Download Extra-Articular Considerations Overview Intra- vs

9/26/2014
Overview
Extra-Articular Considerations
• Intra-Articular
– Labral-chondral Lesions
•
•
•
•
RobRoy L. Martin PhD, PT, CSCS
Duquesne University
Pittsburgh, PA
UPMC Center for Sports Medicine
FAI
Hypermobility
Hypomobility
Traumatic
• Extra-Articular
– Musculoskeletal
– Non-Musculoskeltal
1
2
Intra- vs Extra-Articular Pathology
• Diagnosing Intra-articular pathology:
• Extra-Articular
– Insidious onset of sharp or aching groin pain that limits
activity.
– Physical examination:
– Musculoskeletal
– Non-Musculoskeletal
• Limited hip flexion, internal rotation, and abduction range of
motion
• Positive Flexion-Adduction-Internal Rotation Impingement test
• Positive FABER test
• Recommendation in FAI:
– B grade- Evidence levels 2 and 3
»
»
»
»
Clohisy JC (2009) Clin Orthop Relat Res
Johnston TL (2008) Arthroscopy
Philippon MJ (2007) Traumatol Arthrosc
Tannast M (2007) J Orthop Res
3
4
Nerve Involvement:
Peripheral Entrapment
Nerve Involvement
• Entrapments in the posterior hip region:
– Sciatic
– Pudendal
• Entrapments in the anterior hip region:
–
–
–
–
–
5
Obturator
Femoral
Lateral femoral cutaneous
Ilioinguinal-iliohypogastric
Genitofemoral
6
1
9/26/2014
Posterior Nerve Entrapments
The Seated Palpation Test
• Pain:
– Pudendal Nerve:
• Medial to ischum
– Ischiofemoral Entrapment involving the sciatic nerve:
• Lateral to the ischium
– Deep Gluteal Nerve Entrapment at the level of the
external rotators and piriformis muscle:
• sciatic nerve entrapment by these muscles.
• The Seated Palpation Test
7
8
Greater Trochanter-Ischial
Impingement: A Potential Source of
Posterior Hip Pain
Sciatic Nerve Entrapment
• Sciatic nerve
– Courses distally through
the subgluteal space
anterior to the piriformis
and posterior to the
obturator, gemelli and
quadratus femoris muscles
RobRoy L. Martin, Ph.D., PT, CSCS
Professor
Department of Physical Therapy
John G. Rangos Sr., School of Health Sciences
Duquesne University
Pittsburgh, PA
• Piriformis/Deep Gluteal
Syndrome
Benjamin R. Kivlan PT, OCS, SCS, CSCS
Department of Physical Therapy
John G. Rangos Sr., School of Health Sciences
Duquesne University
Pittsburgh, PA
– The nerve exits the
posterior hip lateral to the
ischial tuberosity and deep
to the long head of the
biceps
• Ischial Tunnel Syndrome
9
METHODS: Greater-Trochanteric
Impingement Testing
Hal D. Martin D.O.
Medical and Research Director
Hip Preservation Center
Baylor University Medical Center
Dallas, TX
10
CONCLUSION
• The greater trochanter can impinge on the ischium when
the hip is extended from 90° flexion in a 60° externally
rotated position.
THIRD TEST POSITION: Patrick-FABER test
• Positive finding was contact between the
greater trochanter and ischium
• This impingement occurred more commonly when the
hip was in 30° abduction compared to neutral abduction.
• The Patrick-FABER test reproduced greater trochanterticischial impingement in almost all specimens.
SN
Isch
Greater Trochanter=GT
Isch=Ischial Tuberosity
Sciatic Nerve=SN
GT
11
12
2
9/26/2014
Clinical Significance
Sciatic Nerve Entrapment
Figure: Posterior view of Patrick–FABER Test
• Symptoms:
• A source of hip pain that has not
been described is greater
trochantertic-ischial impingement.
• Sciatic nerve impingement
between the greater trochanter
and ischium can occur when the
hip is in a flexed, abducted and
externally rotated position.
