Lower Back and Hip Pathology

Question 1

lumbar disk herniation

defn and causes

Answer 1

wear and tear –> minor tears in annulus fibrosis –> major tears in annulus fibrosis –> protrusion of nucleus pulposa –> pain, possible radiculopathy and myelopathy d/t direct compression or inflammation

typically posteriolateral d/t typical pattern of anterior compression from frequent flexion e.g. bending and sitting

also posterior longitudinal ligament

Question 2

lumbar disk herniation

radiculopathy clinical presentation

Answer 2

nerve root exits below level of lumbar disk (as opposed to cervical exiting above)

posterolateral herniation usually spares nerve root at that level and instead the next one below that (so L4 herniation would affect L5 nerve, which is below L5)

far lateral does not spare (L4 herniation would affect L4 root)

most common herniations are L4/L5 and L5/S1 –> most common radiculopathies at L5 and S1. both cause sciatica. sensory and/or motor involvement.

significant compression of thecal sac may also cause cauda syndrome – bowel and bladder incontinence, loss of motor and sensory in legs

else motor and/or sensory following any specific myotomal distribution

Question 3

lumbar dis herniation

clinical presentation and PE findings

Answer 3

local low back pain, midline and/or paraspinals

worse with low back movement

bilateral paraspinal spasm

loss of lumbar lordosis

limited ROM d/t pain

radiculopathy - usually sciatica, foot drop also common –> abnormal gait

possible cauda equina syndrome – bowel and bladder incontinence, loss of motor and sensory to LE

special testing: straight leg raise for sciatica

Question 4

lumbar disk herniation

tx and prognosis

Answer 4

pain relief +/- muscle relaxants +/- epidural corticosteriods

PT, traction, heat/ice

pain usually resolves in 6 weeks w/ conservative tx

radiculopathy and myelopathy have more complications, surgery may be needed

surgery indicated in cauda equina syndrome

Question 5

Answer 5

L4/L5 lumbar disk herniation

Question 6

sacroiliac joint dysfunction

defn and causes

Answer 6

changes in SI alignment d/t changes in ligament integrity

sitting and trauma –> short and tight SI ligaments

trauma and pregnancy –> lax

muscular imbalance –> SI stress

aging –> degeneration, uneven, possible fusion

ligament changes can result in inflammation, but not the same as sacroiliitis, which is inflammation not d/t ligment changes, such as in ankylosing spondylitis

Question 7

lumbar muscle strain

Answer 7

muscle injury d/t exertion, overstretching, or overuse

most common cause of back pain, usually starts in lower back and migrates to hip and buttock

improper lifting technique is common cause of acute strain, esp in normally sedentary individuals or with particularly heavy object

most resolve quickly and spontaneously

paraspinal spasm –> loss of lumbar lordosis, limited ROM d/t pain and stiffness

chronic strain d/t muscle “bracing” (overuse of certain muscles to make up for others) d/t instability, ddd, herniation, stress and anxiety disorders — ie. concurrent muscle strain is common in other neck and back conditions

Question 8

lumbar dermatomes

Answer 8

L2-3 anterior/mid-thigh

L4 knee and medial malleolus

L5 web b/w 1st and 2nd toe

S1 lateral malleolus

L5 and S1 are also associated with sciatica, but that’s not technically a dermatome

Question 9

lumbar myotomes

Answer 9

L2-4 knee extension and hip aDduction

L5 ankle dorsiflexion (extension) and big toe extension

S1 ankle plantarflexion, knee flexion, hip extension (“tuck”)

Question 10

lumbar radiculopathy

clinical presentation and PE findings

Answer 10

painful or antalgic gait

possible reactive paraspinal spasm w/ associated pain, stiffness, tenderness to palpation

limited ROM d/t pain/reproduction of sx

no tenderness to palpation in affected extremities

dermatomal paresthesia and/or myotomal weakness w/ possible loss of reflexes

special testing: straight leg raise, EMG

Question 11

lumbar radiculopathy

tx and prognosis

Answer 11

NSAIDs for inflammatory pain + neuropathic pain meds +/- epidural corticosteroids

acute: laying supine for 2 days to reduce compression
chronic: PT, ergonomics, lifting techniques, weight loss if applicable

