Download Hip, Pelvis, & Thigh Problems PPT

Hip, Pelvis and Thigh
Problems:
Anatomy, Evaluation
and Management
Kevin deWeber, MD, FAAFP
Director, Sports Medicine Fellowship
USUHS Family Medicine
(credits to LTC Erik A. Dahl MD for some slides)
Objectives
 Review pertinent hip, pelvis and thigh
anatomy
 Describe clinical presentation of injuries
 Review best examination techniques for
the hip
 Briefly outline treatment for common
conditions
Hip Examination
 Anatomy
 History
 Physical
Examination
 Radiology and
Laboratory
BONY ANATOMY
Hip Capsule Ligaments
Iliopsoas bursa
Bursae
 Trochanteric bursa
 Between the greater trochanter and ITB
 Ischial bursa
 Between the ischial tuberosity and the overlying gluteus muscle
 Iliopsoas bursa
 Between the iliopsoas tendon and the lesser trochanter, extending
upward into the iliac fossa beneath the iliacus muscle
 Largest bursa in the body
Hip - Anatomy
 Multiaxial ball & socket joint
 Acetabulum
1/2 sphere
 Femoral head
2/3 sphere
 Strong ligaments & capsule
 Maximally stable
History
 Age
 infancy: congenital hip dysplasia
 3-12 year old boys: Legg-Calve-Perthes,
SCFE, acute synovitis
 middle age & elderly: osteoarthritis
 Mechanism of injury
 land on outside hip
 land on knee
 repetitive loading
History
 Pain details
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location
snapping
progression of symptoms
exacerbating factors
alleviating factors
 Weakness
 Occupation, Sport
Observation
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Gait
Posture
Balance
Limb position
 shortened, adducted, medially rotated
 abducted, laterally rotated
 shortened, laterally rotated
 Leg shortening
Inspection
 Pelvic unleveling (iliac crest levels)
 Pelvic rotation (PSIS levels)
 If asymmetric, measure leg lengths
Leg Length Measurements
Eyeball method
Measurement method
Anterior Palpation
Iliopsoas bursa
Posterior Palpation
Sciatic nerve palpation
Range of Motion: pearls
 Quick screen w/ Log-roll IR/ER:
 pain may be from intra-articular fracture,
synovitis, or infection
 Decreased IR:
 First plane to be painful in OA
Range of Motion
 Flexion: 110 to 120
degrees
 Extension: 10 to 15
degrees
 Abduction: 30 to 50
degrees
 Adduction: 30
degrees
 External rotation: 40
to 60 degrees
 Internal rotation: 30
to 40 degrees
Examination
 Strength testing
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isometric
eccentric
knee extension
knee flexion
Hip Flexion Strength
Iliopsoas, rectus femoris, sartorius, tensor fascia lata,
pectineus
Hip Extension Strength
Hamstrings, gluteus maximus
Hip Adduction Strength
Adductor longus, adductor brevis, adductor magnus,
gracilis, pectineus, oburator externus
Hip Abduction Testing
Gluteus medius, gluteus minimus, tensor fascia lata
Internal Rotation Strength
Gluteus medius, gluteus minimus, tensor fascia lata
External Rotation Strength
Piriformis, Obturator internus & externus, Superior/inferior
Gemelli, Quadratus femoris, Gluteus maximus
Abdominal strength
Special Tests
 Patrick’s Test
(FAbER)
 hip joint
 SI joint
Gaenslen’s Sign
Pain at ipsilateral
SIJ is positive test
Special Tests
 modified Thomas Test
 hip flexor and quad flexibility
Special Tests
 Ober Test
 iliotibial band flexibility
Special Tests
 Piriformis Test
 Piriformis flexibility or
pain
Special Tests
 Popliteal Angle
 Hamstring flexibilty
Special Tests
 Labral Injury
 FAdAxL: flexion,
Adduction, Axial
Load + some IR/ER
 pain +/- click
True Hip Pain
Misdiagnosis Common
 The patients studied by Lesher's team received hip
injections for pain. Prior to hip injecton, patients told
doctors where they felt pain:
 Buttocks: 71%
 Thigh: 57%
 Groin: 55%
 Lower leg: 22%
 Foot: 6%
 Knee: 2%
SOURCE: John Lesher, M.D. 22nd Annual Meeting of the American Academy of Pain
Medicine, San Diego, Feb. 22-25, 2006. News release, American Academy of Pain
Medicine.
