Patient Selection and Physical Examination

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1 Ptient Seletion nd Physil Exmintion 2 J. W. Thoms Byrd The key to suessful outomes in hip rthrosopy lies most lerly in proper ptient seletion. The est opertion will fil when performed for the wrong resons. Seletion revolves round imging evidene or t lest linil fi ndings of prolem potentilly menle to rthrosopi intervention. Another importnt seletion ftor is ssuring tht the ptient hs resonle expettions of wht my or my not e omplished y the proedure. The suess of the opertion is guged y the ptient s funtion nd sujetive sense of stisftion. If the ptient hs unresonle expettions of wht the proedure my omplish, then it will e deemed filure, even in the presene of well-performed proedure. Exmintion of the hip joint is suint nd requires only few minutes. However, exmintion of the hip region n e omplex nd requires muh more detil. Numerous disorders n mimi hip joint prolem. Generlly, these re neurologil, viserl or musuloskeletl. An upper lumr disk prolem uses nterior hip pin nd miniml trtion signs, whih is different thn the fi ndings tht would e more esily distinguished in ssoition with more ommon lower lumr disk prolems. Mjor nerves inlude the siti, femorl, nd oturtor, ut ny nerves of the lumosrl plexus n eome entrpped with sometimes vrile nd overlpping pin ptterns tht my need to e deiphered [ 1 ]. Referred symptoms from viserl origin inlude disorders of the gstrointestinl, urologil, or gyneologil systems. Other musuloskeletl prolems suh s mehnil k pin or pelvi dysfuntion from the SI joint or symphysis puis must e differentited. Additionlly, not ll hip prolems re menle to rthrosopi intervention. Stress frtures, vsulr nerosis, nd dvned degenertive disese re just few exmples. Also, keep in mind tht the hip nd pelvis re the sites of origin J.W.T. Byrd, M.D. Nshville Sports Mediine Foundtion, 2011 Churh Street, Suite 100, Nshville, TN 37203, USA e-mil: yrd@nsmfoundtion.org of pproximtely 10 15% of ll primry musuloskeletl tumors, lthough metstti disese is more ommon mong older dults. Beuse of the joint s deeply situted ntomy, tumors n grow to onsiderle size efore eing linilly evident. Rdiogrphs re importnt. These re helpful to rule out other prolems in ddition to ssisting in the dignosis of intr-rtiulr disorders menle to rthrosopy. It is refreshing to evlute ptient who hs simple isolted hip joint prolem. Often there my e oexistent disese or seondry disorders where the ptient hs een ompensting for the hip or simply other oexistent normlities. It is not unommon for n dult ptient with erly degenertive hip disese to perhps hve some onomitnt degenertive prolems of the lumr spine. Differentiting the ontriution of eh n e linil hllenge. Among thletes, hip nd k prolems often oexist, espeilly in sports where rottionl veloity is premium. Dysfuntion of one results in redued ility to ompenste for the other. The physiin my fi nd himself lterntely treting one or the other, ut they tully require omprehensive mngement strtegy. There is mple dt tht hip disorders often go undeteted for protrted period of time [ 2 ]. As individuls ompenste for their hip prolem, seondry disorders develop suh s glutel symptoms or trohnteri ursitis. On exmintion, the seondry disorders my e more evident nd osure the underlying primry hip prolem. Tretment of these seondry disorders fils when the primry prolem is not ddressed. Lstly, there my simply e other oexistent prolems suh s snpping of the iliopsos tendon or iliotiil nd. Sine these hve reognized prevlene in norml popultion nd my e present in someone with hip disorder, these n further hllenge the linil ssessment [ 3 ]. Ptient demogrphis provide useful tips in formulting differentil dignosis. Age, gender, votion, or votion ll provide useful lues. For exmple, femoroetulr impingement (FAI) is ommon soure of prolems in ie hokey. Dysplsi is more ommon in dners where moility J.W.T. Byrd (ed.), Opertive Hip Arthrosopy, DOI / _2, Springer Siene+Business Medi New York