avoid lifting, stooping, bending, prolonged standing or sitting while active sx

lumbar traction (temporary)

if severe, surgical removal of underlying cause e.g. herniation or osteophytes

most sx resolve spontaneously w/ conservative tx

Question 12

lumbar spinal stenosis

defn and causes

Answer 12

narrowing of central spinal canal

disk herniation, large osteophyte, hematoma s/p trauma or spinal procedure, tumor, foreign body

cervical spine: spinal cord compression

lumbar: cauda equina
anywhere: radiculopathy

Question 13

spinal stenosis

clinical presentation and PE findings

Answer 13

usually progression of disk herniation, ddd, or spondylolythesis

multilevel bilateral sensory and motor – high suscpicion if this is present

lumbar: below level of lumbar, common complication is cauda equina syndrome

often stooped posture as this opens up canal and relieves sx

reduced muscle tone and hypo or areflexia

cervical: hyperreflexia of lower extremities and increased tone. upper motor neuron = uninhibited descending pathway; spurling’s sign: pain radiating down arm with neck extension

Question 14

Answer 14

spinal stenosis + L4/L5 herniated disk

lumbar

Question 15

spinal stenosis

tx and prognosis

Answer 15

pain management + oral corticosteroids for pain and weakness

epidural steroids not usually helpful - even small volume injections into already-tight space worsens sx

decompression surgery for osteophyte, disk, etc. removal may be needed; cervical and thoracic needs immediate surgical decompression d/t compression of spinal cord

mild stenosis from herniated disk usually resolves spontaneously

ddd, osteophytes, ligamentum flavum thickening, congenital short pedicles –> likely progressive

tx will typically prevent progression of but not reverse neurological deficits

Question 16

spinal compression frx

Answer 16

collapsing or crushing bone d/t injury and/or weak structure

fall landing on butt or feet

osteoporosis

lower thoracic and thoracic-lumbar most common

cracks may not always be obvious on xray, look for height of vertebral body

Question 17

spondylolysis

Answer 17

pars interarticularis frx

usually L5/S1

neck of “scotty dog” on xray

trauma w/ hyperextension, commonly gymnasts

5% overall lifetime incidence

Question 18

Answer 18

spondylolysis = pars interarticularis frx

Question 19

spondylolisthesis

Answer 19

vertebral slippage

Question 20

spondylosis

Answer 20

any condition of the spine

Question 21

avascular necrosis femoral head

Answer 21

bone death d/t no blood supply

d/t trauma, diabetes, sickle cell SLE, RA, chronic corticosteroids, chronic EtOH

or idiopathic i.e. legg-calve-perthes disease

collapse of bone and destruction of hip joint d/t early asymptomatic i.e. not caught early

groin pain worse with weight-bearing

sx may mimic OA

usually needs total hip replacement

Question 22

Answer 22

avascular necrosis femoral head

Question 23

posterior hip dislocation

Answer 23

more common than anterior

developmental or traumatic

high-energy blunt force trauma e.g. MVA, car vs ped, falling from height

internal rotation and aDduction of hip often w/ sciatic nerve compression

Question 24

Answer 24

posterior hip dislocation

Question 25

proximal femur frx

Answer 25

femoral neck or intertrochanteric falls, elderly, osteoporosis hip or groin pain complication: AVN d/t damage to circumflex femoral artery branches

Question 26

Answer 26

intertrochanteric femur frx

Question 27

legg-calve-perthes disease defn and causes

Answer 27

idiopathic avascular necrosis of femoral head typical blood supply (artery of the ligament to the head of the femur) is gradually replaced by medial and lateral circumflex femoral artery supply this makes femur more prone to AVN almost exclusively in white boys 3-12 y/o, median 7 years usually no trauma hx

Question 28

legg-calve-perthes clinical presentation and PE findings

Answer 28

insidious mild hip or knee pain w/ limp, usually unilateral if bilateral, not symmetric decreased internal rotation and aBduction 3-12 y/o white boy initial phase: normal radiographs degenerative: flattened femoral head regenerative: reossification of femoral head, but doesn't fit right in acetabular cavity

