HIP Flashcards
(337 cards)
1
Q
Psoas Tendinitis Diagnosis
A
Psoas tendinitis can occur:
Following an acute injury
Sports related - repeated hip flexion
Associated with femoro acetabular impingement.
After total hip replacement
After hip arthroscopy
Activities that may predispose to psoas tendinitis include dancing, ballet, resistance training, cycling, rowing, running (particularly uphill), track and field, soccer, and gymnastics.
Effects young adults more commonly with a slight prevalence in females.
2
Q
Psoas Tendinitis Presentation
A
Resisted flexion is positive→ Pain
Pain in the groin→ Hip lesions
Patients often present with complaints of an insidious onset of anterior hip or groin pain.
At presentation, patients may note pain with specific sports-related activities, such as jogging, running, or kicking. Pain with simple activities, such as putting on socks and shoes, rising from a seated position with the hips flexed for some time, walking up stairs or inclines, or brisk walking may be reported.
3
Q
Psoas Tendinitis Special Tests
A
Flexion Abduction External Rotation (FABER) Test / Patrick’s Test (pg. 383)
Thomas Test (pg 404)
4
Q
Psoas Tendinitis Imaging
A
Coronal T1-weighted image of the right hip in a 22-year-old female with hip pain demonstrate normal low signal at the distal iliopsoas tendon.
5
Q
Psoas Tendinitis Treatment
A
Physical therapy is the first treatment approach. At first it is used to alleviate pain, spasm, and swelling and then it is used to return the patient to normal ROM, strength, endurance, proprioception, and activity specific to the patient’s sport. If the symptoms are resistant to physical therapy, a psoas tenotomy or lengthening can improve the painful symptoms.
6
Q
Sartorius Tendinitis Diagnosis
A
Activities where sartorius pain can occur:
- Sitting with legs up and crossed for long periods of time (recliners, sleeping)
- Slipping or a misstep
- Sports that require planting one foot and making a sharp turn (basketball, football)
- Walking with an extended long stride
7
Q
Sartorius Tendinitis Presentation
A
Resisted flexion is positive→ Pain
Pain in the groin→ Hip lesions
Sleeping with a pillow between ones knees seems to decrease the pain.
8
Q
Sartorius Tendinitis Special Tests
A
Thomas Test (pg 404)
9
Q
Sartorius Tendinitis Imaging
A
T2 weighted MRI axial view shows swelling and increased intrasubstance signal intensity in the sartorius (open arrow) and gracilis (straight solid arrow) tendons. Interstitial muscle edema and a perifascial fluid collection (*) are also noted. An associated partial tear of the medial collateral ligament is seen (curved arrow).
10
Q
Sartorius Tendinitis Treatment
A
Physical therapy is the first treatment approach. At first it is used to alleviate pain, spasm, and swelling and then it is used to return the patient to normal ROM, strength, endurance, proprioception.
11
Q
Avulsion Fracture of Greater Trochanter Diagnosis
A
Fractures of the greater trochanter are rare. They may be divided into those involving epiphyseal separation of adolescence and true fractures of adulthood.
12
Q
Avulsion Fracture of Greater Trochanter Presentation
A
Resisted flexion is positive→ Pain and weakness
Resisted abduction is positive→ Pain and weakness
Lateral trochanteric pain
MOI: Forced external rotation of the leg with simultaneous contraction in the gluteus medius and minimus muscles
13
Q
Avulsion Fracture of Greater Trochanter Special Tests
A
Single Leg Stance for 30 seconds (pg 409)
14
Q
Avulsion Fracture of Greater Trochanter Imaging
A
AP radiograph of the pelvis showing the avulsed left greater trochanter.
CT image showing avulsion of the left greater trochanter. The trochanteric apophyseal fragment (T) is lying in a neutral position anterior to the externally rotated femur (F).
15
Q
Avulsion Fracture of Greater Trochanter Treatment
A
ORIF is usually recommended. Following surgery NWB with crutches for 6 weeks is recommended before progressing to FWB. In adults isolated fractures of the greater trochanter have been treated both conservatively and surgically, but are most commonly treated surgically especially when displacement is involved.
16
Q
Adductor Longus Tendinitis Diagnosis
A
Adductor tendinitis is more prevalent among athletes. Some sports where this is commonly seen include football, running, horseback riding, gymnastics, and swimming where the athlete must perform repetitive movements that change directions frequently.
Another cause is the overstretching of the adductor tendons.
17
Q
Adductor Longus Tendinitis Presentation
A
Resisted adduction is positive→ Pain
Pain in the groin→ Hip lesions
Groin pain when palpating the adductor tendons on the pelvis, by closing the legs or abducting from the affected leg. The pain can be gradual or a sudden sharp pain.
The patient can notice swelling or lump in the adductor muscles, stiffness in the groin or inability to contract or stretch the adductors.
18
Q
Adductor Longus Tendinitis Special Tests
A
Adductor Squeeze
- 45 degrees of hip flexion provides optimal force and adductor muscle activity
19
Q
Adductor Longus Tendinitis Imaging
A
Altered signal is seen at the pubic attachment of adductor muscles in this Axial T2 weighted MRI.
20
Q
Adductor Longus Tendinitis Treatment
A
Treatment for adductor tendinitis is initially RICE to aid in decreasing swelling and inflammation. Following RICE or concurrently with RICE physical therapy can be attempted where strengthening and obtaining ideal ROM can be completed.
Corticosteroid injections can be used to reduce inflammation if RICE and physical therapy are not helping.
21
Q
Avulsion Fracture of Lesser Trochanter Diagnosis
A
Avulsion fractures of the lesser trochanter are uncommon injuries. They are mostly seen in adolescent athletes with a 2:1 male to female ratio.
They occur most often in track events like hurdling and sprinting, or games like soccer or tennis.
Most commonly seen in tennis players where rapid uncontrolled hip flexion or rotation of the torso on a fixed externally rotated femur can avulse the lesser trochanter.
22
Q
Avulsion Fracture of Lesser Trochanter Presentation
A
Pain in the groin→ Hip lesions
The athlete will experiences a sudden, shooting pain referred to the involved tuberosity. They may lose muscular function and swelling and local tenderness may also occur.
23
Q
Avulsion Fracture of Lesser Trochanter Special Tests
A
FABER test (Flexion Abduction External Rotation Test) (pg 383)
24
Q
Avulsion Fracture of Lesser Trochanter Imaging
A
Frontal radiograph of the left hip demonstrates an avulsed fragment of bone (white arrow) representing the lesser trochanter of the femur. The fracture is subacute and heterotopic ossification (myositis ossificans) is forming in the soft tissues (black arrow) .
25
Avulsion Fracture of Lesser Trochanter Treatment
ORIF is usually recommended. Following surgery NWB with crutches for 6 weeks is recommended before progressing to FWB.
26
L2 Root Palsy Diagnosis
L2 root palsy can cause compression, as well as discomfort, tingling, numbness or muscle weakness that radiates to the quadriceps.
```
L2 root palsy can be caused by a number of conditions including:
Sciatica
Degenerative disc disease
Herniated disc
Bulging disc
Osteoarthritis
Spinal stenosis
Spondylolisthesis
```
27
L2 Root Palsy Presentation
Resisted flexion is positive→ Weakness
The L2 nerve root innervates the front of the thigh and transmits motor signals that cause the hip to flex. Because of this, L2 root palsy would affect anterior hip sensation and hip flexion strength.
28
L2 Root Palsy Special Tests
Begin by checking the L2 dermatome (mid anterior thigh) for sensation and then check the L2 myotome or hip flexion for muscle activity. Hip flexion is innervated by the femoral nerve.
29
L2 Root Palsy Imaging
Sagittal T2-weighted MRI of an L2 compression fracture. Relatively little deformity of the L2 vertebral body is shown, with less than 5° of kyphotic forward angulation. Compression fractures with little angulation often are associated with significant posterior ligamentous trauma (arrow).
30
L2 Root Palsy Treatment
The symptoms normally can be managed using conservative treatments such as pain medication and physical therapy. However, if chronic lower back pain persists despite weeks of conservative treatment, surgery might become an option.
31
L3 Root Palsy Diagnosis
```
L3 root palsy commonly arise from:
Spondylolisthesis of the L3-L4 segment
Herniation of the L3 disc
Stenosis
Degenerative Disc Disease
Osteoarthritis
```
32
L3 Root Palsy Presentation
Resisted flexion is positive→ Weakness
The L3 nerve root innervates the medial femoral condyle and transmits motor signals that cause the knee to extend. Because of this, L3 root palsy would affect medial femoral condyle sensation and knee extension strength.
33
L3 Root Palsy Special Tests
Begin by checking the L3 dermatome (medial femoral condyle) for sensation and then check the L3 myotome or knee extension for muscle activity. Knee extension is innervated by the femoral nerve.
34
L3 Root Palsy Imaging
Lateral radiograph demonstrates an L3 spinal compression fracture. Note the downward compression of the superior endplate of the L3 (yellow arrow). The anterior portion of the L3 vertebral body has been displaced forward (white arrow).
35
L3 Root Palsy Treatment
Treatment of pain in the L3 segment will be dictated by the underlying diagnosis of the cause of the patient’s pain and the severity of the condition. While many injuries or ailments can be treated with physical therapy or manual manipulation, others will warrant more interventions treatment steps such as spinal injections.