2 8 J.W.T. Byrd is more of premium. Also in this group, even slight impingement n eome prolemti euse of the super physiologi demnds of motion. Older ptients re more likely to hve prolems with rthritis. Advning ge is not n inditor of poor results with rthrosopy, ut the mount of rthritis is [ 4 ]. History There re vrious disorders tht n result in pinful hip, nd thus the history my e eqully vried s fr s onset, durtion, nd severity of symptoms. For exmple, ute lrl ters ssoited with n injury hve gone undignosed for dedes, presenting s hroni disorder. Conversely, ptients with degenertive lrl ter my desrie the ute onset of symptoms ssoited with reltively innouous episode nd grdul progression of symptoms. In generl, history of signi fi nt trumti event is etter prognosti inditor of prolem potentilly orretle with rthrosopy [ 5 ]. Insidious onset of symptoms n e less fvorle prognosti inditor ut not ontrindition to rthrosopy. This sitution re fl ets the likely existene of underlying predisposition to injury. Ptients my reount spei fi preipitting episode suh s twisting injury, ut even with these irumstnes, there is likelihood of some underlying suseptiility to joint dmge. Mehnil symptoms suh s loking, thing, popping, or shrp sting in nture re etter prognosti inditors of prolem orretle y rthrosopy [ 6 ]. Simply pin in sene of mehnil symptoms is poorer preditor. However, the presene of pop or lik is n often overrted feture of the hip exmintion. This my indite n unstle lesion inside the joint, ut mny pinful intr-rtiulr prolems never demonstrte this fi nding, nd popping nd liking n our due to mny extr-rtiulr uses, most of whih re norml. Constnt intrtle pin present even with intivity presents prtiulr hllenge nd is often unlikely to e solved y rthrosopy. There re hrteristi fetures of the history tht n indite mehnil hip prolem (Tle 2.1 ). These re helpful in lolizing the hip s the soure of troule ut re not spei fi for the type of pthology. As expeted, the pin is worse with tivities, lthough the degree is vrile. Stright plne tivities suh s stright-hed wlking or even running re often well tolerted, while twisting mneuvers suh s simply turning to hnge diretion my produe shrp pin, espeilly turning towrd the symptomti side whih ples the hip in internl rottion. Sitting my e unomfortle, espeilly if the hip is pled in exessive fl exion. Rising from the seted position is espeilly pinful, Tle 2.1 Chrteristi hip symptoms Symptoms worse with tivities Twisting, suh s turning hnging diretions Seted position my e unomfortle, espeilly with hip fl exion Rising from seted position often pinful (thing) Dif fi ulty sending nd desending stirs Symptoms with entering/exiting n utomoile Dyspreuni Dif fi ulty with shoes, soks, hose, et. nd the ptient my experiene n ompnying th or shrp sting senstion. Also, fter period of sitting, the fi rst few steps upon rising my e pinful. Symptoms re worse with sending or desending stirs or other inlines. Entering nd exiting n utomoile is often dif fi ult with ompnying pin. This lods the hip in fl exed position long with twisting mneuvers. Dyspreuni is lmost uniformly present nd prolem for sexully tive individuls, lthough often ptients my e relutnt to shre this it of informtion. Dif fi ulty with shoes, soks, or hose my simply e due to pin or my re fl et restrited rottionl motion nd more dvned hip joint involvement. Bsed on the informtion otined in the history, preliminry differentil dignosis should e formulted. The history ssists the exminer in performing n ppropritely direted physil exmintion. Physil Exmintion The informtion otined in the history is just sreening tool. It helps diret the exmintion, ut it should not unduly prejudie the pproh. The exminer must e systemti nd thorough to void potentil pitflls nd missed dignoses (Fig. 2.1 ). In referene to exmintion of the hip, Otto Aufrn [ 7 ] noted tht more is missed y not looking thn y not knowing. Inspetion The most importnt spet of inspetion is stne nd git. The ptient s posture is oserved in oth the stnding nd seted position. Any splinting or protetive mneuvers used to llevite stresses on the hip joint re noted. While stnding, slightly fl exed position of the involved hip nd onomitntly the ipsilterl knee is ommon (Fig. 2.2 ). In the seted position, slouhing or listing to the uninvolved side voids extremes of fl exion (Fig. 2.3 ). An ntlgi git is often present ut dependent on the severity of symptoms. Typilly, the stne phse is

3 2 Ptient Seletion nd Physil Exmintion 9 Fig. 2.1 ( ) It is importnt tht oth hips e exmined. This neessittes tht the exmintion tle e positioned so tht the exminer n pproh the ptient from oth sides. ( ) Alwys egin the exmintion with the uninvolved extremity. This n gin the ptient s on fi dene nd provide potentilly useful informtion for omprison when exmining the involved hip. Filure to do so n result in possily missing useful informtion. (All rights re retined y Dr. Byrd) Fig. 2.2 During stne, the ptient with n irritted hip will tend to stnd with the joint slightly fl exed. Consequently, the knee will e slightly fl exed s well. This omined position of slight fl exion retes n effetive leg length disrepny. To void dropping the pelvis on the ffeted side, the ptient will tend to rise slightly on his or her toes. (All rights re retined y Dr. Byrd) Fig. 2.3 In the seted position, slouhing nd listing to the uninvolved side llow the hip to seek slightly less fl exed position. This is usully omined with slight dution nd externl rottion, whih relxes the psule. (All rights re retined y Dr. Byrd)