– Buttock pain 81%(N=27),
– Inability to sit greater than 30 minutes
76%(N=25),
– Parasethsia 57%(N=19),
– Pain distal to the knee 30%(N=10)
•
GT
SN
Sciatic nerve compression by:
– Fibrovascular scar bands
• Piriformis
• Obturator Internus
• Quadratus Femoris
Isch
• The Patrick-FABER test may be a
useful clinical test to assess for
greater trochantertic-ischial
impingement
Greater Trochanter=GT; Isch=Ischial Tuberosity; Sciatic Nerve=SN
»
Martin HD, Shears SA, Johnson JC, Smathers AM, Palmer IJ (2011) The endoscopic treatment of sciatic
nerve entrapment/deep gluteal syndrome. Arthroscopy 27: 172-181.
13
Sciatic Nerve Entrapment: Level of
External Rotators
14
The Active Piriformis Test
• Symptoms
– With the patient in the lateral position, the
examiner palpates the piriformis.
– The patient drives the heel into the examining
table thus initiating external hip rotation
while actively abducting and externally
rotating against resistance.
– Buttock pain
– Inability to sit for more than 30 minutes
• Examination
– Seated Palpation Test
– Active Piriformis test
– Seated Piriformis stretch
15
Seated Piriformis Stretch Test
16
Sciatic Nerve Entrapment
• Diagnosis
– Positive Active Piriformis Test and/or Seated
Piriformis Stretch
– The patient is in the seated position with knee
extension.
– The examiner passively moves the flexed hip
into adduction with internal rotation while
palpating 1cm lateral to the ischium (middle
finger) and proximally at the sciatic notch (index
finger).
• Sensitivity = 0.91
• Specificity = 0.80
• Diagnostic Odds Ratio = 42
Martin HD, Kivlan, BR, Martin RL. Diagnostic accuracy of clinical tests for sciatic nerve
entrapment. Knee Surgery, Sports Traumatology, Arthroscopy. 22:882-888; 2014.
17
18
3
9/26/2014
Sciatic Nerve Entrapment:
Ischiofemoral
Pudendal Nerve
• Ischial Tunnel Syndrome.
– Entrapment of the sciatic nerve near the ischium
or proximal hamstring
– The insertion of the hamstring tendon can be
thickened due to trauma or partial hamstring
avulsion
– Symptoms radiating down the posterior thigh to
the popliteal fossa aggravated by running
•
The pudendal nerve exits the pelvis
through the greater sciatic foramen
between the piriformis and superior
gemellus muscles.
•
It crosses the sacrospinous ligament
near the ischial spine.
•
The nerve then enters Alcock’s canal,
which is formed by the obturator
fascia and sacrotuberous ligament.
•
In the posterior aspect of the
Alcock`s canal, the pudendal nerve
gives rise to the inferior rectal nerve,
perineal nerve, and dorsal nerves of
the penis or clitoris.
19
Pudendal Nerve
20
Anterior Nerve Entrapments
• Symptoms usually consist of pain
in the penis, scrotum, labia,
perineum, or anorectal region.
– Obturator
– Femoral
– Lateral femoral cutaneous
– Ilioinguinal-iliohypogastric
– Genitofemoral
• Pain is generally worsened by
sitting, except when sitting on a
toilet seat.
• The physical examination should
relatively normal including
normal sensation.
• Careful palpation should be done
looking specifically for
tenderness medial to the ischium
as well as at the sciatic notch,
piriformis, midischial region, and
obturator internus.
21
Obturator Nerve
22
Femoral Nerve
• Entrapment due to thick
fascia overlying the short
adductor muscle
• Symptoms of paresthesia,
numbness, and/or pain
located the medial thigh
• Movements of abduction
and extension increase the
symptoms by stretching
the obturator nerve.
