Hip Fractures Elderlyespecially osteoporotic patients, Pagets disease, metastasis and other traumas Can be seen in younger patients

ts too due to a traumatic event or benign/malignant tumor Traumatic history--fall Generali ed deep pain !nable to bear "eight Inspection - #hort e$tremity - %ip held in e$ternal rotation and slight abduction - !nable to bear "eight Osseous Palpation - &one Soft Tissue Palpation - Contractures ROM - Painful "ith all movement - 'nternal rotation is especially restricted X-ray - (P and lateral vie"s for fracture ') *intra- vs e$tra-capsular+ Special Test - (nvil Test - ,lamingo Test

Stress Fracture of the Hip %igh-level athlete or -ust young and active 'nsidious onset "ith repetitive activity/overuse o .unning, marching, dancing, aerobics, gymnastics Pain increases "ith "eight-bearing (nterior and deep pain &ight pain is common Inspection - Possibly an antalgic gait if they can bear "eight Osseous Palpation - &one Soft Tissue Palpation - &one ROM - End range restriction - Painful fle$ion and internal rotation X-ray - !nrevealing Special Test - /one scan - (nvil Test, ,lamingo Test Congenital Hip Dysplasia 'nfants !sually diagnosed at birth but if not the child "ill have a limp Inspection - (symmetrical s0in folds - (symmetrical leg positions - )uc0 "addling gait

Osseous Palpation Soft Tissue Palpation ROM X-ray

- &one - &one - )ecreased active abduction *Especially in "eight-bearing positions+ - Central edge angle of 1iberg less than 23 degrees - Triad - !nderdeveloped pro$imal femoral epiphysis - 4ateral displacement of femur - 'ncreased inclination of acetabular roof - /arlo"s maneuver - 5.' and diagnostic !# for detection of early dysplastic changes

Special Test

Congenital Hip Dislocation 'nfants Inspection

- (symmetrical s0in folds around groin and along thigh - !nilateral6 abduction lurch gait - /ilateral6 duc0-"addling gait - (symmetrical greater trochanters - Contracted hip adductors - )ecreased active .75 - Passive abduction is limited - Clic0ing - 5ay be normal until infant is 8-9 "ee0s old - 7rolanis clic0 test - %ip Telescoping Test - (llis - Trendelenberg

Osseous Palpation Soft Tissue Palpation ROM

X-ray Special Test

Traumatic Hip Dislocation :;< are posterior o #ports related o ,orce applied to fle$ed, adducted hip =;< are anterior o ,orce to e$tended, e$ternally rotated hip

Inspection

- Posterior6 hip held in fle$ion, adduction and internal rotation - (nterior6 hip held in fle$ion, abduction and e$ternal rotation - ,emoral head may be palpable - #"elling and spastic muscles in anterior or posterior region #everely painful .75 )etermine amount of damage Posterior6 head goes superior (nterior6 head goes inferior or medial

Osseous Palpation Soft Tissue Palpation ROM X-ray

Special Test

- (llis sign

Slippe Capital !piphysis Child or adolescent patient o !sually over"eight o 7r >uic0ly gro"ing patient *?-=@ year olds+ Can be insidious or traumatic onset 5ay only present "ith 0nee pain Posterior-inferior displacement of epiphysis Inspection - (ntalgic gait/posture if its chronic hip held in e$ternal rotation *toe out+, shortened stance phase on affected side - #hort leg Osseous Palpation - (symmetrical trochanters Soft Tissue Palpation - Painful s"elling in overlying soft tissue - #pasms in e$ternal rotators and fle$ors ROM - Passive fle$ion causes the hip to e$ternally rotate - 'nternal rotation is decreased and painful X-ray - 4ateral vie"6 posterior-inferior displacement of epiphysis *#alter-%arris Type ' in-ury+ *acute+ - /lurring of epiphseal line - 'ncreased "idth of epiphyseal plate - Prolongation of superior nec0 fails to cut epiphysis - 4oss of height of epiphysis in comparison "ith normal hip - Alein line Special Test - CT/5.'

