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MSK- HIP for GP’s
Dr Tim Hughes
GP
Kirkbymoorside Surgery
What you will be able to accurately
diagnose by the end of the day
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Osteoarthitis of hip
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Rule out spine as cause hip pain
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Bursitis- trochanteric, gluteal, psoas, ischial
•
Groin strain
•
Hamstring strain
•
Meralgia parasthetica
2
What you will be able to accurately
diagnose by the end of the day
•
Perthes disease
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Slipped upper femoral epiphysis
3
Session plan
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Principles of orthropaedic medicine- 5 mins
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Examination sequence – 15 mins
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7 common presentations and examination patterns45 mins
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Children's hip disorders- 5mins
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Summary- 5 mins
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James Cyriax- principles of
orthopaedic medicine
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All pain has a source
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All treatment must reach the source
5
Sources of pain
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The joint itself- joint surface, joint capsule
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Structures around the joint that move the jointtendons, muscles.
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Inert structures around the joint- ligaments, bursae
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Referred pain
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Exercise 1 -Surface anatomy
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Anterior superior iliac spine
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Posterior superior iliac spines
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Iliac crests
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Greater trochanter
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Ischial tuberosity- origin of hamstring
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Pubic tubercle- origin of adductor longus
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Position of L2,3,4 dermatomes
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1
0
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Passive movements
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Test inert structures- joint capsule, ligaments, bursa,
fascia, nerve root
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Capsular pattern- varies from joint to joint- passive
range of movement patterns
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Hip joint capsular pattern- most limitation of medial
rotation, less limitation of flexion and abduction,
least limitation extension
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Resisted movements
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Test contractile structures- tendons and muscles
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Pain and power
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Test joint in mid position
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Palpation
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Localising precise site of tenderness at end of
examination.
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History
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Age and occupation
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Site and spread of pain
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Onset and duration
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Symptoms: twinges, night pain, pain on activity, cough/sneeze
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Behaviour- effect on life
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Other joints
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PMH
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Medications
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Inspection
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Bony deformity- spinal curvatures,pelvic position, leg
length
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Wasting
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Swelling
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Examination- eliminate spine
Make sure you have a small stool in your room!
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Eliminate lumbar spine- active lumbar extension with
and without hip in flexion- stool. Active side flexion
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Supine lying- SLR
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Exercise 2 - everyone rule out the spine!
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Examination of hip- after ruling out spine
Supine lying
Passive flexion, medial rotation,lateral rotation, abduction, adduction
Resisted flexion, medial rotation,lateral rotation, abduction, adduction
Prone lying
Femoral stretch test- rule out spine
Passive
• Medial
• Knee
and lateral rotation
flexion and extension
Resisted
• Lateral
rotation- small deep muscles hip- piriformis
• Medial
rotation- gluteus medius
• Knee
flexion- hamstrings
• Knee
extension- quadriceps
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Special tests
Psoas bursa test
Sign of buttock test
Trendelenberg test
Thomas's test
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Exercise 3
Run through the examination sequence
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Scenarios
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In groups each take turn to role play the patient and
do the examination.Tell the story and replicate
examination findings.
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7 cases
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Patient 1
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Age 77
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Increase ache pain
around hip on walking
and now at night.
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Sudden sharp pains
groin on getting up
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Using paracetamol
Limp
Pain on extension Lumbar
Spine that goes with hip
In flexion
Restriction medial rotation
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Osteoarthritis of hip
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Patient 2
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Age 67
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Laying a new patio 3m ago
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Ache pain buttock around hip
to groin. No neuro symptoms
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Worse with walking and at
night. Using ibuprofen.
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'FH - everyone's got a new hip'
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Want referral hip surgery
Pain on extension Lumbar
spine
Pain remains with extension
With hip in flexion
SLR normal
Normal hip examination
Normal neuro exam
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Referred pain
from lumbar
spine
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Patient 3
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Age 38
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Zumba class started
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Ache lateral hip, worse at night
when lies on that side and
when she walks
Pain on passive abduction
and adduction
and a little on hip flexion
Pain on resisted hip
abduction
Tender over
Trochanteric
Bursa
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Trochanteric bursitis
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Patient 4
Painful passive straight
leg raise- buttock
Painful resisted
knee extension
Very tender over ischial
Tuberosity
A 40 year old solicitor who is
training for the London Marathon
complains of pain in his right hip
and buttock It is particularly
painful getting out of bed in the
morning and on hills and stairs.
He also has difficulty getting out
of the car.
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Hamstrings
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Patient 5
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Age 77
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Started regular 40 minute a day
walks to get fitter 6 weeks ago
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Ache pain right buttock more
she walks and now when she
sits down
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I think I might have arthritis
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Paracetamol helps a bit
Point to upper outer buttock
As site of pain
Painful passive flexion,
abduction and
Adduction
Painful resisted abduction
And extension.
Tender point upper outer
Buttock
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Gluteal bursitis
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Patient 6
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22 year old footballer
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Slide tackle
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Severe pain right groin not
settled rest 3 weeks
Point to right groin as site
Of pain
Painful passive adduction
Painful resisted
Adduction
Tender pubic tubercle
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Groin strain
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Patient 7
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Age 38
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Keen footballer
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Lorry driver
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Ache pain groin all timeterrible when driving
Point diffuse area around groin
as site pain
Normal lumbar spine
Pain passive flexion, adduction
and abduction
Pain resisted flexion and
adduction
Positive psoas bursa test
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Psoas bursitis
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Two children's conditions to
cover
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Perthes
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SUFE
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SUFE
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Groin, hip, thigh or knee pain.
Some people only have knee
pain, even though the condition
affects the hip. Adolescent
males- 2:1. Obesity.
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Limp
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Limited movement of the hip
joint
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There may be slight shortening
of the affected leg.
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Perthes disease
Children with Perthes' disease
usually complain of pain in the
groin, the thigh or the knee particularly after physical activity.
They limp and have a restricted
range of movement (stiffness) of
the hip joint. These symptoms may
persist on and off for many
months. The disease itself lasts for
a few years.
Age 4 to 8 most common
Can occur 2 to 15 yrs
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Condition
History
Osteoarthritis
Age
Lumbar spine
Quality of pain
Radiation
Trochanteric
bursa
Fall
Overuse
Groin strain
Exam findings
Management
Capsular
Oxford hip score
pattern- loss
Analgesia
medial rotation
Physio/aids
Pain remains
spine extension
hip flexed
Exercises
Physio
Mixed picture
Tender over
bursa
Exercises
Injection
Pain resisted
adduction
Tender insertion
Overuse
Trauma
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Exercises
Injection
Condition
Hamstring
Gluteal bursa
Ischial bursa
Psoas bursa
History
Exam findings
Treatment
Overuse
Trauma
Resisted knee
flexion
Tenderness
Exercises
Overuse
Trauma
Mixed
passive/resisted
pain
Tenderness
Exercises
Injection
Overuse
Trauma
Mixed
passive/resisted
pain
Tenderness
Exercises
Injection
Overuse
Mixed
passive/resisted
pain
Positive test
Injection
Exercises
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