36
S1 Root Palsy Diagnosis
```
Several incidents can cause S1 nerve root palsy including:
Nerve root compression
Disc herniation
Disc degeneration
Compression of the sciatic nerve
Isthmic Spondylolisthesis
```
37
S1 Root Palsy Presentation
Resisted extension is positive→ Weakness
S1 Root Palsy can present with paralysis with involuntary tremors involving the ankle joint since the S1 myotome is in control of ankle plantarflexion, making it hard for one to stand on their toes or ball of the foot. Numbness and/or pain can radiate along the outside of the calf, down to the sole or outside of the foot and the toes.
38
S1 Root Palsy Special Tests
Begin by checking the S1 dermatome (lateral heel) for sensation and then check the S1 myotome or ankle plantarflexion for muscle activity. Ankle plantarflexion is innervated by the tibial nerve. Also one can check the S1 reflex or the achilles tendon reflex.
39
S1 Root Palsy Imaging
Left Sagittal View MRI: A Large "Far Lateral" Herniated Disc at L3,4 (Horizontal Arrow points to the "Black" oblong Herniated Disc "mass" extending out of the L3,4 Disc Space and pushing into the Spinal Canal). In addition, this patient has multi-level degenerative disease as indicated by the Disc Space collapse at L4,5 & L5,S1. Both levels demonstrate "Disc Bulges" (Up-curved Arrows)
40
S1 Root Palsy Treatment
Most cases of lumbar herniated disc symptoms resolve on their own within six weeks, so patients are often advised to start with non-surgical treatments. However, this can vary with the nature and severity of symptoms. Non-surgical treatments include, ice application, pain medications, muscle relaxants, heat therapy, and heat and ice alternations. While applying these interventions, one could attend physical therapy to aid in passive physical therapy to help reduce the patient's pain to a more manageable level followed by active exercises to improve strength and teach the patient better ways to perform strenuous activities that may have caused the initial onset of the disc herniation. If pain is not proving to get better within 6 weeks with these interventions, surgery may become the next option.
41
S1, S2 Root Palsy Diagnosis
```
Several incidents can cause S1, S2 nerve root palsy including:
Nerve root compression
Disc herniation
Disc degeneration
Compression of the sciatic nerve
Isthmic Spondylolisthesis
```
42
S1, S2 Root Palsy Presentation
Resisted flexion of knee is positive→ Weakness
S1 innervation provides the body's ability to plantarflex the ankle while S2 allows the knee to flex. Decreased strength in these movements may be present along with pain coursing down the back of the thigh and lower leg and in the buttock region. Also bowel and bladder loss or dysfunction may be present.
43
S1, S2 Root Palsy Special Tests
Begin by checking the S1 dermatome (lateral heel) and the S2 dermatome (Popliteal Fossa) for sensation and then check the S1 myotome or ankle plantarflexion and the S2 myotome or knee flexion for muscle activity. Ankle plantarflexion and knee flexion are innervated by the tibial nerve. Also one can check the S1 reflex or the achilles tendon reflex.
44
S1, S2 Root Palsy Imaging
A midsagittal T2-weighted MRI illustrating early imaging signs of disc degeneration at L4-5 and L5-S1.
(I was unable to find an image that demonstrated S1,S2 nerve root palsy so I decided to use this image since it labels the vertebrae nicely. As mentioned above this image demonstrates early signs of disc degeneration at the L4-5 and L5-S1 areas.)
45
S1, S2 Root Palsy Treatment
Multiple treatments include:
Rest
Medication to reduce inflammation
Ice in acute cases to reduce inflammation
Steroidal medication to reduce inflammation in moderate to severe conditions
Physical therapy to reduce inflammation, restore joint function, improve motion, and help the return of full function
46
L2-L4 Root Lesion Diagnosis
It is caused by damage to the lower spine which causes compression of the L2-L4 nerve roots which exit the spine. The compression can lead to tingling, radiating pain, numbness, paraesthesia and occasional shooting pains. Radiculopathy can occur in any part of the spine, but it is most common in the lower back.
The most common causes of lumbar radiculopathy are:
A prolapsed disk
Stenosis (either of the central canal or the foramen)
Impinging or irritating a nerve root(s)
47
L2-L4 Root Lesion Presentation
Resisted adduction is positive→ Weakness
Symptoms of nerve root compression or damage are often initial and most prominent complaint of patients with spine disease. Principal symptoms are dermatomal pain, paresthesias, and sensory loss; selective motor loss; and bowel or bladder dysfunction when the cauda equina is involved (L2-L5, S1-S5, and the coccygeal nerve).
48
L2-L4 Root Lesion Special Tests
Begin by checking the L2 dermatome (mid anterior thigh) for sensation and then check the L2 myotome or hip flexion for muscle activity. Hip flexion is innervated by the femoral nerve. Then check the L3 dermatome (medial femoral condyle) for sensation and the L3 myotome or knee extension for muscle activity. Knee extension is innervated by the femoral nerve. Lastly check the L4 dermatome (medial malleolus) for sensation followed by the L4 myotome for muscle activity. The L4 myotome is ankle dorsiflexion and is innervated by the deep peroneal nerve.
49
L2-L4 Root Lesion Imaging
Images of an 82-year-old man with right lower extremity weakness and pain, primarily in the upper leg and thigh. Electromyography suggested right L2, L3, and L4 abnormality.
A−C, Contiguous axial view T2-weighted MR images obtained at the L3–L4 level. Root compression was identified by one observer at L3–L4 on the right (arrows) but was labeled noncompressive (grade 1) by the second observer. Root compression was also correctly identified on the right by both observers at L2–L3 (grades 2 and 3).
D, Conventional myelogram shows right-sided root compression at L2–L3 (curved arrow) and L3–L4 (straight arrow), identified and assessed as grades 2 and 3 by both observers. The patient underwent right-sided keyhole decompression at L2–L3 and L3–L4. Severe root compression was surgically identified at both levels, and the patient achieved resolution of leg pain after surgical decompression.
E−H, Contiguous axial view post-myelogram CT images obtained at the L3–L4 level show slight angular distortion on the right lateral recess (arrows). The nerve roots within the canal are slightly more prominent at this level and may be somewhat edematous. Both observers labeled this lateral recess root compressive (grade 2).
50
L2-L4 Root Lesion Treatment
Medications are used to help with the pain and can improve your quality of life whilst healing take place. Along with medications, one can attend physical therapy to aid in decreasing inflammation and increasing lost ROM. If neither of these seems to be benefiting, one can consider injection therapy or surgery. Injection therapy and surgery are generally only used if other less invasive measures are not providing the desired results within a 6-12 weeks.
51
L3 Root Lesion Diagnosis
Loss of sensation in the L3 dermatome or loss of strength in the L3 myotome as compared to the non affected side may be present with this disorder. Paralysis or pain may also be present coursing down the medial side of the leg following the L3 dermatomal distribution pattern.
52
L3 Root Lesion Presentation
Resisted extension of knee is positive→ Weakness
Symptoms of nerve root compression or damage are often initial and most prominent complaint of patients with spine disease. Principal symptoms are dermatomal pain, paresthesias, and sensory loss; selective motor loss; and bowel or bladder dysfunction when the cauda equina is involved (L2-L5, S1-S5, and the coccygeal nerve).
53
L3 Root Lesion Special Tests
Begin by checking the L3 dermatome (medial femoral condyle) for sensation and then check the L3 myotome or knee extension for muscle activity. Knee extension is innervated by the femoral nerve.
54
L3 Root Lesion Imaging
Images of a 70-year-old man with bilateral leg pain and weakness, with reduced sensation in both upper and lower legs.
A−C, Contiguous axial view T2-weighted MR images show a trefoil-shaped canal at L2–L3 that was judged to be root compression (grade 2) on the right by one observer because of the small recess size but was judged to be noncompressive (grade 0) by the other observer (arrows).
D, Conventional myelogram shows right-sided root compression at L2–L3 (curved arrow), assessed as grades 2 and 3 by both observers. Compression at L3–L4 was also identified by both observers by using MR imaging and conventional myelography. Surgical findings revealed evidence of root compression on the right at L2–L3 as well as at L3–L4. The patient was free of leg pain at the time of postoperative discharge.
E−G, Contiguous axial post-myelogram CT images obtained at the L2–L3 level show narrowing of the right lateral recess (arrows) with a normal appearance of the left lateral recess. One observer graded the right lateral recess as abnormal (grade 2), and the second observer graded this recess as narrow but not compressive (grade 1). Observer grading in this instance was reversed between MR imaging and CT myelography. One observer graded the MR imaging findings as root compressive but graded the CT myelography findings as not compressive. The other observer graded the MR imaging findings as compressive but graded the CT myelography findings as narrow but not root compressive.