Cluneal "er#e !ntrapment &umbness and tingling over iliac crest bet"een P#'# and iliac tubercles Inspection - &/( Osseous Palpation - .eproduction of symptoms "ith iliac crest palpation Soft Tissue - .eproduction of symptoms "ith Palpation gluteus ma$imus palpation *if inferior and middle cluneal nerves are involved+ ROM - (ctive e$tension if middle and inferior are involved "ill produce symptoms X-ray - &one Special Test - sensory testing $ateral Femoral Cutaneous "euralgia Patient has lateral sensory complaintsnumbness and tingling Patient may be obese or pregnant Patient may sit for long periods of time Patient may carry 0eys or "allet in front poc0et Inspection - &/( Osseous Palpation - .eproduction of symptoms "ith pressure applied to medial (#'# Soft Tissue Palpation - Palpation of lateral femoral cutaneous nerve =B belo" (#'# ma0es symptoms "orse - Passive %ip e$tension and fle$ion "ill elicit symptoms - &/( - Positive Tinel over (#'# or inguinal ligament - Electrodiagnosis/sensory testing - .esisted 0nee fle$ion elicits symptoms

ROM X-ray Special Test

Merlagia Paresthetica Cust another name for 4ateral ,emoral Cutaneous &euralgia S!! %&O'! Snapping Hip Syn rome &o pain -ust snapping Inspection - Gait abnormalities to prevent snap Osseous Palpation - Greater trochanter Soft Tissue Palpation - Palpable tendon snap "ith movement ROM - Popping "ith motion X-ray - 4oose bodies - 'ncreased -oint space *suction+ Special Test - .esisted muscle tests produce pop

%#ascular "ecrosis #econdary to6 o #ubcapital fractures o Posterior hip dislocations o 4ong-term steroid use o %yperlipidemia o (lcoholism o Pancreatitis o %emoglobinopathies Inspection

Osseous Palpation Soft Tissue Palpation ROM

- 5uscle atrophy - 4imb length ine>uality - Gait is abducted and e$ternally rotated - &one - #pasms in piriformis, gamellus, tensor fascia lata, and gluteus medius - )ecreased active and passive internal rotation - )ecreased abduction - Progression6 small radiopa>ue femoral nucleus, crescent sign, fragmentation, reossification "ith remodeling, deformity at femoral head - Crescent sign on (P vie" 5.' Positive Trendelenburg Test Positive Thomas Test Positive ,(/E.s test

X-ray

Special Test

Ischial &ursitis Patient sits for long periods of time on hard surface Pain may be referred do"n bac0 of legirritates sciatic nerve Pressing foot do"n relieves pain *e$tension of 0nee+ Can be seen in a young athlete doing speed "or0 *sprintingusing hamstrings+ o %amstring strain Can be due to traumatic blo" Inspection - #hortened stride length Osseous Palpation - Pain elicited at ischial tuberosity Soft Tissue Palpation - Tenderness in overlying soft tissue ROM - Painful passive hip fle$ion and adduction - Painful active hip e$tension and abduction and lateral rotation X-ray - &/(

Special Test

- #4. and Patric0s test may reproduce pain - Thomas/5odified Thomas pain - .esisted hip e$tension

$egg-Cal#e-Perthes Disease (a#ascular necrosis in chil ren) Child or adolescent patient *8-: year old+ 5ild hip pain *medial+ (ggravated by active play 'nsidious onset/traumatic history/metabolic disease 5ay only present "ith 0nee pain Inspection - 4imp Osseous Palpation - &/( Soft Tissue Palpation - #pasms in adductor and psoas muscle - 5uscle "asting in thigh and buttoc0 ROM - 4imited hip abduction - 4imited internal rotation - 4imited e$tension - 4imited fle$ion $imitations are secon ary to muscle spasms - End range is painful - 4aterall active .75 is painful X-ray - ,issuring, flattening, and sclerosis of epiphysis "ith secondary phase of remodeling leading to mushroom deformity - Darus deformity "ill usually result - Crescent sign on (P vie" - Thomas Test - 5.' - /one scan - Positive ,(/E.