4 10 J.W.T. Byrd Fig. 2.4 Norml phses of git. (All rights re retined y Dr. Byrd) Heel strike Foot flt Midstne Push off Aelertion Midswing Deelertion Fig. 2.5 ( ) During multion, the stne phse of git is shortened. Hip extension is voided y keeping the joint in slightly fl exed position. This slight fl exion retes funtionl leg length disrepny with shortening on the involved side nd prtilly retes lurh. ( ) Further dutor lurh my our s ompenstory mehnism to redue the fores ross the joint. Shifting the torso over the involved hip moves the enter of grvity loser to the xis of the hip, shortens the lever rm moment, nd redues ompressive joint fore. (All rights re retined y Dr. Byrd) Fig. 2.6 Assessment is mde of spinl lignment, pelvi oliquity, or symmetry. (All rights re retined y Dr. Byrd)

5 2 Ptient Seletion nd Physil Exmintion 11 Fig. 2.7 Leg lengths re mesured from the nterior superior ili spine to the medil mlleolus. (All rights re retined y Dr. Byrd) shortened, nd hip fl exion ppers entuted s extension is voided during this phse (Fig. 2.4 ). Vrying degrees of dutor lurh my e present s the ptient ttempts to ple the enter of grvity over the hip, reduing the fores on the joint (Fig. 2.5 ). Oservtion is mde for ny symmetry, gross trophy, spinl lignment, or pelvi oliquity tht my e fi xed or ssoited with gross leg length disrepny (Fig. 2.6 ). Mesurements Certin mesurements should e reorded s routine prt of the ssessment. Leg lengths should e mesured from the nterior superior ili spine to the medil mlleolus (Fig. 2.7 ). Signi fi nt leg length disrepnies (greter thn 1.5 m) my e ssoited with vriety of hroni onditions. Typilly, if this ppers to e ontriuting ftor, we try to orret for hlf of the reorded disrepny in the ourse of onservtive tretment, preferly with n insert tht is osmetilly more eptle thn uilt-up shoe. Thigh irumferene, lthough rude mesurement, my re fl et hroni onditions nd musle trophy (Fig. 2.8 ). The involved leg is ompred to the uninvolved side. Sequentil mesurement on susequent exmintion n e n inditor of response to therpy. This only indiretly re fl ets hip funtion, ut hip disese ffets the entire lower extremity. Rnge of motion of the hip must e reorded in onsistent nd reproduile fshion. This is importnt for ompring sides nd lso hroniling the response to tretment on Fig. 2.8 Thigh irumferene should e mesured t fi xed position, oth for onsisteny of mesurement of the ffeted nd unffeted lims nd for onsisteny of mesurement on susequent exmintions. ( ) A tpe mesure is pled from the nterior superior ili spine (ASIS) towrd the enter of the ptell. ( ) A seleted distne elow the nterior superior ili spine is mrked (typilly 18 m). ( ) Thigh irumferene is then reorded t this fi xed position. (All rights re retined y Dr. Byrd)

6 12 J.W.T. Byrd susequent exmintions. The degree of fl exion nd the presene of fl exion ontrture re determined y using the Thoms test (Fig. 2.9 ). Extension is reorded with the ptient in the prone position, rising the leg (Fig ). There re severl methods for reording rottionl motion of the hip. It is importnt to selet one nd e onsistent. Flexing the hip 90 nd then internlly nd externlly rotting the joint re esy nd reproduile mens for reording rottionl motion (Fig ). Adution nd ddution re reorded s well (Fig ). People with limited rnge of motion of the hip eome dept t ompensting y inresed pelvi motion. Thus, when ssessing motion, the exminer must e vigilnt tht the pelvis remins stle. Fig. 2.9 ( ) In the supine position, the uninvolved hip is kept in mximl extension. This stilizes the pelvis nd voids ontriution of pelvi tilt to hip fl exion. The ffeted hip is then mximlly fl exed nd motion reorded. ( ) To hek extension or presene of fl exion ontrture, the unffeted hip is rought into mximl fl exion nd held y the ptient, loking the pelvis. The ffeted hip is then rought out towrd extension nd motion reorded. (All rights re retined y Dr. Byrd) Fig In the prone position, extension n lso e quntitted. (All rights re retined y Dr. Byrd) Fig (, ) Supine, with the hip fl exed 90, the hip is mximlly rotted internlly nd externlly with motions reorded. This method is simple quik nd reproduile. (, d ) Alterntively, rottionl motion n e reorded with the hip extended in the prone position. Whtever method is hosen, it is importnt to e onsistent on sequentil exmintions. (All rights re retined y Dr. Byrd)

7 2 Ptient Seletion nd Physil Exmintion 13 d Fig (ontinued) Fig (, ) The hip is duted nd dduted nd rnge of motion reorded reltive to the midline. (All rights re retined y Dr. Byrd) Symptom Loliztion The One Finger Rule Although this is less well pplied to the hip thn to other joints, suh s the knee, it is still importnt to sk the ptient to use one fi nger nd point to the spot tht hurts the worst (Fig ). This provides muh useful informtion efore eginning plption. It llows the exminer to disern the point of mximl tenderness. Consequently, this re is reserved until lst when performing the exmintion. This fores the exminer to e more systemti, exploring uninvolved res fi rst, nd enhnes the ptient s trust y not stimulting pin t the eginning of the exmintion (Fig ).