55
L3 Root Lesion Treatment
Possible treatments include:
Medications to aid in reducing inflammation and pain
Physical therapy to aid in decreasing inflammation and increasing lost ROM and strength
Spinal injections and surgery only if medications and physical therapy are not obtaining the desired outcomes in a timely manner (6-12 weeks)
56
Fractured Sacrum Diagnosis
- Caused by injury
- Sacral fractures occur in 45% of all pelvic fractures
- Neurologic structures are at risk because of the placement of the lumbosacral plexus
- Denis Classification: (one of the many ways to classify)
- Zone 1: Fractures are lateral to the neural foramina
- Zone 2: Fracture pass through the foramina
- Zone 3: Fractures are medial to the foramen and involve the spinal canal
57
Fractured Sacrum Presentation
- Non-capsular pattern
- Limited ROM
- May see neurological issues
- Pain
58
Fractured Sacrum Special Test
+ Buttock sign
| Neuro screen
59
Fractured Sacrum Imaging
- Transverse sacral fracture at S3
- (A) Outlet radiograph
- (B) Sagittal CT reconstruction
- (C) Coronal CT reconstruction
60
Fractured Sacrum Treatment
-Non-displaced fractures are treated nonsurgical
•Restricted weight-bearing
-Displaced fractures require surgery
61
Aseptic Necrosis Diagnosis
- Also known as avascular necrosis and osteonecrosis
- Poor blood supply to an area of bone resulting in bone death
- Causes include: trauma, damage to the blood vessels that supply bone its oxygen, abnormally thick blood, poor blood circulation to the bone, and atherosclerosis, medications
62
Aseptic Necrosis Presentation
-Non-capsular pattern
-Limited ROM
-May or may not have pain
•Pain can be felt in the groin, buttock, front of the thigh
-Limp with walking
-Stiffness
63
Aseptic Necrosis Special Tests
- Resisted movements are negative
| - X-ray
64
Aseptic Necrosis Imaging
- X-ray (frogleg view) femoral head aseptic necrosis
| - X-ray (AP view) Bilateral femoral head aseptic necrosis
65
Aseptic Necrosis Treatment
-Dependent of the stage of the condition
•Very early stage: nonsurgical (progression of condition still occurs)
•Early stage: surgery (core decompression)
•Later stages: surgery (joint replacement)
66
Gluteal Bursitis Diagnosis
-Cause: Too much repetition or high force, irritation and inflammation of the ischiogluteal bursa
•Prolonged sitting
•Repetitive running, jumping, kicking
67
Gluteal Bursitis Presentation
- Non-capsular pattern
- Lateral trochanteric pain
- Pain in the buttock
- Pain with activities
68
Gluteal Bursitis Special Tests
-Resisted movements are positive
•Resisted medial rotation + (Pain)
•Resisted lateral rotation + (Pain)
69
Gluteal Bursitis Imaging
- (A) MRI, T1
- (B) MRI, T2
- (C) MRI, T1
- (D) MRI, T2
70
Gluteal Bursitis Treatment
- Physical therapy (most patients heal well from PT)
- Medication
- Corticosteroids
- Draining of the bursa
71
Trochanteric Bursitis Diagnosis
-Inflammation of the bursa near the greater trochanter of the femur
-Common causes:
•Acute or chronic trauma
•Hematoma
•Arthritis
•Infection
•Tendon or muscle tear
72
Trochanteric Bursitis Presentation
-Non-capsular pattern
-Lateral hip pain
•Can radiate to the knee or down the lateral side of the thigh
-Pain with activity
-Pain with palpation over the greater trochanter
73
Trochanteric Bursitis Special Tests
-Passive external rotation +
74
Trochanteric Bursitis Imaging
-MRI, T2 trochanteric bursitis
75
Trochanteric Bursitis Treatment
```
-Conservative treatment
•Physical therapy
•Rest
•Ice
•NSAIDs
-Some refractory cases may need corticosteroids or surgery
```
76
Rectus Femoris Tendinitis Diagnosis
```
-Some causes include:
•Overstretching
•Running
•Swimming
•Power walking
•Cycling
•Etc.
```
77
Rectus Femoris Tendinitis Presentation
- Groin pain
- Gradual onset of pain and tenderness at the front of the hip
- Pain and stiffness may be worse after rest
- Pain with hip extension and knee flexion
- May see limited ROM and tightness
78
Rectus Femoris Tendinitis Special Tests
-Resisted movements are positive
•Resisted flexion is + (Pain)
•Resisted extension of the knee is + (Pain)
79
Rectus Femoris Tendinitis Imaging
-MRI, T2, “bull’s-eye” sign
80
Rectus Femoris Tendinitis Treatment
```
-Physical therapy
•US, laser, massage, rehab program
-Rest
-Ice
-Anti-inflammatory medication
```
81
Obturator Hernia Diagnosis
- Rare type of hernia of the pelvic floor
- Pelvic or abdomen contents protrude through obturator foramen
- More common in women
82
Obturator Hernia Presentation
- Pain in the medial thigh
| - Bowel obstruction
83
Obturator Hernia Special Tests
-Resisted movements are positive
•Resisted flexion is + (Pain)
-Howship-Romberg sign
84
Obturator Hernia Imaging
CT
85
Obturator Hernia Treatment
-Surgery and repair of the hernia orifice
86
Avulsion Fracture of ASIS Diagnosis
-Occurs in young athletes
-Causes include:
•Trauma
•Sudden or forceful contraction of Sartorius and TFL
•Can occur during hip extension
-Often a pop or a snap is reported
87
Avulsion Fracture of ASIS Presentation
- Groin pain
- Weakness with hip flexion and knee extension
- Can result in a limp
88
Avulsion Fracture of ASIS Special Tests
-Resisted movements are positive
| •Resisted flexion is + (Pain and weakness)
89
Avulsion Fracture of ASIS Imaging
-Reconstructed 3D CT scan
90
Avulsion Fracture of ASIS Treatment
-Nonsurgical:
•Rest
•Crutches for protected weight bearing
•Early ROM and stretching
-Surgical: ORIF of the avulsion fracture (displacement >3cm)
91
Iliac Apophysitis Diagnosis
- Mechanical overloading injury at the tendon insertion site
- Normally in younger individuals
- In runners this can happen when there is a simultaneous contraction of the abdominal musculature, gluteus medius, and TFL. Excessive arm swing and trunk rotation while running or even a sudden change in direction.
92
Iliac Apophysitis Presentation
- Tenderness with palpation of iliac crest
- Sudden onset of pain
- Swelling
- Weakness
93
Iliac Apophysitis Special Tests
-Resisted movements are positive
| •Resisted abduction is + (Pain and weakness)
94
Iliac Apophysitis Imaging
-X-ray (AP view) Iliac Apophysitis
95
Iliac Apophysitis Treatment
-Several conservative phases:
•1: Rest and protection
•2: Gentle stretching
•3: Progressive resistive exercises
•4: Long term flexibility and strengthening program
-Surgery is rare
96
Hamstring Syndrome Diagnosis
```
-Also known as hamstring tendinosis
•Stress, small tears, thickening
-Semimembranosus tendon mostly affected
-Sometimes biceps femoris
-Usually develops as overuse
```
97
Hamstring Syndrome Presentation
- Pain in the buttock
- Pain at and with palpation at the ischial tuberosity
- Sitting is uncomfortable or painful
- Side differences in forward bending
98
Hamstring Syndrome Special Tests
-Resisted movements are positive
•Resisted flexion of the knee is + (Pain)
-Puranen-Orava test +
-SLR +
99
Hamstring Syndrome Imaging
- MRI, T1
- First image is normal
- Second image is hamstring syndrome
100
Hamstring Syndrome Treatment
```
-Conservative:
•Rest
•Avoid long sitting
•Avoid over stretching
•Mobility exercises of hip
•Muscle strengthening
•Massage
•NSAIDs
•Corticosteroid injections
-Surgery
```
101
Rheumatoid-type Arthritis Diagnosis
-Autoimmune disease where the body attacks the synovium of both sides of the body
-Cause is unknown but possibilities include:
•Genetics
•Environmental factors
•Hormones
102
Rheumatoid-type Arthritis Presentation
```
-Symptoms: (can come on gradually or suddenly)
•Pain
•Stiffness
•Swelling
-Can lead to:
•Hip joint damage
•Loss of function
•Limited ROM
•Disability
```
103
Rheumatoid-type Arthritis Special Tests
Capsular Pattern
104
Rheumatoid-type Arthritis Imaging
-X-ray RA of bilateral hips
105
Rheumatoid-type Arthritis Treatment
- DMARDs
- NSAIDs
- Corticosteroids
- Exercise
- Surgery
106
Monoarticular Steroid Sensitive Arthritis
Presentation- patient will complain of joint pain, aggravated by activity.
Diagnosis- can be initial manifestation many joint disorders. The first step is to rule out surrounding tissue and confirm the pain in the joint. Crystals from gout or psudo gout are the most common cause. One must examine joint fluid for leukocyte/uric acid or use light microscopy to identify crystals
Special Tests- Capsular Pattern
Imaging- X-rays
Treatment- NSAIDS, corticosteroids, exercise, surgery
107
Septic Arthritis(aka infectious)
Presentation- Rapid intense pain, joint swelling, the presence of extra-articular symptoms and usually the triad of Fever, Pain, and Imapired ROM
Diagnosis- Arthrocentesis = look at synovial fluid for luekocyte cell count and infection from bacteria.
Special Tests- Capsular Pattern
Imaging- X-rays to look fr joint damage
Treatment- Powerful antibiotics, drain infected fluid, corticosteroids, NSAIDs for pain
108
Tuberculosis Arthritis
Presentation- Can affect LE joints, wrists, and spine, causing decreased ROM, excessive sweating, low fever, joint swelling, muscle atrophy and spasms, numbness/tingling below affect level of spine, weight loss, and it starts slow.
