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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