Case 2

Using the precis of hip assessment as shown below create your own differential diagnosis
and management plan for:

45 year old male patient brought in for assessment. He walks with a limp and complains of
anterior hip and buttock pain after his weekly soccer game that is becoming increasingly
worse throughout the season.

Differential Diagnosis of Hip OA Osteoarthritis verses FAI Femoral Acetabular Impingement

Differential Diagnosis Femoral Acetabular Impingement and Osteoarthritis

FAI OA
History Questions LODCTRAPPA LODCTRAPPA
Type of work? Any snapping, popping or
ADL’s grinding?
Typical posture? Is there morning stiffness? How
Sleeping posture? long does it last?(>30mins)
Where is the pain? Is it difficult sitting to
Is there any groin pain? standing?
Is there pain on squatting? Is it difficult getting in and out
Is there pain when you run? Stop? Or of the car?
change direction? Do any particular positions
Is there pain when you stop the ball? increase your pain?
Injury history? Have you had any previous
injuries/accidents? If yes, what
were they?
Is there any medical history?
Blood tests etc.
When was your last check up?

Observations Movement restrictions Movement restrictions

Pain Crepitus
Altered gait (shortened stride) Altered gait (painful limp)
Muscle contracture Pain reduction on rest
Stiffness after rest, morning
joints 30mins
Shortening of limb
Reduced internal rotation
Various positive ortho tests
Deep achy joint pain,
exacerbated by extensive use

Active Movements Flexion restriction Flexion restriction

Extension restriction Extension restriction
medial rotation restriction Limited adduction
 Limited abduction
Limited medial rotation
Limited lateral rotation
Limited squatting

Passive Movements Medial rotation Medial rotation restriction

Flexion Flexion
90 degrees Extension
90 degrees

Resisted Isometric
Movements
Special Tests Hip scour test Patrick FABERE test
Sign of the buttock Flexion-adduction test
Thomas’s test Hip scour test
Prone springing Cluster of Sutlive
Ober’s test Craig’s test (degree of
Flexion-adduction test anteversion)
Patrick FABERE test Hibbs test
Anterior labral tear test SLR
Posterior labral tear test Sign of the buttock
SIJ distraction provocation test Internal rotation < 25 degrees
Thigh thrust SIJ provocation test Thomas’s test
Gaenslen’s provocation SIJ test
Compression provocation SIJ test
Sacral thrust provocation SIJ test
Sensation Dermatomes thigh/groin L1-2, S3 Dermatomes thigh/groin L1-2,
Obturator nerve L2-L4 S3
Femoral nerve L2-L4 Obturator nerve L2-L4
Femoral nerve L2-L4
Reflexes None None
For lower limb always perform SMR For lower limb always perform
SMR
Joint Play Flexion Long-axis distraction
Movements Internal rotation Anterior-to-posterior glide
Posterior-to-anterior glide
Internal rotation
External rotation
Inferior glide in flexion
Diagnostic Imaging X-ray X-ray
CAM Reduction in superior joint
PINCER space of hip
Osteophytes
Spurs forming
Management Plan:

- Nutrition
- Reasons for presenting now
- Lifestyle, movement habits (Active care plan)
- Posture hygiene
- Sleeping habits (mattress)
- Water activities
- PIR
- Mobilisation Soft tissue work
- Stretching exercises PNF
- Trigger points therapy work (correction of factors that perpetuate trigger points)
- Manipulation Long-axis distraction techniques
- Activator work
- Drop table adjustments
- TENS muscle stimulation

Case Study 3
Robert is a 30-year-old solicitor.

Presenting Complaint
Robert complains of right hip pain.

History of Presenting Complaint

There has no previous history of hip pain, and his medical history is unremarkable. He
reports a gradual onset of pain that started approximately two months ago and is now felt
more often, whereas before he would feel it only when lying down on his right side. Robert,
unfortunately, cannot recall any incident that may have caused his hip pain. He rates it at a
level of 5/10, describing it as being very sore and tender.
He also mentions that he occasionally gets pain in his right shoulder, which is not related to
movement or physical activity. This shoulder pain has been present for about six months.

Physical Examination
Robert walks into your office with no visible limitations.
Active right hip ROM: 30 degrees of abduction with pain, 20 degrees of external rotation
with pain. All other ranges of motion of the right hip are normal.
Lumbar ROM: Flexion is reduced by 50% due to hamstring tightness. All other movements
are unremarkable.
Muscle strength: 4/5 on the abductors and external rotators; other muscles are normal.
Patrick Fabere test is negative
Right Sign of Buttock test reproduces the pain in the right hip
Right Ober’s test reproduces the pain in the right hip.
Palpation: Robert exhibits increased tenderness on the right greater trochanter with slight
tenderness on the middle portion of the buttock on the right side.
Shoulder examination: Unremarkable. Pain cannot be reproduced during your consultation.
1. List the statements (clues) in the case history that aligns with the diagnosis of hip
pain. Use the script concordance.

- Hip pathology (limited hip flexion, positive sign of buttock)1+

- Subtrochanteric bursitis ( pain when lying down on right side) 1+
- Contracture ITB, Snapping Hip (positive Ober’s test) 1+
- Muscle Strain Tight Hamstrings (50% reduced flexion, hamstring tightness) 1+
- SIJ disfunction (positive sign off the buttock) 1+

1. The above case history is incomplete. What further questions or what information
would you need to acquire?

- Are there any aggravating factors?