Diagnosis- Caused by bacteria known as Myobacterium tuberculosis, few people who have TB will get this, affects one joint typically.
Special Tests- Capsular Pattern
Imaging- Chest X-ray, CT of spine, joint x-ray
Treatment- Cure the infection with drugs that fight the TB bacteria: Isnaizid, Rifampin, Pyrazinamide, and ethambutol to name a few.
109
Haemarthrosis
Presentation- Joint pain and inflammation leading to a decrease in PROM/AROM, pain/tenderness upon palpation, bruising around joint, and a tingling sensation may be present.
Diagnosis- Bleeding into joint following injury, but main occurs in patients with a predisposition to hemorrhage (taking warfarin) and is associated with TKA patients, but definitive diagnosis requires joint aspiration.
Special Tests- Capsular Pattern
Imaging- MRI
Treatment- depends on cause, can do synovectomy, menisectomy, osteotomy, ablation, joint replacement, give clotting agents, or Physical Therapy
110
Crystal Synovitis (aka pseudogout)
Presentation: older adults, asymptomatic, can present as acute or chronic inflammatory arthritis, WBC raised, polyarticular, crystal form within aricular tissues, and commonly affects the knees wrists and hips. Due to this it can be misdx as carpal tunnel syndrome.
Diagnosis: Two elements, radiology and joint fluid analysis- X-ray/CT/MRI show calcific mass within joint capsule while arthrocentesis tests for cyrstals with H&E stain.
Special Test: Capsular Pattern
Imaging: H&E Stain applicable?
Treatment: aspiration of synovial fluid, NSAID's, corticosteroids either injection or orally, pulsed US, and possibly total joint replacement
111
Beginning Arthrosis
Presentation: develops slowly with early stages casuing cartilage erosion that can go unnoticed for a long time because it is a non-inflammatory disease that does not present until it is too late, and the patient is in the early stages of arthritis. The pain is typically monoarticular, worse during movement, and stiff in general, but not accompanied by swelling. The patient may begin to notice loss of ROM and bony outgrowths may be felt with palpation. Essentially early arthritis.
Diagnosis: Mechanical stress on articular cartilage causing wear and tear. Typically related to age, obesity, genetics, hormonal imabalances, and work.
Special Tests: Capsular Pattern
Imaging: X-Ray = degredation of cartilage and possible narrowing of joint space, but that would be arthritis.
Treatment: Manage pain and reduce stress on joints. Modalities, NSAID's, Cortisone, chronic = mobs, and hot therapies.
112
Hamstring Tendonitis
```
Presentation
Diagnosis
Special Tests
Imaging
Treatment
```
113
Pain in the groin: referred from Aneurysms
| Diagnosis
Abdominal Aortic Aneurysms are areas of the Aorta at the level of the abdomen that are swollen or bulging out due to weak walls. The cause is unknown, but risk factors include: High BP, Smoking, and Vascular Infection,
114
Pain in the groin: referred from Aneurysms
| Presentation
Most aneurysms have no symptoms unless they rupture. If this does occur you can experience: Sudden pain in the abdomen or back that can move into your pelvis legs or buttocks, increased HR, shock or loss of consciousness, sweaty or clammy skin.
115
Pain in the groin: referred from Aneurysms
| Special Tests
```
CT scan of the abdomen
abdominal ultrasound
chest X-ray
abdominal MRI study
Palpation of a pulsing mass
```
116
Pain in the groin: referred from Aneurysms
| Imaging
This is a CT scan of an abdominal aortic aneurysm
117
Pain in the groin: referred from Aneurysms
| Treatment
Option 1: The doctor will monitor the aneurysm regularly and continue to assess the situation. This is done normally if the aneurysm is small.
Option 2: Endovascular Surgery is less invasive and uses a graft to repair weak walls of the aorta.
Option 3: Open Abdominal Surgery is done with the aneurysm is large or fast growing or if it has already ruptured.
118
Pain in the groin: referred from Genitalia
| Diagnosis
Orchitis is inflammation of the testicles due to a virus or bacteria. It can present in both testicles, but is more common to occur in only one. A common cause of this is the mumps.
119
Pain in the groin: referred from Genitalia
| Presentation
Pain in the testicles or groin is normally the primary sign, but you can also have: tenderness in the scrotum, painful urination, painful, ejaculation, a swollen scrotum, blood in the semen, abnormal discharge, an enlarged prostate, swollen lymph nodes in the groin,
a fever
120
Pain in the groin: referred from Genitalia
| Special Tests
A doctor may ask questions about past medical history as well as doing a physical to rule out other diagnosis. A ultrasound can also be performed.
121
Pain in the groin: referred from Genitalia
| Imaging
This is an Ultrasound of Orchitis in the left testicle.
122
Pain in the groin: referred from Genitalia
| Treatment
Bacterial Orchitis can be treated with antibiotics and anti-inflammatory drugs.
Viral Orchitis has no cure, but will go away on its own over time.
You can manage symptoms with ice, elevation, and pain relievers.
123
Pain in the groin: referred from Urinary Tract
| Diagnosis
A UTI is caused by the growth of bacteria in any part of the urinary system. This occurs most commonly in the bladder.
124
Pain in the groin: referred from Urinary Tract
| Presentation
```
Chills and shaking or night sweats
Small amount of urine, even though you have urge to go
Side, back or groin pain (sometimes severe abdominal pain)
Fatigue and general ill feeling
Flushed, warm, or reddened skin
Mental status changes or confusion (particularly in the elderly)
Frequent and urgent urination
Painful or difficult urination
Discomfort above the pubic bone
Blood in the urine
Cloudy or foul smelling urine
Nausea and/or vomiting
Fever above 101° Fahrenheit
```
125
Pain in the groin: referred from Urinary Tract
| Special Tests
A urinalysis is the best test with a urine culture used to specify which antibiotic is best.
126
Pain in the groin: referred from Urinary Tract
| Imaging
Imaging is only done to see if the anatomy predisposes someone to getting UTI's.
CT scan of the abdomen
Intravenous pyelogram (IVP) Kidney scan
Kidney ultrasound
Voiding cystourethrogram
127
Pain in the groin: referred from Urinary Tract
| Treatment
Antibiotics are used to treat UTI's.
Pain relievers and heating pads can improve symptoms. Drinking plenty of water and avoiding alcohol, caffeine and smoking can improve recovery.
128
Pain in the groin: referred from Rectus Abdominus
| Diagnosis
A Desmoid Tumor is a fibrous neoplasm that can occur in the abdominal wall as well as over the rest of the body. It occurs more commonly involving genetics, but can still occur rarely in random cases.
129
Pain in the groin: referred from Rectus Abdominus
| Presentation
Internal Desmoid Tumors on the abdominal wall can cause severe pain, rupture of intestines, compression of the kidneys or ureters or rectal bleeding. They look or feel like firm lumps under the skin if they are superficial enough to notice at all.
130
Pain in the groin: referred from Rectus Abdominus
| Special Tests
A biopsy is needed to confirm a tumor although an Ultrasound is usually first used to identify the tumor. An MRI or CT can later be used to determine if the tumor is attached to surrounding tissue.
131
Pain in the groin: referred from Rectus Abdominus
| Imaging
Ultrasounds are used to Identify Desmoid Tumors, but MRI and CT can be used for further exam if the tumor is free floating or not. This image is a CT with contrast.
132
Pain in the groin: referred from Rectus Abdominus
| Treatment
Radiation or Chemotherapy are commonly used along with surgery to remove the tumors and to try to prevent recurrence. A multi-disciplinary team is usually needed for best outcomes.
133
Sacroiliac Joint Strain
| Diagnosis
Sacroiliac Joint dysfunction can come from the joint being either hyper or hypo mobile. Dysfunction can occur because of muscle surrounding the SI joint being to active or by being weak.
134
Sacroiliac Joint Strain
| Presentation
SI joint dysfunction can commonly be mistaken for many other diagnosis. It presents with pain in the lower back, hip, groin buttock and sciatic region. It is typically worse with standing or walking or other physical activity of the hip.
135
Sacroiliac Joint Strain
| Special Tests
A thorough exam by a PT is the best diagnostic method.
136
Sacroiliac Joint Strain
| Imaging
X-Ray is very ineffective and MRI is done usually just to rule out other diagnosis.
137
Sacroiliac Joint Strain
| Treatment
Techniques to reduce inflammation such as ice and electrotherapy are used as well as rest and deloading of the joint. NSAIDS can also be used.
Therapy to return ROM and strength follows after the inflammation has been controlled.
138
Iliolumbar strain
| Diagnosis
A strain of the iliolumbar ligament that connects the 4th and 5th lumbar vertebrae to the iliac bone at the back of the pelvis.
139
Iliolumbar strain
| Presentation
Pain in the lumbar region with occasional sudden stabbing sensations. The area can feel tendor or even weak.
140
Iliolumbar strain
| Special Tests
Clinical Examination
141
Iliolumbar strain
| Imaging
Imaging not normally used.
142
Iliolumbar strain
| Treatment
Anti-inflammatory drugs, ice, rest.
| Once pain subsides then stretching and strengthening can begin.
143
Septic bursitis diagnosis
Inflammation of the bursa due to infection. Results in significant edema.