23
• Entrapment occurs:
– Iliacus compartment
– Inguinal ligament
24
4
9/26/2014
Femoral Nerve
Lateral Femoral Cutaneous Nerve
•
The main clinical feature of patients with
femoral nerve entrapment is quadriceps
muscle weakness.
•
Pain, numbness, and paresthesia may also be
noted in the anterior thigh and with
saphenous nerve involvement noted in the
anteromedial knee joint, medial leg, and
foot.
•
Symptoms are typically worsened with
movements of hip extension and knee
flexion, such as with the Modified Thomas
test position.
•
Patients with proximal nerve injury can
present with iliopsoas muscle weakness.
–
•
However, the psoas muscle is also directly
innervated by the L2 and L3 nerve roots and
may function adequately without femoral
nerve innervation.
Severe femoral nerve lesions produce
quadriceps muscle atrophy and an absence
of the patellar tendon reflex.
• Entrapment can occur as
it perforates the inguinal
ligament
• Obesity and pregnancy
are risk factors
• Symptoms of tingling,
stinging, or burning
sensation in the anterior
lateral thigh with
associated to numbness
or hypersensitivity to
touch.
25
Ilioinguinal-iliohypogastric
•
–
•
•
Arch and Twist Maneuver
Entrapment of the ilioinguinal and
iliohypogastric need to be considered in
those with pain in the abdominal wall, groin,
thigh, and genital region.
–
•
26
Particularly after trauma to the abdomen
region.
Abdominal surgeries, including hernia repairs,
can cause entrapment of these nerves and in
particular the ilioinguinal nerve.
Stabbing pain in the distribution of the nerve
that is aggravated by stretching movement is
the most common complaint.
Tinel’s sign may be able to be elicited in the
area of abdominal entrapment.
Madura et al. suggests an “arch and twist”
maneuver to stretch the affected nerves and
recreate symptoms.
Madura JA, Madura JA, 2nd, Copper CM, Worth RM. Inguinal neurectomy for inguinal nerve
entrapment: an experience with 100 patients. American journal of surgery. 2005;189:283-287
27
Genitofemoral
28
Athletic Pubalgia/Sports Hernia
• Entrapment of this nerve can
occur after abdominal surgery or
in rare cases blunt trauma to the
groin.
• Entrapment of the genital branch
can cause symptoms in the
genital region while entrapment
of the femoral branch can cause
symptoms in a small area in the
proximal anterior thigh.
• Spectrum of chronic
pubic/inguinal pain
• Tear in the
muscles/tendons of
the lower abdomen.
• Typically movements into hip
extension can aggravate
symptoms.
29
30
5
9/26/2014
Pathogenis of Athletic
pubalgia
ATHLETIC PUBALGIA
•
Hip flexor muscles tilt the pelvis forward
and stretch the lower abdominal wall
muscles
•
Repetitive forces to pubic symphysis or
tendinous insertions of the adductors and
rectus abdominus
•
Disruption of inguinal canal components
(external oblique aponerosis, conjoined
tendon, etc.)
•
Often noted in sports that require forceful,
repetitive twisting and turning
31
32
Athletic Pubalgia
Athletic pubalgia
• Symptoms:
• Hip ROM
– chronic pain, often during
exertion.
– Sharp burning pain
– Localized to the lower
abdomen and inguinal region
– Full and painless – except minor soreness at endrange hip abduction
• Manual Muscle Testing
– Weak and painful adduction on involved side
– Weak and painful iliopsoas on involved side
– Inguinal region pain with resisted sit-up
• radiates to the adductor region
and potentially testicular region
• Palpation
– Tenderness superior to inguinal ligament region
33
Femoral Neck Stress Fractures
Femoral Neck Stress Fractures
• Etiology
– At the femoral neck, fractures may occur at the superior aspect due to tensile
forces or on the inferior aspect secondary to the compressive forces.
– Femoral neck stress fractures are the result of excessive stress without
sufficient time for remodeling. In effect, the catabolic process (break down) of
bone exceeds the anabolic process (build up).
– In the majority of cases, improper training is the most obvious cause of a
stress fracture.