Think outside the pelvis!
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Abdominal exam
Obturator and Iliopsoas signs
Back exam
Pelvic exam in females
Hip joint problems can radiate to KNEE
Diagnostic Imaging
 Radiographs
 Anterior-Posterior view
 Frog leg view
 STANDING films to r/o early
OA
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Bone scan: stress fxs
CT: subtle fractures
MRI: soft tissue, stress fx
Arthrogram: labral tears
Approach to hip problems
 Better anatomy knowledge  better
diagnoses
 Differentiate Anterior, Lateral, and
Posterior Hip Pain
 Develop an appropriate differential based on
the location and the exam
 Consider AGE in DDx
Margo K, et al. Evaluation and management of hip
pain: An algorithmic approach J Fam Pract. 2003, 52:8
Common Hip Problems by
Age
 Newborn – Congenital dislcation of hip
 Age 2-8 – AVN of hip (Legg-CalvePerthes), sysnovitis
 Age10-14 – Slipped Cap Fem Epiphysis
 Age 14-25 – Stress Fracture
 Age 20-40 – Labral Tear
 Age >40 – Osteoarthritis
Anterior Hip Pain
 Differential Dx
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Osteoarthritis
Muscle strains or tendinopathy
Stress fracture (femoral neck, pubis)
Sports “hernia”
Osteitis pubis
Acetabular labral tears
Obturator or ilioinguinal nerve entrapment
Meralgia paresthetica (may be lateral)
Inflammatory arthritis
Iliac crest apophysitis
AVN of femoral head
Lateral Hip Pain
 Differential Dx
 Greater trochanteric bursitis
 ITB
 Meralgia paresthetica
 OA, labral tear, AVN
 TFL or gluteus medius strain
Posterior Hip Pain
 Differential Dx
 Lumbar spine disease and radicolopathy
 Eval for “red flags”
 Sacroiliac joint disorders
 Hip extensor strain or tendinopathy
 Glut max, hamstrings
 External rotator strain
 Piriformis strain or “syndrome”
 Aortoiliac vascular occlusive disease (rare)
Specific Conditions
Osteitis Pubis
 Repetitive trauma to pubic symphysis due to
overuse
 Running/cutting, esp soccer, football, basketball
 S/Sx: insidious onset dull anterior groin pain;
may radiate; TTP over PS; +/- pain w/
resisted Adduction or passive Abduction
 Xrays helpful
 Tx: relative rest, brief NSAID, cross-tng,
stretching/strength rehab,
 consider steroid injection
Hip Pointer
 Contusion to the iliac crest
 S/Sx: pain, swelling, and
ecchymosis
 severe limit to motion
 +/- palpable hematoma
 Xrays to r/o fractures
 TX: rest, ice, compression,
?benefit from steroid/lido inj after
acute phase, progressive ROM,
strength rehab
 RTP: padding over area
Piriformis Syndrome
 Pain due to sciatic nerve
compression at piriformis
 Cause: trauma, prolonged
sitting, overuse; anomalies in
15-20%
 S/Sx:
 dull buttock pain +/- radiation
into leg
 TTP over mid-buttock
 Pain worse with passive IR or
resisted ER
-Tx: relative rest, ER stretching,
+/- steroid injection
Trochanteric bursitis
 Causes:
 friction between IT band, glut
medius/minimus/max and greater
trochanter; common in running w/
improper biomechanics and overtraining
 direct blows
 S/Sx:
 local pain, tenderness over the greater
trochanter
 Eval for leg length discrep,
adductor/abductor muscle imbalance,