144
Septic bursitis presentation
Patient may present with:
- redness/warmth of area
- local tenderness, stiffness
- edema
- pain
- (+)buttock sign
145
Septic bursitis special tests
Bursa fluid punction to confirm infection of bursa.
Cyriax sign of the buttock
146
Septic bursitis imaging
X-ray to rule out arthritis and bone deformities.
Axial and Coronal T2 weighted MRI to confirm clinical suspicion.
147
Septic bursitis treatment
Antibiotics
Bursa aspiration every 3 days
Do not use steroids
Excision in severe cases or when other methods fail.
148
Ischiorectal Abscess Diagnosis
Occurs in deeper tissue of ischiorectal region.
Infection in space between rectum and pelvis
Horseshoe shaped abcess
Commonly develop in those with hematologic disease
149
Ischiorectal Abscess Presentation
Throbbing, constant pain in perianal region.
Swelling in anal region
Reported bleeding, constipation, or diahrrea.
May experience chills or fever
150
Ischiorectal Abscess Special Tests
Refer to a physician
Complete Blood Count
Pus sample from abcess to confirm organism responsible for infection
151
Ischiorectal Abscess Imaging
Usually not required for diagnosis
Axial and Coronal T2 weighted MRI useful to identify abscess.
152
Ischiorectal Abscess Treatment
Drainage and antibiotics to eliminate infection.
Surgical intervention is indicated in severe cases in which tissue death has occurred.
153
Osteomyelitis of upper femur diagnosis
Bone infection
Can be result of open fracture, infected intramedullary nail, or idiopathic
More common in immunodepressed patients
154
Osteomyelitis of upper femur presentation
May present with:
- Pain/tenderness (deep constant)
- Inflammation, edema, warmth in affected area
- fever, chills, sweating
- nausea, malaise
- distal extremity swelling
Antalgic gait pattern
155
Osteomyelitis of upper femur special tests
Refer to physician if infection is suspected.
156
Osteomyelitis of upper femur imaging
X-Ray not as sensitive to detect changes.
- AP
- lateral
MRI is imaging of choice.
- T2 weighted
- axial
- sagittal
- coronal
157
Osteomyelitis of upper femur treatment
Treat immediately with high dose antibiotic.
Surgery indicated if tissue necrosis if present.
Amputation is considered if severe.
158
Loose Femoral Prosthesis Diagnosis
Usually occurs after 5-10 years post THA.
Often seen in patients who do not follow restrictions or are very active.
159
Loose Femoral Prosthesis Presentation
Patient Presentation:
- thigh pain
- pain during walking
- antalgic gait pattern
- obesity
- radiating pain into knee or low back
160
Loose Femoral Prosthesis Special Tests
None
Patient history and presentation.
161
Loose Femoral Prosthesis Imaging
X-rays
- A/P
- Bilateral Frog leg
- Bilateral projection
162
Loose Femoral Prosthesis Treatment
Surgical Revision
163
Traumatic Arthritis:
| Diagnosis
Traumatic arthritis is diagnosed through the following:
• Thorough patient history – hx of traumatic injury or surgery, how and when the joint is bothersome, what makes it better/worse?
• Blood Testing
• Diagnostic Imaging
164
Traumatic Arthritis:
| Presentation
```
Occurs following a traumatic incident to the articular cartilage.
Signs & Symptoms:
• Capsular pattern of the affected joint
• Joint pain & tenderness
• Inflammation
• Fluid accumulation around the joint
• Decreased ROM
• Decreased tolerance of activities
• Potential Inability to bear weight
```
165
Traumatic Arthritis:
| Special Tests
There are no special tests for this condition, however blood tests may be ordered.
166
Traumatic Arthritis:
| Imaging
X-ray: AP view of R pelvic tilt due to R coxofemoral arthritis
167
Traumatic Arthritis:
| Treatment
* Anti-inflammatory drugs
* Low impact exercise
* Lifestyle changes
* Weight loss
* Surgery is an option in severe cases
168
Psychogenic Pain:
| Diagnosis
Diagnosis is made when symptoms or exam findings are not compatible with the function of the nervous system.
Medical doctors and mental health specialists working together are often most helpful to those with this disorder.
169
Psychogenic Pain:
| Presentation
```
Common symptoms include:
• Headaches
• Muscle pains
• Back pain
• Stomach pains
```
170
Psychogenic Pain:
| Treatment
Treatment for psychogenic pain may include:
• Psychotherapy
• Antidepressants with pain reducing properties
• Non-narcotic painkillers
171
Psychoneurosis:
| Diagnosis
Psychoneuroses are minor mental disorders characterized by inner struggles and disturbed social relationship.
Two essential features: precipitated by emotional stresses, conflicts and frustrations and are most effectively treated by psychological techniques.
172
Psychoneurosis:
| Presentation
```
Frequent psychological complaints are:
• Anxiety
• Depressed spirits
• Inability to concentrate or make decisions
• Memory disturbances
• Irritability
• Morbid doubts
• Obsessions
• Irrational fears
• Insomnia
Common physical symptoms include:
• Loss of voluntary control of sensory functions
• Shortness of breath
• Persistent tension
• Fatigue
• Headaches
• GI disturbances
• Multiples aches and pains
```
173
Psychoneurosis:
| Treatment
Referral to a psychologist for individual psychotherapy and behavior modification therapy.
174
Femur Metastasis:
| Diagnosis
The femur is the most likely long bone to be affected by metastatic bone disease. The upper third is involved in 50% of cases.
Diagnosis is made following a biopsy of the area and lab workup.
175
Femur Metastasis:
| Presentation
Patients with lower extremity metastasis have concerns related to pain and ability to walk. Fractures are more common and the surgical techniques to stabilize the bones are becoming more standardized.
176
Femur Metastasis:
| Special Tests
* Screen for red flags such as:
* Severe pain out of proportion to musculoskeletal origin
* Night pain
* Positive sign of the buttock
* Empty end feels = noncapsular pattern of joint restriction
177
Femur Metastasis:
| Imaging
Whole body bone scan - intense uptake present in left upper femur, correlating with diagnosis of femoral metastasis
178
Femur Metastasis:
| Treatment
Femoral head & neck: Procedure of choice = joint replacement. The indication for partial vs. total hip reconstruction is determined by the extent of acetabular involvement.
Femoral shaft: treated with plates or placement of a metal rod down the central canal of the bone
Supracondylar: This weakened area of the bone may be stabilized with a plate and screws. If the metastasis effects the joint a knee replacement may be beneficial.
179
Psoas bursitis diagnosis
Inflammation in Psoas Bursa (largest in body)
Can be caused by overuse of hip flexor, extensor groups.
Common in rheumatoid arthritis
180
Psoas bursitis presentation
Presentation:
- pain in anteromedial thigh
- radiating pain
- upper quad tenderness
- snapping sensation in anterior thigh
- pain during active/passive hip flexion
- pain during internal rotation
- stiffness or pain after rest
- worsens during activity
- relieved with rest.
181
Psoas bursitis special tests
Deep palpation to femoral triangle
182
Psoas bursitis imaging
X-Ray to rule out bone pathology
- AP
- Lateral
T2 MRI
- axial
- coronal
- sagittal
183
Psoas bursitis treatment
Conservative:
- rest
- cryotherapy
- lengthen hip flexors
- strengthen external hip rotators
- increase hip stability
184
Gluteus maximus lesion diagnosis
Can be the result of trauma or injury to the gluteus maximus. Hematoma may form in the gluteus maximus.
May also include gluteal strain.
185
Gluteus maximus lesion presentation
Pain with resisted hip extension.
Strain
- sudden or sharp pulling sensation in region.
- increase in pain with activity
- morning pain
Hematoma
- palpable lump
- pain in region
- skin discoloration
186
Gluteus maximus lesion special tests
Resisted hip extension test
Sign of the Buttock
187
Gluteus maximus lesion imaging
X-Ray to rule out bony pathology
- AP
- Lateral
T1/T2 MRI to examine soft tissue of gluteal group
- coronal
- sagittal
- axial
188
Gluteus maximus lesion treatment
```
Sprain:
Conservative
-RICE
-strengthening of affected tissues
-soft tissue massage
-scar management
```
Hematoma
- refer to physician
- do not use heat
189
Inguinal Hernia Diagnosis
Protrusion of soft tissue from abdominal cavity.
Direct: intestine protrudes through weak point in abdominal wall
Indirect: intestine protrudes through deep inguinal ring
190
Inguinal Hernia Presentation
Direct
- painless
- reduces when supine
- round swelling near pubis
Indirect
- pain with straining
- may decrease when supine
- increased protrusion with increased intra-abdominal pressure
191
Inguinal Hernia Special Tests
Palpation while coughing
| -increased protrusion should occur while coughing.
192
Inguinal Hernia Imaging
Usually not required.
ultrasonography
Axial CT scan
193
Inguinal Hernia Treatment
Conservative
- watch and wait.
- patient education to reduce abdominal pressure
Surgical
- herniorrhaphy
- laparoscopy
- hernioplasty
- activity restrictions
194
Ilioinguinal Hernia Diagnosis
Protrusion of soft tissue from abdominal cavity.