- Is sit to stand painful?
- Getting in and out of car painful?
- Do you feel a repeatable pop of ITB?
- Any radiating pain?
- Course of pain, constant, ease on rest etc?
- Has there been previous treatment?
- Has the treatment been effective or outcome?
- Are there any relieving factors?
- Is there any previous medical history, operations, medications?
- Is there anything you would like me to know about?
- Run your hand along the line of pain?

2. Based on the given information from the case history and physical examination, do
you think Robert has a hip problem, facet syndrome (referral pattern) or muscle
strain (shorter duration)? Give reasons for your answer.

- Hip problem
- Presents with right hip pain
- 2 months duration
- Pain when lying down on right side
- 30 degree abduction with pain
- Positive sign of the buttock
- Limited hip flexion
-
3. For the above case history alone, give 3 possibilities (differential diagnoses) for his
hip pain. Explain each answer.

- Hip pathology (limited hip flexion, positive sign of buttock)

- Trochanteric bursitis ( pain when lying down on right side)
- Tight ITB, avulsion fracture (positive Ober’s test)
- Muscle Strain Tight Hamstrings (50% reduced flexion, hamstring tightness)
- SIJ disfunction (positive sign off the buttock)
 4. Your colleague thinks that Robert has an ischiogluteal bursitis (weaver’s bottom).
Do you agree with your colleague?

- Ischiogluteal bursitis (weaver’s bottom) – possible reasons;

- aggravated by long sitting
- cannot sleep on affected hip
- swelling limited mobility
-
5. Using the information from the above case history and physical examination, what
is the more likely diagnosis for

1. His hip pain

- Presents with right hip pain

- 2 months duration
- Pain when lying down on right side
- 30 degree abduction with pain
- Positive sign of the buttock
- Limited hip flexion
-
2. His shoulder pain

- Not enough information

- Shoulder exam unremarkable
- Perhaps working at desk

Case Study 4

Joey is a 45-year-old computer programmer

Presenting Complaint:
Joey presents to your office with right low back pain which occasionally radiates into the
right buttock.

History of Presenting Complaint and Onset: The pain had been present for three weeks. It
started one day after he played a game of golf. He has no history of back pain, and he
denies any medical history of significance. X-rays are unremarkable.
Aggravating Activities
Running, prolonged fast walking of more than a mile. When the symptoms are at its worst,
he is unable to stand or walk without pain. Joey also finds it difficult to stand from a seated
position. When the pain is present, he is unable to sleep, waking him as he rolls over in bed.

Physical Examination
Observation: Standing on the right foot reproduced his pain in the right low back area. He
also has a right flat foot.
 Trunk extension was full range but reproduced his pain. All other movements were pain-
free and full range.
Neurological: Unremarkable.
SLR: Full range but mildly painful in the right low back at 70 degrees.
Nachlas and Ely’s: Unremarkable(SIJ Femoral)
Lumbar Compression/distraction: Unremarkable.
Standing on the right leg only reproduced the pain in the right low back however, if the
sacro-iliac joints were supported (as in supported Adams or the belt test) the pain
disappeared.
NB If the question incorporates ‘Based on the information in the case history and/or
physical examination’ assume that all other tests are unremarkable.

1. List the statements (clues) in the case history that aligns with the diagnosis sacro-
iliac pain. Use the script concordance.

DDx
- SIJ 1+
- Hip pathology 1+
- Facet syndrome 1
- Muscle strain 0-1
- Disc herniation 1
- Spondylolisthesis 1-

- Had X-rays done

- supported Adams or the belt test the pain disappeared
- mildly painful in the right low back at 70 degrees (herniated disk)
- Standing on the right leg only reproduced the pain
- unable to stand or walk without pain
- unable to sleep, waking him as he rolls over in bed

2. The above case history is incomplete. What further questions or what information
would you need to acquire?

- Is there any previous medical history, operations, medications?

- Is there anything you would like me to know about?
- Run your hand along the line of pain?
-
3. Based on the given information from the case history and physical examination, do
you think Joey has a sacro-iliac problem, hip problem, facet syndrome or muscle
strain? Give reasons for your answer.

- Sacro-iliac problem
- supported Adams or the belt test the pain disappeared
- Standing on the right leg only reproduced the pain
- unable to stand or walk without pain
- unable to sleep, waking him as he rolls over in bed
-

4. For the above case history alone, give 3 possibilities (differential diagnoses) for his
back and buttock pain? Explain each answer.

- Facet pathology/syndrome (pain which occasionally radiates into the right buttock,
Trunk extension was full range but reproduced his pain)
- Bursitis (When the pain is present, he is unable to sleep)
- Hip Pathology (finds it difficult to stand from a seated position)
- Muscle strain (pain had been present for three weeks, started one day after he
played a game of golf)

5. What other tests would you like to perform?

- Facet - cluster

- Kemp’s
- Prone springing
- Slump
- Yeomans

- SIJ - cluster

- Supported Adam’s test

- SIJ compression
- SIJ distraction provocation test
- Thigh thrust SIJ provocation test
- Gaenslen’s provocation SIJ test
- Compression provocation SIJ test
- Sacral thrust provocation SIJ test
- Hibbs test

- Hip Pathology - cluster

- Gaenslen’s
- Thigh thrust
- Patrick Faber
- Hibb’s test
- Sign of the buttock
- Ober’s test
- Thomas’s test
- Scour test

6. Joey presents with the x-ray below: Would this change your diagnosis?
- Soft tissue work
- Mobilisation
- Block the pelvis