Special Test

Femoroaceta*ular Impingement #harp, deep hip pain "ith s>uatting .unning, stopping and starting or changing direction may cause pain (nterior pain .esult of hip abnormalities that limit movement *especially fle$ion and internal rotation+ (nterior impingements are more common than posterior impingements Inspection - #hortened stance phase - Circumducted gait Osseous Palpation - &/( Soft Tissue Palpation - &/(

ROM X-ray

Special Test

- )ecreased fle$ion and internal rotation - Possibly decreasd e$ternal rotation - (nterior asphericity of femoral head - 4ac0 of femoral head-nec0 offset - .etroversion of acetabulum - Pincer lesion - Cam lesion - Passive hip fle$ion, adduction and internal rotation causes pain *anterior impingement+ - Passive e$tension and e$ternal rotation causes pain *posterior impingement+ - ,it gerald Provocative 5ovement - 5cCarthy #ign - ,(/E. can cause lateral pain - CT/5.'

%ceta*ular $a*ral Tears )amaged from traumae$treme e$ternal rotation Traumatic or non-traumatic 1ill predispose patient to degeneration and early 7( 5oderate to severe hip and groin pain &ight pain 5ade "orse "ith activity Clic0ing and occasional giving a"ay Inspection - 4impdecreased step length Osseous Palpation - &/( Soft Tissue Palpation - &/( ROM - %ip loc0ing/catching - )ecreased active and passive .75 X-ray - &ot helpful for )E but can give indirect evidence of cause of effect of tear Special Test - Gold standardF arthroscopy - 5.(/5.' - 'ndirect *,(/E., ,(' tests, long a$is tr$n+ Su*trochanteric &ursitis Patient 8;-9; years old o Can be seen in younger adults due to repetitive activity .esult of a fall 4ateral hip pain"ell locali ed o 5ay radiate to lo" bac0, lateral thigh or 0nee 5ay be caused subgluteus medius/ma$imus/minimus bursae

Cannot sleep on involved side - 4imp - Tenderness and s"elling over greater trochanter - /oggy, tender bursa - )ecreased and painful internal rotation - Painful active e$ternal rotation - (bduction and fle$ion "ill be painful *active+ - Passive adduction and e$tension "ill be painfule - no findings - Patric0s and 7bers Test "ill be painful

Inspection Osseous Palpation Soft Tissue Palpation ROM

X-ray Special Test

Iliopectineal &urstitis #evere, acute pain )eep anterior hip pain o Pain may radiate if the femoral nerve is being compressed )ue to hip fle$or tightness and repetitive activity Inspection - (ntalgic gait/posture *fle$ed hip to"ard involved side+ Osseous Palpation - &one Soft Tissue Palpation - %ip fle$or tightness - Tender iliopsoas - 'nguinal area "ill be tender ROM - Painful active e$tension - Passive e$tension "ill be painful at endrange X-ray - &ormal Special Test - .esisted hip adduction and fle$ion "ill be painful - Thomas Test, 5odified Thomas Test, &achlas, Elys Iliopsoas &ursitis #ame as above 'nguinal area pain *groin and anterior thigh+ Transient Syno#itis Generali ed deep pain *inguinal+ (dolescent/young adult patient *child younger than =;+ (cute or gradual onsetusually not traumatic

 )ifficulty bearing "eight 5ay have a viral infection in recent history Inspection - %ip held in e$ternal rotation, abduction, and fle$ion Osseous Palpation - &one Soft Tissue Palpation - #pastic e$ternal rotators, abductors and fle$ors ROM - )ecreased internal rotation *active and passive+ - 5ay have decreased adduction and e$tension *active and passive+ X-ray Special Test - &o findings - /one scan - !# may sho" fluid in -oint

Rheumatoi %rthritis 1omen 23-33 years old Inspection Osseous Palpation Soft Tissue Palpation ROM X-ray

Special Test

- #horter gait stride - Evidence else "here - &/( - &/( - )ecreased .75 "ith crepitus - Early6 uniform, symmetric loss of -oint space "ith associated periarticular osteoporosis - 4ater6 subchondral cyst formation and destruction of femoral head or acetabular roof even to the point of protrusio acetabuli - Elevated E#. and positive rheumatoid factor - ,(/E.