Direct: intestine protrudes through weak point in abdominal wall
Indirect: intestine protrudes through deep inguinal ring
195
Ilioinguinal Hernia Presentation
Direct
- painless
- reduces when supine
- round swelling near pubis
Indirect
- pain with straining
- may decrease when supine
- increased protrusion with increased intra-abdominal pressure
196
Ilioinguinal Hernia Special Tests
Palpation while coughing
| -increased protrusion should occur while coughing.
197
Ilioinguinal Hernia Imaging
Usually not required.
ultrasonography
Axial CT scan
198
Ilioinguinal Hernia Treatment
Conservative
- watch and wait.
- patient education to reduce abdominal pressure
Surgical
- herniorrhaphy
- laparoscopy
- hernioplasty
- activity restrictions
199
Ischial Bursitis Diagnosis
Rare
Usually results from chronic microtrauma.
Occurs most commonly in sedentary individuals
Acute but can become chronic inflammation of bursa
200
Ischial Bursitis Presentation
Pain/warmth over ischial tuberosity
Pain while sitting/sidelying
Swelling
Regional Muscle dysfunction
Limitation in hip flexion
201
Ischial Bursitis Special Tests
Trendelenberg test
Leg length test
Straight leg raise
Active resisted hip extension
202
Ischial Bursitis Imaging
X-ray to rule out bone involvement
- AP
- Bilateral view
T1/T2 weighted MRI to confirm inflammation of ischial bursae
- Axial
- Sagittal
- Coronal
203
Ischial Bursitis Treatment
Conservative
- NSAIDS
- Rest
- cryotherapy
- hamstring stretching
- increase hip rotator strength
Surgical:
-injection of steroid and local anesthetic into bursa.
204
Inflamed Gluteal Bursa Diagnosis
Commonly caused by repetitive trauma.
Inflammation of the ischiogluteal bursa.
Can be the result of restricted hamstrings or activities that require kicking and jumping.
205
Inflamed Gluteal Bursa Presentation
Resisted hip extension is positive
Pain in lower glute
Pain worsened by activities
Inflammation/warmth/redness over gluteal bursa
May demonstrate pain in the hamstring tendons.
Hamstring Weakness
206
Inflamed Gluteal Bursa Special Tests
Resisted hip extension test
Palpation of gluteal bursa
207
Inflamed Gluteal Bursa Imaging
X-ray to rule out bone involvement
- AP
- Bilateral view
T1/T2 weighted MRI to confirm inflammation of gluteal bursa
- Axial
- Sagittal
- Coronal
208
Inflamed Gluteal Bursa Treatment
Conservative:
- Rest
- cryotherapy
- pain management
- NSAIDS
- activity modification
209
Osteitis Pubis:
| Diagnosis
Pathophysiology: The gradual ossification and widening of the pubic symphysis.
Caused by rotational, tension, or shear forces placed on the symphysis, fractures, or possibly a leg length discrepancy. In the physically active population, long-term activites such as running, kicking, or vigorous ice skating may lead to the development of this condition.
210
Osteitis Pubis:
| Presentation
Patients complain of pain centered over the symphysis pubis, lower abdominal muscles, and adductor muscles. Spasm of the adductor muscles may also occur.
Walking, rising from seated position, or any motion that places shear forces on the symphysis pubis may also be symptomatic.
211
Osteitis Pubis:
| Special Tests
* Valsalva maneuver - rule out athletic pubalgia/hernia
| * Hip scour & FABER tests - rule out hip labral tear
212
Osteitis Pubis:
| Imaging
X-ray images are typically negative until approximately 4 weeks when some widening of the pubic symphysis may be seen on an AP film. As this condition progresses, sclerosis and osteolysis can be seen.
213
Osteitis Pubis:
| Treatment
Osteitis Pubis:
Treatment Goals: Alleviate pain, decrease inflammation, restore flexibility, & reveal mechanical problems that caused the condition.
• Rest, Ice, NSAIDs, stretching/yoga, and occasional manipulation may be beneficial once pain has subsided.
214
Sacroiliac Joint Lesion:
| Diagnosis
Inspection: assess for asymmetric pelvic height, leg length discrepancy, scoliosis, and hip motion restriction.
Palpation (most reliable indication of SIJ pain): reproduction of pain over PSIS. More diffuse back or buttock and leg pain - suspect differential diagnosis
215
Sacroiliac Joint Lesion:
| Presentation
The key element in the diagnosis of SIJ dysfunction is pain.
Quality: dull ache or sharp, stabbing, or knifelike.
Distribution: buttock region, posterior thigh, and upper back. Can be unilateral or bilateral.
Patients typically report pain in one or both buttocks at or near the PSIS. Pain especially worsens when they have been sitting for long periods or when they perform twisting motions.
216
Sacroiliac Joint Lesion:
| Special Tests
* Gaenslens test: +
* FABER: + for pain in SIJ
* Thigh trust: +
* Sacral thrust: +
* Mennell’s Test: +
217
Sacroiliac Joint Lesion:
| Imaging
Typical SIJ examination is performed using AP pelvis/lumbar spine radiography. Sclerosis or obliteration of the SIJ can be observed in older patients.
Patients with ankylosing spondylitis usually have normal radiographic findings; in older patients with this disease, the joint can appear fused
Below is an AP x-ray depicting bilateral sacroiliac joint sclerosis and irregular widening in keeping with ankylosing spondylitis.
218
Sacroiliac Joint Lesion:
| Treatment
Acute phase: Pain control – ultrasound/phonophoresis, cryotherapy, myofascial release, muscle energy techniques. Avoid activities that aggravate the condition
Chronic phase: recovery cannot proceed without active, aggressive rehab. Address muscle imbalances:
• Shortened/tight: hip flexors, hamstrings, TFL, obturator internus, and rectus femoris.
Weak/inhibited: gluteal and abdominal muscles
Correct any mechanical or leg-length asymmetries, stretch overly tight lumbopelvic muscles, and strengthen weak and inhibited muscles.
219
Neoplasm in the illium diagnosis
tumor located in the illium.
Often secondary neoplasm.
220
Neoplasm in the illium presentation
Pain tenderness over area
Swelling
Palpable soft tissue mass
Antalgic gait
Limited ROM
221
Neoplasm in the illium special tests
(+) buttock sign
Painful AROM, PROM, ARROM of hip.
Refer to physician
Blood tests
222
Neoplasm in the illium imaging
X-ray
- AP
- Bilateral projection
Bone scan with tracer
PET/CT scan
- Axial
- coronal
- sagittal
T1/T2 MRI
- Coronal
- Sagittal
- Axial
223
Neoplasm in the illium treatment
Chemotherapy
Radiation therapy
Surgical excision
Post-op physical therapy
224
Neoplasm at the upper femur diagnosis
Malignant tumor located in the proximal femur.
Often secondary neoplasm.
225
Neoplasm at the upper femur presentation
Pain tenderness over area
Swelling
Palpable soft tissue mass
Antalgic gait
Limited ROM
226
Neoplasm at the upper femur special tests
(+) buttock sign
Painful AROM, PROM, ARROM of hip.
Refer to physician
Blood tests
227
Neoplasm at the upper femur imaging
X-ray
- AP
- Bilateral projection
Bone scan with tracer
PET/CT scan
- Axial
- coronal
- sagittal
T1/T2 MRI
- Coronal
- Sagittal
- Axial
228
Neoplasm at the upper femur treatment
Chemotherapy
Radiation therapy
Surgical excision
Post-op physical therapy
229
Septic Sacroiliac Arthritis Diagnosis
Bacterial arthritis.
Most common in the hip and knee
230
Septic Sacroiliac Arthritis Presentation
Symptoms in newborns/infants:
- Cries when infected joint is moved
- Fever
- Unable to move the limb
- Irritability
Symptoms in adults:
- Unable to move the limb
- Intense sacroilliac pain
- radiating pain
- Joint swelling
- Joint redness
- Low fever
- Chills may occur
- Possible Tachycardia
231
Septic Sacroiliac Arthritis Special Tests
Symptoms should lead to referral.
- FABER
- Thigh Thrust Test
- Gaenslen test
- Mennell’s
- scaral thrust test
232
Septic Sacroiliac Arthritis Imaging
X-ray
- A/P
- Bilateral projection
T1/T2 MRI
- coronal
- axial
- sagittal
233
Septic Sacroiliac Arthritis Treatment
Needle joint aspiration
IV antibiotic administration based on cultures.
Severe cases may indicate surgical removal of infected joint tissue.
