Download Hip-back pain

Hip & Back Pain
CAUSE
Hip Anatomy
DESCRIPTION
PICTURES/PRESENTATION
-function is to support the weight of
the body
-bones:
*acetabulofemoral joint & joint
capsule (femur & acetabulum)
*pelvis (ischium, pubis & ilium, which
make up the acetabulum)
-muscles:
*gluteal group
*adductor group
*iliopsoas group
*lateral rotator group
Common
causes of
pain
-ligaments:
*extracapsular
*intracapsular
-anterior:
*osteoarthritis
*psoas syndrome
*patellofemoral syndrome
-lateral:
*IT band syndrome
*greater trochanteric bursitis
*meralgia paresthetica
*”Dead Butt” syndrome
Psoas
syndrome
(AKA
“Iliopsoas
Syndrome”
or “Snapping
Hip
Syndrome”)
-posterior:
*piriformis syndrome
*spondylolysis
*spondylolisthesis
-muscle originates at L1-L4, joins
w/iliacus m at the inguinal ligament &
inserts on the lesser trochanter of the
femur
-acts as a primary hip flexor
-occurs when tendon or the bursa
between the tendon & the hip joint
become inflamed & irritated
-common in gymnasts, dancers, and
track-and-field athletes who perform
frequent hip flexing exercises
-Dancer presents w/anterior groin pain & hip stiffness,
sometimes c/o clicking or snapping hip, exam w/tight
hip flexors, can palpate the “snap” when the iliopsoas
tendon slides over iliopectineal eminence
CAUSE
DESCRIPTION
Patellofemoral -overuse syndrome, usually in younger
syndrome
athletes or runners
PICTURES/PRESENTATION
-Young runner presents w/anterior knee pain that
worsens with squatting, descending stairs or sitting for
long periods of time
-complain of anterior knee pain
-believed to be d/t prolonged repetitive
compressive/shearing forces on the
patellofemoral joint  irritation &
inflammation
-presents in part d/t tight hamstrings &
weak hip abductors (gluteus medius,
gluteus minimus & tensor fasciae latae)
IT band
syndrome
-Usu. Present w/lateral knee pain, but
occasionally the iliotibial band becomes
inflamed at its proximal origin & causes
referred hip pain
-thick fascial band formed proximally by
the confluence of fascia from the
gluteus maximus, gluteus medius,
tensor fascia latae & the vastus lateralis
*band originates at the lateral iliac
crest & inserts on the lateral tubercle of
the tibia
-runner w/lateral thigh & knee pain, worse when foot
strikes the ground, + Ober’s Test
CAUSE
DESCRIPTION
PICTURES/PRESENTATION
-overuse injury, often seen in runners &
cyclists, that arises from inflammation
along IT band
-Ober’s Test:
*patient laying on opposite side, DO
abductions & extends the affected hip,
then allows the leg to drop to the table
*if produces pain along the lateral side
of the thigh  indicates IT band
syndrome
Greater
trochanteric
bursitis
-inflammation of the trochanteric bursa
*one of the most common causes of
hip pain
*occurs in lubricating sac located
between the greater trochanter and the
gluteus medius tendon/iliotibial tract
-Runner or other physically active patient presents
w/lateral hip pain, may radiate down ipsilateral thigh,
hip movements and laying on affected side often
exaggerate the pain
-caused by an exaggerated movement
of the gluteus medius tendon & the
tensor fascia over the outer femur
*repetitive flexing of the hip (such as
in runners), & direct pressure (possibly
from a fall), aggravate the condition
Meralgia
paresthetica
-painful mononeuropathy of the lateral
femoral cutaneous nerve (LFCN)
*commonly d/t focal entrapment of
this nerve as it passes through the
inguinal ligament, can also be d/t an
abdominal mass
-can be caused by tool belts, body
armor or duty belts in carpenters,
soldiers & police
-common in obese patients, middle age,
DM, also seen in runners (typically
unilateral)
-middle age diabetic patient w/numbness & tingling
on lateral aspect of hip/upper thigh, worse w/walking
or standing, improved w/sitting, Sx reproduced
w/deep palpation below ASIS & tapping over the
inguinal ligament
CAUSE
DESCRIPTION
PICTURES/PRESENTATION
-diagnosis by tapping over the nerve,
like you would for carpal tunnel in the
wrist
-paresthesias of the anterolateral thigh
in all or part of the area, sometimes
assoc. w/hyperesthesia
“Dead Butt”
syndrome
(AKA “gluteus
medius
tendinitis or
tendinopathy”)
Piriformis
syndrome
-gluteus medius originates on external
ilium & runs laterally to its insertion on
the greater trochanter
*acts as a hip abductor & helps
w/pelvic stability during running
-Runner presents w/lurching or wobbly gait, pain
w/hip abduction & rotation, point tenderness at