Myositis Ossificans )irect blo" to 0nee/>uads follo"ed by s"elling Patient returns to strenuous activity Patient applied deep heat/massage Inspection - #"elling and discoloration - Possible Osseous Palpation - Palpable mass in >uad Soft Tissue Palpation - %ard contents in muscle mass

ROM X-ray Special Test

- )ecreased 0nee and hip .75 *active and passive+ - Calcification response - .esisted >uad - .adiographs

Osteoarthritis of the Hip 5iddle- aged or elderly patient o 'nsidious onset o Pain, in hip, buttoc0, groin, or 0nee o #tiffening o 5ay have accompanying lo" bac0 pain "hen "eight bearing to compensate for limited e$tension o (ggravated "ith "al0ing better "ith rest o %ard to sit, rise from sitting and going up stairs Gounger patient *secondary 7(+ o Traumatic history Inspection - %ip held in e$ternal rotation and abduction "hile "al0ing - 'ncreased H angle *due to "ear on 0nee+ Osseous Palpation - &/( Soft Tissue Palpation - &one ROM - .estricted but increases "ithin I hour of moving - crepitus "ith movement X-ray - &on-uniform loss of -oint space Special Test - Positive ,(/E.# test - E- ray Paget+s Disease Generali ed deep paininsidious onset o !sually patients are asymptomatic though 'ncrease in hat si e Patient over 8; yo Inspection - /o"ing of lo"er leg - Change in H angle Osseous Palpation - &/( Soft Tissue Palpation - &/( ROM - &/(

X-ray

- Thic0ening of bone - Trabeculae is more apparent *crosshatching+ - ,emoral nec0 or shaft shape "ill eventually distort - Cotton "ool appearance in s0ull - Enlarged vertebral bodies - /lood "or0 "ill sho" increased serum al0aline phosphatase levels - /one scan

Special Test

Osteitis Pu*is #udden, forced adduction in-ury .epetitive minor trauma0ic0ing or running Pregnant "omen Cannot lay on side Inspection - (ntalgic gait Osseous Palpation - Pain elicited at pubic bone - Pain "hen (#'#s are compressed together Soft Tissue Palpation - Tender adductors ROM - )ecreased active adduction - )ecreased passive abduction X-ray - &ot sensitive enough Special Test - .esisted adduction is provocative - /one scan % uctor Strain Groin pain J anterior thigh pain #udden movement onset T"isting (thletes involved in 0ic0ing, sprinting, "ater s0iing, or -umping Inspection - (dducted gait - #"elling - /ruising Osseous Palpation - Pubic bone *adductor attachment+ is tender - Pes anserine and adductor tubercle Soft Tissue Palpation - (dductor group is tender *adductor longus, brevis and magnus, gracilis, and pectineus+ ROM - )ecreased active adduction - Painful passive abduction and e$ternal rotation at end range

X-ray Special Test

- &ot sensitive enough - (dductor muscle testing "ill be painful - /one scan

Hamstring Strain #udden movement onset o .unning to first base or sprinting o ,orceful 0nee e$tension Posterior thigh pain (thlete Inspection - Change in gait *hamstrings fire from acceleration heel stri0e+ Osseous Palpation - Pain elicited at ischial tuberosity, pes anserinus , pro$imal posterior tibia and fibula Soft Tissue Palpation - Pain/spasms in distal muscle belly of hamstring - )efects in muscle belly ROM - )ecreased and painful active 0nee fle$ion hip e$tension - )ecreased and painful passive 0nee e$tension and hip fle$ion X-ray Special Test - &one - 5uscle testing

,ua riceps Strain #udden movement onset o .unning to first base or sprinting o 5issing a 0ic0 o #uddenly stopping (nterior thigh pain Inspection - #hortening of gait - 5ass if there is rupture - #"elling - /ruising Osseous Palpation - Tender (''# *rectus femoris origin+ - Tender tibial tuberosity Soft Tissue Palpation - )efects in muscle belly

ROM

X-ray Special Test %* uctor Strain #udden movement onset Inspection

- Painful active 0nee e$tension and hip fle$ion - Painful passive hip e$tension and 0nee fle$ion - &one - Painful resisted hip fle$ion - Painful resisted 0nee e$tension

Osseous Palpation

Soft Tissue Palpation

ROM

- (bducted gait - #"elling - /ruising - Tender lateral iliac crest - Tender greater trochanter - Tender Gerdys tubercle - #"elling, tenderness, defects in glute muscles, T,4 and 'T/ - (ctive abduction is painful - Passive adduction and e$ternal rotation is painful