hyperpronation
 Tx: relative rest, ice, brief NSAID, ITB
stretching, +/- steroid injection
 Address biomechanical defects above
Ischial bursitis
 Cause: excessive friction over ischial
tuberosity, or direct blow (hematoma, scarring)
 S/Sx: pain with sitting, TTP over ischial
tuberosity, pain w/ passive hip flexion and
active/resistive hip extension
 Xray to r/o fractures in traumatic hx
 Tx:
 Ice, padding, brief NSAID
 Prolonged: steroid injection
 Refractory: surgical excision
Iliopsoas bursitis
 Cause: overuse of hip flexors
 S/Sx:
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anterior hip pain, +/- snap
preferred position of hip in flex/ER,
TTP to deep palpation anteriorly,
pain with passive hip extension
 Tx: relative rest, ice, brief NSAID,
stretching of iliopsoas,
 +/- steroid injection (preferably w/
guidance)
Sports “hernia”
 TTP lower abd wall
 No palpable hernias
 Co-incident injuries
 Adductor tendinopathy
 Osteitis pubis
 Imaging: consider MRI to
r/o other conditions
 Dynamic US helpful?
 Tx: relative rest, flexibility,
strength  surgery if
refractory
Muscle strains
 Adductors, gluteals, quads, hamstring tears
usually from overstretching during eccentric
contraction, esp when muscle fatigued
 Risk factors
 Early in season
 Muscle imbalance, inflexibility, inadequate warmup
 S/Sx: localized pain and TTP, +/- swelling or
ecchymosis , rarely palpable muscle defect,
and decreased ROM
 Graded I, II, III similar to sprains
 Xrays to r/o avulsion fxs if near muscle origins;
MRI if suspected complete tear
 Tx: PRICEMM, Rehab
(ROMstrengthcardiosport-specific tng)
Quadriceps Contusions
 Direct blow to muscle causes tissue damage
 S/Sx: localized TTP, +/-ecchymosis
 Grade I: knee flexion >90
 Grade II: knee flexion 45-90
 Grade III: knee flexion <45
 Tx: PRICE; avoid NSAID 48 hrs
 Max knee flexion, wrap in place 24 hrs
 Crutches, gradual WB, rehab (ROMstrength)
 RTP when FROM, 90%+ strength, activity w/o pain
 Complications:
 Compartment syndrome (acute)
 Myositis ossificans (chronic)
 Slowly enlarging mass, redness, increasing pain
 Xrays + 3-4 weeks, BS/US sooner
Stress Fractures
 Caused by repetitive overuse stresses
 RF’s: training errors, females, inadequate footwear,
intrinsic factors
 Pelvic, femoral neck, femoral shaft
 S/Sx: insidious pain w/ activity; +/- local TTP or
pain w/ hop test, +/- decreased ROM
 Xrays first, MRI or BS if neg but suspected
 Tx
 Femoral: immediate NWB, Ortho referral
 Tension sidesurgery
 Pelvic/femoral shaft: painless relative rest; graduated
WB, strength/stretching rehab, address other RF’s
Hip fractures
 Most common
through femoral neck,
various traumatic
causes
 S/Sx: pain, swelling,
and loss of function
 Involved leg
shortened and
externally rotated
 Tx: Ortho referral,
surgery
Hip Dislocation
 Femoral head usually goes
posteriorly
 common mechanism: knee to
dashboard during traffic collision
 S/Sx: extreme pain, obvious
deformity, unwilling to move the
extremity; position typically
flexion, adduction, and internal
rotation (FAdIR)
 Tx: emergent reduction in ER
under sedation (Ortho STAT!)