insertion site on the greater trochanter, +
Trendelenburg test
-encompasses weakness of the gluteus
medius in conjunction w/a tight
iliopsoas & weak abdominal muscles
*can dx gluteus medius weakness
w/Trendelenburg test
-caused by hypertrophied or inflamed
piriformis muscle from gluteal spasm,
overuse or trauma
-can be seen in sedentary patients,
runners or athletes who do not engage
in lateral stretching or strengthening
exercises
-sedentary patient presents with sciatic pain starting
in buttock that radiates down leg, worse w/walking or
sitting for prolonged periods, often w/point
tenderness in belly of piriformis m, pain reproduced in
internal rotation and adduction (elongation of the
muscle)
CAUSE
DESCRIPTION
PICTURES/PRESENTATION
-dysfunction of the muscle can cause
sciatic pain d/t location of the sacral
plexus directly beneath or through the
muscle
-piriformis:
*originates on anterior lateral sacrum
& inserts on posterior medial aspect of
greater trochanter
*externally rotates & abducts the hip
Spondylolysis
-common in young athletes and older
patients >60yo
-defect in the pars interarticularis  the
narrow isthmus of the neural arch that
connects the superior & inferior
articular processes
*defect in the vertebra (85% of cases
occur at L5)
-athlete or older patient presents w/LBP often related
to activity or hyperextension maneuvers, generally
w/o a hx of neurologic sx, exam w/possibly some
midline tenderness on palpation, no pain in flexion,
pain reproduced in extension
-leads to stress fractures on one or both
sides of the affected vertebra
-must get an oblique XR  “Scotty dog”
sign
-repetitive trauma to the lower back,
stress fractures, or increased lumbar
lordosis/extension
Spondylolisth
esis
-when one vertebral body translates
anteriorly or posteriorly w/respect to an
adjacent vertebral body  can
exacerbate spinal canal narrowing
-can occur at any level of the spinal
column, although most common in the
-LBP, often accentuated by hyperextension or activity,
rarely involves neurologic deficits from compression of
L5 or S1 nerves unless there is severe translation,
where you may feel a step-off on palpation over
spinous processes
CAUSE
DESCRIPTION
PICTURES/PRESENTATION
lower lumbar spine (specifically
anterior slippage of L5 on the sacrum)
-result from minor overuse trauma,
particularly repetitive hypertension of
the lumbar spine
*also d/t trauma, congenital, or other
degenerative disorder not involving the
pars
-may be assoc. w/spondylolysis
*if pars defect is bilateral, allows
slippage of the vertebra, typically L5 on
S1
Referred pain
-To hip:
Lumbar radiculopathy
Sacroiliac dysfunction
Spinal tumor
Knee pathology
Inflammatory processes
-From hip:
Osteoarthritis
Osteonecrosis
Hip dislocation
Hip/back
exam
-inspection of lumbar spine & both hips
*atrophy, swelling or bruising, include
leg lengths
-evaluate gait both stance and swing
states
-evaluate ROM:
*flexion (90-120 degrees)
*extension (30 degrees)
*internal rotation (40 degrees)
*external rotation (45 degrees)
*abduction (45 degrees)
*adduction (30 degrees)
-evaluate posture
*shoulder and pelvis level, evaluate
spinal curves
-nerve testing:
*reflexes, sensation, muscle strength
-palpate spinous processes for
tenderness or step-offs
*palpate paravertebral m for spasm or
tenderness
-special tests:
*Trendelenburg test  tests for weakness in gluteus
medius on weight-bearing side
*Ober’s test tests for IT band tightness
CAUSE
DESCRIPTION
*palpate for sciatic n discomfort
w/patient’s hip flexed & laying on
opposite side (lateral recumbent) 
palpate between the greater trochanter
& the ischial tuberosity
PICTURES/PRESENTATION
*Straight leg test tests for disc herniation
*Thomas test tests for iliopsoas tightness
*Patrick test (FABERE) tests for ipsilateral hip
disorder or contralateral sacroiliac dysfunction
-palpate hip:
*anteriorly palpate the ASIS, laterally
the iliac crest and great trochanter, &
posteriorly the PSIS and ischial
tuberosity
Hip OMT
-lumbar somatic dysfunction
*soft tissue, ME, HVLA, counterstrain
-pelvis
*innominate ME, pubic ME,
piriformis/psoas counterstrain
-sacrum
*articulatory, HVLA, ME
-piriformis counterstrain:
*located in the belly of the piriformis m, halfway
between the greater trochanter & sacrum
*find TP
*assign pain scale
*Tx position is marked flexion of the hip & abduction
(may require external rotation of the hip)
*improve pain scale
*hold for 90 seconds
*passively return to test
*recheck