X-ray - &one Special Test - .esisted abduction is painful IT&-Tensor Fascia $ata Syn rome 4ateral hip pain that may radiate to lateral thigh or 0nee or lo" bac0 Cant sleep on involved side Inspection - (bducted s"ing to gait - 5inor limp Osseous Palpation - Tenderess at Gerdys tubercle - #"elling/tenderness over greater trochanter Soft Tissue Palpation - 'T/ and Tensor ,ascia 4ata are tender ROM - )ecreased active fle$ion and abduction - Painful passive and active e$tension and adduction X-ray - &egative Special Test - Positive Patric0s test - Positive 7bers test - .esisted abduction "ill be painful Tumor Patient older than 3; )eep bone pain 'nsidious onset

 Pain not relieved by rest Pain "orse at night Past history of cancer Inspection

- Possible mass - Patient s0in "ill be pallor *have a grey hue+ - 5ay have an odor that doesnt match presenting hygiene - &one - 5ass in inguinal lymph nodes - &ormal - 1ill only be restricted if tumor goes into the femoral head/acetabulum - 4ytic or blastic changes - 5.' - 'ncreased E#., serum calcium, al0aline phosphatase, P#(, /ence-Cones proteinuria - 4imp - &one - &one - Potentially decreased active and passive .75 - #ublu$ation - Hi**s - F%&!Rs

Osseous Palpation Soft Tissue Palpation ROM

X-ray Special Test

Hip Su*lu.ation Inspection Osseous Palpation Soft Tissue Palpation ROM X-ray Special Test

Hip Fi.ation Same as a*o#e Femoral "er#e !ntrapment (nterior numbness, paresthesias or "ea0ness Patient is usually diabetic (ssociated "ith signs of canal stenosisclaudication signs "ith "al0ing Inspection - Trun0 fle$ion and hip e$ternal rotation to relieve pain Osseous Palpation - &one Soft Tissue Palpation - (trophy of fle$ors and pectineus ROM - (ctive 0nee e$tension is decreased - Passive hip e$tension causes pain X-ray - &one Special Test - 5.# $um*ar Ra iculopathy

Inspection Osseous Palpation Soft Tissue Palpation ROM X-ray Special Test

- (ntalgic posture - 4eg length ine>uality - 4umbar vertebra - Paraspinals - decreased .75 in lumbar spine - evidence of sublu$ation - 5opal - #4. - Aemps - 4eg chec0

Piriformis Syn rome Piriformis assists in e$tension Piriformis is main muscle to e$ternal rotation #ciatic nerve is compressed piriformis muscle and causes leg pain 4eg and butt pain "orsens during sitting *"ithout lo" bac0 pain+ Inspection - (ltered gait Osseous Palpation - #acrum - Greater trochanter Soft Tissue Palpation - Tender #ciatic nerve - Palpation of piriformis reproduces symptoms ROM - #ymptoms reproduced "ith internal rotation, adduction *passive+ - #ymptoms reproduced "ith abduction and e$ternal rotation *active+ X-ray Special Test - &one - #4. - 5uscle testing

Sacro-Iliac /oint Dysfunction Inspection Osseous Palpation Soft Tissue Palpation ROM X-ray Special Test

- (ntalgia gait - #' -oint is tender - Paraspinals "ill be tender - Painful in all planes - #ublu$ation - Elys - &achlas - 5opal - 4eg chec0s

0RO1PI"0S K o

Children 4egg-calves-perthes

o o o o o o K o o o o o o o o K o o o o o o K o o o o o o o o o o

Congenital hip dislocation/dysplasia #lipped capitial epiphysis Transient synovitis Cant lay on side 'T//T,4 syndrome #ubtrochanteric bursitis 7steitis pubis 4ateral hip (bductor strain 'T//T,4 syndrome 5eralgia paresthetica 4umbar radiculopathy #ubtrochanteric bursitis Traumatics ,ractures )islocations #tress fracture Gluteal pain Cluneal nerve entrapment %amstring strain 'schial bursitis 4umbar radiculopathy Piriformis syndrome #' Coint dysfunction (nterior hip ,emoral nerve entrapment 'liopectinal/iliopsoas bursitis 4umbar radiculopathy 7steitis pubis Huadriceps strain Elderly (D& .( 7( %ip fracture Pagets disease