AVN of Femoral Head
 Causes:
 Trauma: fxs, hip dislocation, surgery
 Medical conditions (numerous)
 S/Sx: nonspecific hip pain, may radiate to knee;
exam may be relatively unremarkable, with decr
IR/ER as dz advances
 Xrays usually diagnostic >3mo duration; MRI or
BS if normal
 Tx: make pt NWB and refer to Ortho
 Conservative tx vs hip replacement depending on
severity
Conditions in adolescents
and children
Pelvic Apophysitis
THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO. 1 - JANUARY 2001
Pelvic Apophysitis
 Cause: overuse at tendinous insertion at
apophysis
 Iliac crest > ASIS, AIIS, lesser troch, greater
troch, ischial tuberosity
 S/Sx: localized pain, TTP, pain w/
passive stretch of attached muscle
 Xrays to r/o avulsion fxs
 Tx: relative rest (rare crutches), ice, brief
NSAID?, cross training, strength rehab,
flexibility
Pelvic Avulsion Fractures
 Caused by violent contraction of the attaching
muscle in skeletally immature athlete
 Sprint, jump, soccer, gymnast, dancer, football
 Ischial tuberosity > AIIS > ASIS > iliac crest, lesser
troch, greater troch
 S/Sx: sudden pain +/- pop, poor ROM, local pain
and TTP +/- muscle bulging away from the
attachment
 Xrays needed to eval size/displacement
 Tx: PRICEMM, progressive rehab
 Ortho referral if displacement >2 cm
Slipped Capital Femoral
Epiphysis (SCFE)
 Slippage of femoral epiphysis laterally off
femoral head
 Most prevalent ages 9-15, esp overweight
 Bilateral up to 50%
 S/Sx: insidious poorly localized hip/groin
pain +/- radiation to knee, worse w/ activ
 May have limited IR
 Xrays usually diagnostic; MRI early if neg
but dz suspected
 Tx: immed NWB, Ortho referral, surgery
Kline’s Line: tangent to superior femoral neck on
AP view
Abnormal:
Less or no
transsection
of physis
Normal
transsection
of physis
Legg-Calve-Perthes Dz
 Avascular necrosis of proximal femoral epiphysis
 Most prevalent ages 4-9, males 4:1
 Develops slowly
 S/Sx: intermittent deep hip pain worse w/ activity,
+/- radiating to groin, ant/med thigh, knee;
 limping, decreased ROM, and hip flexor tightness may
be noted
 Xrays usually diagnostic: MRI or BS early if xray
neg but AVN suspected
 Tx: Ortho referral; crutches, pain meds
Acute Transient (“Toxic”)
Synovitis
 inflammatory process of hip w/ chronic irritation
and excess secretion of synovial fluid within
the capsule; ? cause
 Most common dx in limping child <10, but it’s a
Dx of exclusion;
 r/o septic arthritis, SCFE, stress fx, etc.
 Xrays normal; MRI helpful ruling out other causes
 Labs: normal CBC, CRP
 S/Sx: pain w/ walking, low-grade fever
 Tx: relative rest, analgesics
Conclusion
 Know your anatomy
 Know why you’re doing an exam
References
 Birrer R. and O’Connor F. Sports Medicine for the Primary Care
Physician. Boca Raton: CRC Press, 2004.
 Greene W. Essentials of Musculoskeletal Care. Rosemont:
American Academy of Orthopaedic Surgeons, 2001.
 Hoppenfeld S. Physical Examination of the Spine and
Extremities. East Norwalk: Appleton-Century-Crofts, 1976;5974.
 Lillegard W. Evaluation of Knee Injuries. In W Lillegard (ed),
Handbook of Sports Medicine. Boston: Butterworth-Heinemann,
1999: 233-249.
 Netter F. Atlas of Human Anatomy. West Caldwell: CIBAGeigy, 1989.
 Tandeter H. et al. Acute Knee Injuries: Use of Decision Rules
for Selective Radiograph Ordering. American Family Physician.
Dec 1999; 60: 2599-608. (For Radiograph Images)