of cases Pain may radiate into low back or gluteals Aggravating factors: Physical activity & positions where the hip is flexed (deep squatting, rising from a low chair or bed) Possible joint locking, repeatable clicking or catching Patient may describe sensation of “hip giving way” or stiffness in the joint Acetabular Labral Tear Physical: Inspection: May have Trendelenburg gait and decreased step length Palpation: Rarely but sometimes tenderness to palpation Motion: AROM & PROM: 80% of patients have an audible/palpable click Possible sharp pain with full hip flexion RROM: WNL or limited due to pain Neurovascular: Unremarkable Acetabular Labral Tear Special Tests: IMPINGMENT TEST (+) Snapping or clicking sounds or pain RESISTED SLR (+) Increased pain secondary to the pull of the rectus femoris muscle on the labral attachment FABERE (+) Unable to perform the test or pain of the anterior hip Hip Degenerative Joint Disease Definition: Degeneration (wear and tear) of articular cartilage in the acetabulum & head of femur Advanced stages = osteophytes, narrowing of the joint space, sclerosis or hardening of bone and joint surface Differential Diagnosis: Rheumatoid arthritis Septic arthritis Iliopsoas strain or bursitis Transient hip synovitis Hip Degenerative Joint Disease History: Pain: Insidious onset of deep achy pain in the groin, buttock, thigh or knee Morning stiffness ( hip pathology, OA, capsulitis, labral tear, acetabular impingement FABERE (+) Painful or unable to perform https://foothillsrehab.com/blog/hip-quadrant-scour-test-explained/ Additional Special Test ELYS (+) Pain with knee flexion -> femoral nerve or root compression, quadriceps muscle contracture (+) Pain with hip extension -> femoral nerve compression or root compression, iliopsoas muscle strain or inflammation https://www.physiotutors.com/wiki/elys-test/ Additional Special Test HIBBS (+) Sacroiliac pain -> SIJ pathology (+) Hip pain -> Hip Lesion (+) Radicular pain -> piriformis entrapment of sciatic nerve https://media.cheggcdn.com/prep/bcd/ bcdd7826-e0f0-4c05-a36b-1c58ba645fe5/hibbstest.jpg Additional Special Test NACHLAS (+) Local pain -> SI/lumbar/knee ligament sprain, quadriceps strain (+) Radiating pain -> femoral nerve pathology https://learnmuscles.com/blog/2017/10/29/nachlas-yeomans-special-orthopedic-assessmenttests/ Additional Special Test NOBELS COMPRESSION TEST (+) Pain over the lateral femoral epicondyle or palpable tendon snapping -> ITB Syndrome https://ykhoa.org/d/image.htm?imageKey=SM/113615 Additional Special Test PIRIFORMIS TEST (+) Radicular leg or buttock pain -> piriformis syndrome, piriformis myospasm Additional Special Test TRENDELENBURG TEST (+) Pelvic lateral tilt -> weak hip abductor muscles (glute med), neurologic or muscle conditions deficit (+) Pain in SI on support leg -> SI Joint pathology https://medizzy.com/feed/23252716 Myositis ossificans a condition characterized by the formation of bone within muscle tissue or other soft tissues, such as tendons or ligaments. It typically occurs as a result of trauma or injury to the affected area, although in some cases it may develop without an obvious cause. https://medizzy.com/feed/23252716 Myositis ossificans Here's how it typically progresses: Initial Trauma: Myositis ossificans often begins with a significant injury or trauma to the muscle, such as a direct blow or repetitive trauma. This trauma can lead to inflammation and damage to the muscle tissue. Formation of Bone: In response to the injury, the body initiates a healing process. However, in myositis ossificans, this process goes awry, and instead of forming normal muscle tissue, the body begins to deposit calcium and other minerals in the injured area. Over time, this mineralization can lead to the formation of mature bone within the muscle. https://medizzy.com/feed/23252716 Myositis ossificans Symptoms: Can vary depending on the location and severity of the condition. Common symptoms include swelling pain stiffness and decreased range of motion in the affected muscle or joint. In some cases, a firm mass or lump may be palpable at the site of injury. https://medizzy.com/feed/23252716 Myositis ossificans Diagnosis: Typically diagnosed based on a combination of clinical findings medical history and imaging studies such as X-rays, CT scans, or MRI scans. These imaging studies can help visualize the extent of bone formation and rule out other possible causes of the symptoms. https://medizzy.com/feed/23252716 Myositis ossificans Treatment: For myositis ossificans is aimed at managing symptoms, preventing further bone formation, and restoring function to the affected area. Initially, conservative measures such as rest, ice, compression, and elevation (RICE therapy) may be recommended to reduce inflammation and pain. Physical therapy may also be beneficial to improve range of motion and strengthen the surrounding muscles. https://medizzy.com/feed/23252716 Myositis ossificans Prognosis Overall, for individuals with myositis ossificans it can vary depending on the severity of the condition and how well it responds to treatment. With appropriate management, many people are able to recover fully and regain function in the affected muscle or joint. https://medizzy.com/feed/23252716