Common Causes of Pain

• Osteoarthritis • Osteonecrosis of the Hip • Sciatica • Stress Fracture • Infection • Impingement / labral tear • Trochanteric Bursitis • IT Band Pathology

Physical Exam 1. Gait analysis 2. Examination Standing • Hip / spinal alignment • Crouch may be hip Gait Analysis 3. Examination Supine • • Range-of-motion • Strength testing • Distal pulses 4. Provocative maneuvers

Pathologic Gait Antalgic: Shortened stance on painful side Steppage: Leg lifts higher to clear ground Waddling: Broad-based, pelvis drops towards raised leg during swing . . . proximal myopathy Trandelenburg: Trunk towards weak side during stance . . . abductor weakness

Look at posture…leaning forward might be spine Steppage gait . . . Antalgic gait . . .

- Compensatory for foot drop - “Limping” - Exaggerated hip flexion - Shortened stance allows foot on weak side to clear ground phase on painful / - Tibialis anterior weakness affected limb -RX: • AFO brace, • Refer, especially if acute

Trandelenburg gait . . .

- Weak abductors - Superior gluteal nerve - Prior hip surgery

Exam Standing . . .

- Walk around the patient - Overall posture - Pelvic tilt Exam Standing • Scoliosis • Leg length discrepancy - Crouch • Hip contracture • Spinal hyperlordosis - Adductor contracture Exam Supine . . . - Palpation… • know your anatomy / landmarks - . . . . Exam Supine • Flexion: 110 - 120° • Extension: 10 - 15° • IR/ER: 30 - 40° / 40 – 60° - Strength and sensation testing - Don’t forget distal pulses

Exam Supine . . . Exam Supine . . .

- Inspection - Strength Testing - Swelling, ecchymosis - Hip flexors, ABductors, ADductors - Palpation - Distal muscles for spine helath - Abdomen / inguinal region - Provocative testing - Lateral vs medial - Log Roll (fracture, infection, RA, AVN, etc) - Low back and posterior hip/pelvis - (radiculopathy) - Range of motion - Ober’s test (IT band, trochanteric bursitis) - Flexion/extension - FABER (Flexion ABduction External Rotation) - Internal/external rotation • Impingement / Labral Tear - Obligate external rotation with hip - FADIR (Flexion ADduction Internal Rotation flexion . .. . CAM lesion • Impingement

Log roll

Insert Chiodo Log roll image Special Tests . . .

- Fracture - Infection - Advanced chronic pathology - Image and/or refer ! Straight-leg raise Faber / Patrick Test

- Lumbar nerve root irritation - Positive: . . . radicular sx’s reproduced - SI joint - Intra-articular pathology Treatment: - Inflammatory disease - PT, injections, time - Iliopsoas strain - Refer if neurologic deficits - SI joint - Intra-articular pathology - Inflammatory disease - Iliopsoas strain

FadIR Test

- Femoroacetabular Impingement (FAI) Ober’s test

- Iliotibial band - Contracted, inflamed, or painful - Positive: Affected leg remains . . .orthoinfo.com AAOS elevated / abducted after released - Rx: PT, NSAIDs, rarely surgery FAI RX: NSAIDs, injection, PT, arthroscopy

Gaenslen’s test

Thomas test

- Leg lifts off table with contralateral hip flexion - Test for hip flexion contracture Big picture . . .

- Always consider joints above and join below - Lateral pain and tenderness . . . • IT band, greater trochanter, radicular - Anterior / medial pain . . . Thank you! • Hip joint proper (arthritis, fx, infection, AVN, impingement) • Inguinal and abdominal pathology (e.g. hernia) - Posterior pain and tenderness . . . • SI joint, radicular pain, hamstrings, ischium

Anterior Hip Pain

• DDX: • Perform this exam • Order these tests • Treat with NSAIDs, Injection, referral

Lateral Hip Pain Posterior Hip Pain

• DDX: • DDX: • Perform this exam • Perform this exam • Order these tests • Order these tests • Treat with NSAID’s, Injection, referral • Treat with NSAID’s, Injection, referral