Question 29

Answer 29

legg-calves-perthes degenerative phase

Question 30

legg calve perthes tx and prognosis

Answer 30

activity restriction or bedrest casting, bracing, or surgical immobilization kids remodel bone quickly, so early intervention usually allows femoral head to remold back into round shape

Question 31

sacroiliac joint dysfx clinical presentation and PE findings

Answer 31

low back and buttocks pain, may radiate to anterior or posterior thigh deep, aching gradual worse with any hip movement, walking, standing, weight-bearing worse with palpation over SI ligaments or near posterior superior iliac spine +FABER (flexion, aBduction, external rotation radiology usually normal

Question 32

sacroiliac joint dysfx tx and prognosis

Answer 32

NSAIDs acute: ice chronic: deep heat/ultrasound glute and paraspinal strengthening if refractory, injection with corticosteroid and/or proliferative agent + PT usually self-limiting, esp if treated early if tx delayed, can b//c chronic and debilitating

Question 33

hip OA

Answer 33

progressive cartilage degeneration groin pain, but w/o tenderness to palpation in inguinal area ranges from dull, aching, throbbing, to sharp, stabbing worse with weight-bearing possible limp restricted ROM d/t structural changes and pain - internal rotation and aBduction non-uniform joint space narrowing, bone cyst, bone sclerosis, osteophytes

Question 34

developmental hip dysplasia

Answer 34

aka congenital hip dislocation poor fit b/w femoral head and acetabulum --\> easy posterior subluxation unilateral or bilateral seems genetic, more in girls (80%) newborn screening pavlik harness = brace to prevent aDduction and hip extension if treated in 1st few weeks good prognosis, otherwise juvenile OA likely

Question 35

slipped capital femoral epiphysis

Answer 35

physis = growth plate normal: hip growth plate changes orientation during development to better bear weight increased stress on joint + risk factor e.g. Down's, obese, hypothyroid --\> head of femur shifts through growth plate (frx) sharp, severe pain in groin, may radiate to butt and knee worse with movement or weight-bearing leg is in external rotation, limp decreased internal rotation and aBduction xray requires surgical pinning

Question 36

toxic synovitis of hip

Answer 36

idiopathic, transient synovitis usually boys 3-7 y/o acute pain, limp, sometimes inability to walk on affected limb most commonly in morning generally not sick, CBC and ESR are normal usually lasts 3-5 days limited internal rotation of hip w/o pain on palpation

Question 37

trochanteric bursitis

Answer 37

inflammation of bursa between greater trochater and glute max insertion IT band tightens and puts pressure, friction on bursa usually acute, repetitive trauma e.g. running gradual onset lateral hip initially deep and aching, progresses to constant deep when severe may be associated with pain down IT band and at lateral insertion site on knee sometimes bruising or swelling over lateral hip pain over trochanteric bursa and IT band on palpation IT stretching reproduces pain groin or knee pain on internal rotation would suggest OA or other pathology NOT bursitis normal XR

Question 38

piriformis syndrome

Answer 38

local tenderness of piriformis with reproduction of sx on stretching or contraction of piriformis

Question 39

causes of lateral hip/thigh pain

Answer 39

trochanteric bursitis: pain on palpation, +/- IT pain and tightness lateral femoral cutaneous nerve syndrome: neuropathic, no pain on palpation

Question 40

causes of groin pain in adults

Answer 40

OA: gradual, esp w/ old age AVN: dx by MRI esp when risk factors present

Question 41

causes of groin pain in kids

Answer 41

developmental hip dysplasia: newborn/infant toxic synovitis: transient, 3-5 days, boys 3-7 legg calves perthes: AVN in boys 3-12 slipped capital femoral ephisys: adolescent boys esp obese, hypothyroid, Down's

Question 42

causes of buttocks pain

Answer 42

referred from lumbar disk ddd, radiculopathy, herniation SI joint dysfunction: tenderness over ligaments piriformis syndrome: piriformis spasm + sciatica

Question 43

lateral femoral cutaneous nerve syndrome

Answer 43

meralgia paresthetica compression of lateral femoral cutaneous nerve as it courses deep to lateral edge of inguinal ligament burning, numbness, parethesias down proximal-lateral thigh no motor sx (this is a sensory nerve) causes: tight belts, seat belt injury, obesity