Post infection physical therapy
234
Glute med/min lesion:
| Diagnosis
* Typically chronic onset with no specific injury
* Tearing is a typically a degenerative process
* Highly correlated with trochanteric bursitis
235
Glute med/min lesion:
| Presentation
* Pain at the side of the hip which can extend up to the buttock
* Weakness when lifted the leg to the side
* Pain rolling over in bed on the affected side
* Fatigue easily with prolonged walking
236
Glute med/min lesion:
| Special Tests
* Trendelenburg: +¬¬
* Resisted Hip Abduction: +
* Passive Internal Rotation Test: +
237
Glute med/min lesion:
| Imaging
T2 weighted MRI displaying a gluteus medius tear with high signal
238
Glute med/min lesion:
| Treatment
* Physical therapy treatment of a strain to the gluteus medius:
* Decrease inflammation
* Decrease pain
* Increase hip ROM
* Increase strength
* Treatment of a tear of the gluteus medius: surgery
239
Tensor Fascia Latae lesion:
| Diagnosis
* Typically associated with an overuse injury resulting from:
* Running, climbing, cycling, dancing, excessive walking
* Court sports requiring cutting motions: basketball, volleyball, and tennis
240
Tensor Fascia Latae lesion:
| Presentation
* Pain in the outer hip
* Referred pain down the outer thigh
* Pain when lying on the affected hip
* Increased pain with weight bearing on affected side
241
Tensor Fascia Latae lesion:
| Special Tests
* Resisted Hip Abduction: +
| * Ober Test: +
242
Tensor Fascia Latae lesion:
| Imaging
AP x-ray of the left hip demonstrates a large crescent-shaped bone fragment adjacent to the ASIS compatible with avulsion fracture (attachment site of tensor fascia latae)
243
Tensor Fascia Latae lesion:
| Treatment
* Responds well to physical therapy:
* Decrease inflammation & pain
* Increase flexibility of hip abductors
* Trigger point release
* Increase strength of hip musculature
244
Trochanteric Bursitis:
| Diagnosis
* Trochanteric bursitis can result from:
* Direct pressure
* Overuse injury
* Tear of the gluteus medius
* Running on banked surfaces
* Leg length discrepancy
* Lateral hip surgery
* Increased Q-angle
* **may mimic s/s of femoral neck stress fracture**
245
Trochanteric Bursitis:
| Presentation
* Dull pain and irritation in the lateral hip
* Pain during midstance phase of gait
* Point tenderness over the greater trochanter
* Pain may radiate posteriorly or into the thigh
* Bursal swelling may be present but may be difficult to distinguish
246
Trochanteric Bursitis:
| Special Tests
* Resisted Hip Abduction: +
* Single-leg stance (held for 30 seconds): +
* Resisted external rotation: +
247
Trochanteric Bursitis:
| Imaging
T2 weighted MRI showing a thickened wall and fluid collection in the left trochanteric bursa.
248
Trochanteric Bursitis:
| Treatment
* Responds well to physical therapy:
* Decrease pain
* Decrease inflammation
* Stretching of ITB
* Increase hip strength
* Anti-inflammatory medications/cortisone injections
249
Hemorrhagic Psoas Bursitis Diagnosis
Inflammation of the illipsoas bursa that is the result of trauma to the area. Bleeding into the bursae results in destruction and further irritation to the bursa.
250
Hemorrhagic Psoas Bursitis Presentation
Patient Presentation:
- Swelling of bursa
- extreme tenderness
- pain and impaired function
- decreased hip ROM
- redness and skin discoloration.
251
Hemorrhagic Psoas Bursitis Special Tests
No special tests usually needed.
Resist active hip movement
252
Hemorrhagic Psoas Bursitis Imaging
Not usually required
Ultrasonography
T1/T2 weighted MRI
- coronal
- sagittal
- axial
253
Hemorrhagic Psoas Bursitis Treatment
Rest
Injection of local anaesthetic
Fluid aspiration of bursa
NSAIDs
254
Abdominal Neoplasm Diagnosis
Neoplasm within the abdomen or the abdominal wall.
255
Abdominal Neoplasm Presentation
Patient presentation
- weight loss
- abnormal swelling
- pain localized to the abdomen
- general malaise
256
Abdominal Neoplasm Special Tests
none
palpation of abdominal mass
257
Abdominal Neoplasm Imaging
- Early ultrasound or CT scan.
- Ultrasound or CT-guided fine-needle biopsy.
-FBC with film, ESR, U&Es.
LFTs.
-CXR and abdominal X-ray.
258
Abdominal Neoplasm Treatment
Chemotherapy
Radiation therapy
Surgical intervention
259
Intermittent Claudication Diagnosis
Decreased blood flow to active tissues during exercise resulting in pain or decreased function. Usually a symptom of underlying disease such as peripheral artery disease.
260
Intermittent Claudication Presentation
Patient presentation:
- pain during exercise
- intermittent pain
- unexplained leg pain
- pain during rest
- discolored skin or ulcerations
- can result in a blueish tinge to distal extremities.
Refer to physcian
261
Intermittent Claudication Special Tests
Van Gelderen bicycle test
Check dorsal pedal pulse for decrease
262
Intermittent Claudication Imaging
Angiogram
| Aortogram
263
Intermittent Claudication Treatment
Behavior modification
- halt smoking
- angioplasty to remove flow restriction.
http: //ptjournal.apta.org/content/79/6/582
* nice case study
264
Lesion of L5 Nerve Root:
| Diagnosis
* Can be caused by a disc herniation at the level of L5-S1
* Numbness, paresthesias, and pain in the L5 distribution (see image)
* Weakness of the tibialis anterior, peroneal muscles, and gluteus medius.
* A circumduction gait may be noted due to decreased innervation of the tibialis anterior.
* Increased ankle inversion may also be seen due to decreased innervation of the peroneal muscles.
* Decreased hip abduction strength
265
Lesion of L5 Nerve Root:
| Presentation
* Pain in the buttock, posterior lateral thigh, calf, and foot (“sciatica”)
* Footdrop with weakness or possible atrophy of the anterior tibial, posterior tibial, and peroneal muscles
* Sensory loss over the shin and dorsal foot
266
Lesion of L5 Nerve Root:
| Special Tests
* Resisted Hip Abduction: +
* Resisted Hip Internal Rotation: +
* Trendelenburg test: +
* Valsalva maneuver: +
* Lower Quarter Neurologic Screen: diminished sensation of L5 dermatome (see image), extension of toes, and achilles tendon reflex.
267
Lesion of L5 Nerve Root:
| Imaging
Sagittal T2 weighted image of the lumbar spine.
L4-5: focal right paracentral disc extrusion extends inferiorly and impinges the descending L5 nerve root in the right lateral recess. No significant central canal or foraminal narrowing.
268
Lesion of L5 Nerve Root:
| Treatment
* Responds well to physical therapy interventions such as:
* Therapeutic exercises:
* Lumbar stabilization
* Core strengthening
* Myofascial release or massage to increase surrounding soft tissue extensibility
* Lumbar traction (disc involvement)
* Patient education of proper lifting techniques - keep the back safe
* Surgical intervention may be required if radiculopathy is severe
269
IT Band Syndrome:
| Diagnosis
* Inflammation of the Iliotibial band as a result of:
* Repetitive flexion/extension of the knee
* Decreased flexibility of the ITB increased tension on the ITB
* Long distance running/walking/cycling
* Leg length discrepancy
* Abnormal pelvic tilt
* Genu varum
270
IT Band Syndrome:
| Presentation
* Lateral knee pain or irritation
* Pain may be exacerbated by running hills, at heel strike, or walking up or down stairs.
* Reports of an audible, repetitive popping in the knee with walking or running.
271
IT Band Syndrome:
| Special Tests
* Ober Test: +
* Resisted Hip Abduction: +
* Thomas Test: + with lateral excursion of the LE
272
IT Band Syndrome:
| Imaging
T2-weighted MRI demonstrates edema between the iliotibial band and the lateral femoral condyle. The edema’s location is consistent with a diagnosis of iliotibial band syndrome.
273
IT Band Syndrome:
| Treatment
* Responds well to physical therapy management:
* Decrease inflammation and pain
* Stretching of the ITB
* Trigger point release of TFL or hip abductors
* Strengthening of hip musculature
274
Muscle lesion of the quadratus femoris
| Diagnosis
A lesion can occur with simple activities such as twisting, lifting, or quickly changing directions. Exercising or being suddenly active can cause lesions as well if the muscles are not warmed up first.
275
Muscle lesion of the quadratus femoris
| Presentation
Depending on the severity of the lesion the pt might feel discomfort, sharp pain, or very sharp pain. There could also be bruising or swelling within a couple hours or days.
276
Muscle lesion of the quadratus femoris
| Special Tests
Adequate history and thorough exam.
Radiographs
Ultrasound
MRI
277
Muscle lesion of the quadratus femoris
| Imaging
T2 image of a quad lesion
278
Muscle lesion of the quadratus femoris
| Treatment
RICE, NSAIDS, followed by stretching, strengthening, ROM, proprioception exercises.
279
Rectus Femoris Tendonitis
| Diagnosis
Inflammation of the tendon due to trauma or overuse injuries. Can be caused by forceful movements or activity without proper stretching or warming up.
280
Rectus Femoris Tendonitis
| Presentation
pain at the hip
difficulty extending the knee
tenderness
Decreased ROM or strength
281
Rectus Femoris Tendonitis
| Special Tests
ROM, MMT
x-ray to check for avulsion
MRI to identify involved tendon and severity.
282
Rectus Femoris Tendonitis
| Imaging
X-Ray can be used to check for avulsions
| T2 MRI to identify involved tendon and severity.
283
Rectus Femoris Tendonitis
| Treatment
RICE, stretching and strengthening
284
Metastasis of femur
| Diagnosis
Cancer cells that break off from a tumor and deposit into bone.
They are classified as either osteolytic or osteoblastic lesions depending on the way the interact with the bone.
285
Hamstring Tendonitis: Diagnosis
- Resisted Extension will cause pain
- Overuse injury common in running and jumping activities
- excessive speed changing whilst running
- insufficient warm-up to exercise
- poor core strength
286
Hamstring Tendonitis: Special Tests
Bent Knee Stretch test
| Tripod Test
287
Metastasis of femur
| Imaging
CT scan of metastasis of femur
288
Metastasis of femur
| Treatment
Chemotherapy, targeted therapies, hormone therapies, radionuclide therapy, surgery, radiation therapy.