• Risk factors:
–
–
–
–
–
34
• Epidemiology
– Incidence
• ~15% of runners will develop a stress fracture. Of these
15%, ~10% are classified as femoral neck stress
fractures.
– Gender
high body mass index (BMI)
decreased fitness
improper footwear
change of running surface
prior history of a stress fracture.
• Females especially those with the female athlete triad
(disordered eating, menstrual cycle dysfunction and
osteoporosis) seem to be at greater risk.
35
36
6
9/26/2014
Femoral Neck Stress Fracture
• Groin pain to anteromedial thigh
• Pain with weight bearing activity
Non-Musculoskeletal
Source of hip pain
– With progression night pain can occur
• Physical examination
– Often negative
– Pain at the extreme of internal and external
rotation
• Advanced imaging techniques are often
necessary.
37
38
Differential Diagnosis
Symptom Presentation
• Bilateral hip pain
• Poorly localized
• Identify “RED FLAGS”
– Systems Review
•
•
•
•
•
– Unable to point to a specific spot
CV/pulmonary
Integumentary
Neuromuscular
Musculoskeletal
Communication
• No specific movements aggravate symptoms
• All movements increase symptoms with empty
end-feels
• Aggravated by activities that increase intraabdominal pressure
– (i.e.-OX3, emotional-behavior response)
– i.e. Coughing, bowel movements
39
40
Key Questions
Pain Locations
– Changes in bowel or bladder function
• Unusual stool or urine color
– Changes in menstruation
• Do symptoms correlate with menstrual cycle?
–
–
–
–
–
–
–
Painful menstruation
Possibility of being pregnant
Painful intercourse
Sexual difficulty
Discharge from penis or vagina
Fever chills nausea, vomiting
Recent infections or illness
• “Just cannot get rid of a cold”
• “The cold keeps coming back”
–
–
–
–
41
Unusual changes in skin including rashes
Unusual fatigue, irritability or difficulty sleeping
Loss appetite
Unexplained weight loss
42
7
9/26/2014
Non-Musculoskeletal Source of hip
pain
Non-Musculoskeletal Source of hip
pain
• Cancer- Bone Tumors
• Vascular- Arterial Insufficiency
– Hodgkin's lymphoma
– AVN
• Enlarged and tender lymph glands
• Long term use of corticosteroids,
immunosuppressants
– Best predictor for CA is previous history of CA
– Abdominal aortic aneurysm
• Rapid onset of sharp sever groin pain
• Pulsating abdominal pain
• Can be associated with back pain
43
Non-Musculoskeletal Source of hip
pain
44
Non-Musculoskeletal Source of hip
pain
• Urogenital
• Psoas Abscess
– Abdominal pain and tenderness in femoral triangle
– Psoas spasm
– Fever and sweats
– Changes in bladder function
– Genital symptoms
• Testicular Cancer
• Crohns’ Disease
– Testicular irregularities
– A type of inflammatory bowel disease
– Skin rash associated with the onset of hip pain
• Endometriosis
• Pelvic inflammatory conditions
• Prostrate impairment
• Reiter’s Syndrome
– Also called reactive arthritis
– Occurs as a reaction to certain infections of the reproductive system and
digestive system.
• Kidney
• Tuberculosis
– Fevers chills
45
46
Non-Musculoskeletal Source of hip
pain
Conclusion
• Pagets’ Disease
• Intra-Articular
• Caused by the excessive breakdown and formation of bone,
followed by disorganized bone remodeling.
• This causes affected bone to weaken, resulting in pain,
misshapen bones, fractures and arthritis in the joints near
the affected bones
– Labral-chondral Lesions
•
•
•
•
• Other metabolic Diseases
FAI
Hypermobility
Hypomobility
Traumatic
• Extra-Articular
– Gaucher’s disease
– Ochronosis
– Hemochromatosis
– Musculoskeletal
– Non-Musculoskeltal
47
48
8
9/26/2014
Thank You
49
9