289
Pubis ramus fracture
| Diagnosis
Classified as either stable or unstable fractures.
Stable - normally low energy, one break that lines up well.
Unstable - Higher energy with multiple break points that do not line up correctly.
290
Partial rupture of Rectus Femoris: Diagnosis
Caused by explosive movements
| Overuse and repetitive
291
Pubis ramus fracture
| Special Tests
Physical exam with a neuro screen
| X-ray, CT scan, MRI
292
Partial rupture of Rectus Femoris: Treatment
RICE
NSAID’s
Rehab program with PT involving stretching and strengthening after acute phase
293
Capsular Lesions of the Hip: Presentation
Anterior hip and groin pain
Less often in lateral region or posterior buttocks
Pain can radiate to knee
Clicking, locking, catching, or giving way
Hip may feel unstable
Constant dull pain with intermittent episodes of sharp pain
Almost 90% limp and activities aggravate symptoms
Decreased ROM
294
Capsular Lesions of the Hip: Diagnosis
Caused by mechanical trauma typically
Can be due to overuse or repetitive movements
Typically need to get MRA and/or X-ray to confirm
295
Capsular Lesions of the Hip: Special Tests
FADDIR Test
296
Capsular Lesions of the Hip: Treatment
Try conservative treatment initially: including rest, NSAID’s, pain meds combined with PT protocol for 12 weeks
Can do an intraarticular fluoroscopy guided corticosteroid injection
Analyze Gait of patient to try and fix abnormalities that may have caused the capsular lesion
Mobs to increase ROM and reduce pain
Conservative treatment fail = Refer to orthopedic surgeon
297
Loose Body in Hip Joint: Presentation
Hip pain, particularly with flexion
| Catching, clicking, or locking
298
Loose Body in Hip Joint: Diagnosis
Result of trauma such as a fall, MVA, sport, or from a degenerative disease
Detect with CT scan
Can become arthritis if left untreated
299
Loose Body in Hip Joint: Special Test
Hip Scour
300
Loose Body in Hip Joint: Treatment
Early stage AVN= core decompression w/ or w/out bone graft
| Late stage AVN= THA
301
Psoas Bursitis: Presentation
Pain in anteromedial aspect of thigh possibly radiating to knee, leg, and lower back
Tenderness in upper quads
A snapping sensation at the front of the hip.
Pain develops during walking or specific movements like crossing the legs.
Pain on hip flexion, resisted as well as passive.
Pain on internal rotation or passive hyperextension.
Stiffness or pain after a rest or in the mornings.
Pain is worse while performing activities.
Rest can relieve the pain
Decreased ROM in non-capsular pattern
Most painful is adduction with hip flexion
302
Psoas Bursitis: Diagnosis
Often underdiagnosed d/t nonspecific symptomatology
Mainly caused by rheumatoid arthritis, acute trauma, and overuse injury
Likely the result of multiple mini-traumas caused by vigorous hip flexion and extension
303
Psoas Bursitis: Special Tests
Thomas Test
304
Psoas Bursitis: Imaging
MRI T1
305
Psoas Bursitis: Treatment
NSAID’s
Individualized for each patient
US to confirm snapping
Combo of local anesthetic and corticosteroid injection to avoid need for surgery
Surgery to remove bursa may be necessary
PT
RICE
Stretching of hip flexors, strengthening hip rotators, lasting 6-8 weeks
Strengthen gluteus medius to assist in maintain proper gait
306
Femoral Neck Stress Fracture: Presentation
Runners and military develop FNSF d/t chronic repetitive activity
Pain gradually worsens over a few weeks = stress fracture
Antalgic gait
Pain at extreme PROM, especially external and internal rotation is most sensitive for stress fx
Pain associated with log rolling, axially loading in supine patient (heel tap), and with single-leg standing or hopping also suggests a stress fx
307
Femoral Neck Stress Fracture: Diagnosis
Improper training is most common cause
Increasing duration, frequency, and/or intensity of training too quickly causes microscopic bone damage
Increased risk factors include previous stress fx, coxa vara, and possibly changing the running surface
308
Femoral Neck Stress Fracture: Special test
Fulcrum Test (stress fracture fulcrum test)
309
Femoral Neck Stress Fracture: Imaging
T2 MRI
310
Femoral Neck Stress Fracture: Treatment
Acute (compression side fractures): PT
PRICE
Medication = NSAID’s
After acute phase, about 6 weeks, begin rehab protocol for 8-12 weeks with PT
Should be able to run 3 miles pain free
If pain returns during rehab period decrease patient's activity until walking is pain free again
Non-weight bearing training can be done here
Tension-side FNSF should be non-weightbearing and receive immediate referral to an orthopedic surgeon
311
Metastasis of femur
| Presentation
The main signs are pain, fracture, spinal cord compression and a high calcium blood level.
312
Metastasis of femur
| Special Tests
Biopsy, blood test for calcium levels
| Bone scan, PET, X-ray, CT, or MRI.
313
Metastasis of femur
| Imaging
CT scan of metastasis of femur
314
Pubis ramus fracture
| Diagnosis
Classified as either stable or unstable fractures.
Stable - normally low energy, one break that lines up well.
Unstable - Higher energy with multiple break points that do not line up correctly.
315
Pubis ramus fracture
| Presentation
Pain, possible swelling or bruising, pain with movement.
316
Pubis ramus fracture
| Imaging
X-ray of pubic ramus fracture
317
Pubis ramus fracture
| Treatment
Stable Fracture: walking aids, pain meds
| Unstable Fracture: External fixation, ORIF
318
Iliotibial Band Bursitis: Presentation
Lateral knee swelling
Pain
Decreased ROM
319
Iliotibial Band Bursitis: Diagnosis
Iliotibial bursa located on lateral knee between IT band and its insertion of Gerdy tubercle and the adjacent tibial surface
Due to overuse and varus stress of the knee
Fluid will collect near insertion of IT tract in its distal part near lateral aspect of the tibia
320
Iliotibial Band Bursitis: Special Test
Ober's Test
321
Iliotibial Band Bursitis: Imaging
T2 MRI
322
Iliotibial Band Bursitis
```
RICE
Corticosteroids
NSAID’s
Needle Aspiration of build-up of fluid
PT- Acute rest and then after 3-4 weeks stretch and strengthen IT band
```
323
Hip Joint Lesions (Articular Lesions): Presentation
Caused by trauma in young, degeneration/labral tears in old
Pain
Decreased ROM
Antalgic Gait
74% of patients with torn labrum had some degree of articular surface damage
Possible swelling
Flares up with activity
324
Hip Joint Lesions (Articular Lesions): Diagnosis
Articular surface lesions produce irregular contour on the joint surface and leads to abnormal intra-articular forces with motion and weight bearing, which results in the patient developing a degenerative disease
Found following trauma and associated with labral lesions leading to early arthritis in hips
Frequency increases with age
325
Hip Joint Lesions (Articular Lesions): Special Test
Faber's (Patrick's test)
326
Hip Joint Lesions (Articular Lesions): Imaging
T2 MRI
327
Hip Joint Lesions (Articular Lesions): Treatment
Conservative
RICE
Corticosteroids
NSAID’s
Surgery
Arthroscopic debridement of chondral flaps
Fix labral pathology if it coexists
Full thickness chondral defects = microfracture or acute repair of lesions
Internal fixation of large lesions
Open approach if results can’t be achieved through arthroscope
328
Major Lesions Presenting with ‘Sign of the Buttock’
Gluteal pain, that may or may not spread down the leg
If redness and swelling are present in the buttock aread without history of trauma ‘sign of buttock’ may be suspected
Buttock large and swollen and tender to touch
Straight Leg Raise (SLR) limited and painful
Limited trunk flexion
Hip flexion with knee flexion limited and painful
Empty end feel on hip flexion
Non capsular pattern of restriction at hip (flex,abd,IR)
Resisted hip movements painful and weak esp hip extension
329
Major Lesions Presenting with ‘Sign of the Buttock’: Diagnosis
Part of a combination of findings indicates serious gluteal pathology posterior to axis of flexion and extension of hip.
It helps to determine whether a patient’s buttocks pain has its origin in the buttock as local lesion or is referred from the hip, sciatic nerve, or hamstring muscles.
Red flag and requires referral to physician for further investigation
330
Major Lesions Presenting with ‘Sign of the Buttock’: Special Test
SLR if positive passively flex hip with ipsilateral flexed to end range, if no change in ROM the pathology is within the hip or buttock, and not the hamstring or sciatic nerve
331
Major Lesions Presenting with ‘Sign of the Buttock’: Imaging
T2 MRI
332
Major Lesions Presenting with ‘Sign of the Buttock’: Treatment
```
Conservative
NSAID’s
RICE if swelling
PT protocol
Refer to physician
```
333
Advanced arthrosis
| Diagnosis
breakdown of joint surface
334
Advanced arthrosis
| Presentation
pain
stiffness
swelling
335
Advanced arthrosis
| Special Tests
ROM
Strength
Hip scour
336
Advanced arthrosis
| Imaging
X-Ray
337
Advanced arthrosis
| Treatment
PT or arthroscopy