8 14 J.W.T. Byrd L1 L2 L3 L4 S1 S2 L5 Fig Often the ptient will wve over lrge re of involvement. However, the ptient is sked, with enourgement nd instrution, to point with one fi nger to the re of mximl involvement. (All rights re retined y Dr. Byrd) Fig The hip joint reeives innervtion from rnhes of L2 to S1 of the lumosrl plexus ut predominntly from the L3 nerve root. (All rights re retined y Dr. Byrd) T11 T12 L1 L2 L2 L3 L3 Fig This is where it hurts?. (All rights re retined y Dr. Byrd) Hilton s lw sttes tht the sme trunks of nerves whose rnhes supply the groups of musles moving joint furnish lso distriution of nerves to the skin over the insertion of the sme musles, nd the interior of the joint reeives its nerves from the sme soure [ 8 ]. While this my ensure physiologil hrmony mong the vrious strutures, it lso explins why musle spsms nd utneous senstions my ompny joint irrittion. Clssi mehnil hip pin is desried s eing nterior, typilly emnting from the groin re. The hip joint reeives S1 L4 L5 Fig The L3 dermtome rosses the nterior thigh nd extends distlly long the medil thigh to the level of the knee. (All rights re retined y Dr. Byrd) L4 L5 S1

9 2 Ptient Seletion nd Physil Exmintion 15 innervtion from rnhes of L2 to S1 of the lumosrl plexus, predominntly L3 (Fig ). Consequently, hip symptoms my e referred to the L3 dermtome, explining the presene of symptoms referred to the nterior nd medil thigh, distlly to the level of the knee (Fig ). Intrpsulr hip pthology usully hs omponent of nterior hip pin. Osionlly, there my e more deep lterl disomfort ut only rrely posterior pin. The C Sign The lssi omplint of ptients with hip pthology is groin pin. However, the uthor hs identi fi ed very ommon hrteristi sign of ptients presenting with hip disorders. The ptient will up their hnd ove the greter trohnter when desriing deep interior hip pin. The hnd forms C, nd thus, this hs een termed the C sign (Fig ). Beuse of the position of the hnd, this n e misinterpreted s inditing lterl pthology suh s the iliotiil nd or trohnteri ursitis, ut quite hrteristilly, the ptient is desriing deep interior hip pin. Plption Deep plption over the nterior hip psule my rete slight disomfort with n irritle hip. Plption is otherwise more useful for distinguishing vrious extr-rtiulr prolems. The exminer must e systemti nd fmilir with the topogrphi nd deep ntomy in order to orrelte the strutures eing plpted. Aufrn noted in referene to exmintion tht ontinuing study of ntomy mrks the differene etween good nd expert ility [ 7 ]. Plption is generlly roken down into nterior, lterl, nd posterior regions. These re detiled in Figs. 2.18, 2.19, nd Mnul musle testing is rude mesure of hip funtion ut my eliit useful informtion (Fig ). If injury to spei fi musle group is suspeted, resisted ontrtion should reprodue lolized symptoms. Ative rnge of motion nd resisted tive rnge of motion my lso reprodue joint symptoms. However, when refully interpreted, distintion n e mde etween symptoms of musle strin nd hip pin. This differentition my e lest ler with strin of the hip fl exors. In this setting, tive hip fl exion reprodues pin while pssive fl exion should not. Fig (, ) The C sign. This term re fl ets the shpe of the hnd when ptient desries deep interior hip pin. The hnd is upped ove the greter trohnter with the thum posterior nd the fi ngers gripping deep into the nterior groin. (All rights re retined y Dr. Byrd) Speil Tests There re vrious spei fi exmintion mneuvers for evluting the hip joint s well s ssessing the surrounding extr-rtiulr strutures. These re helpful to distinguish different disorders tht my hve similr presenttions s well s oexistent prolems tht my our either oinidentlly or s ompenstory disorder. Keep in mind tht none of these tests re 100% relile in every irumstne. Also, s prt of the linil relity of evluting ptients, the

10 16 J.W.T. Byrd d e Fig Anterior plption inludes the following strutures. ( ) Anterior hip nd hip fl exor region. ( ) Srtorius. ( ) Anterior superior ili spine. ( d ) Pui rmus. ( e ) Symphysis puis. (All rights re retined y Dr. Byrd) exminer my e onfronted with on fl iting exmintion fi ndings tht will require prioritizing the importne of the oservtions enountered. The single most spei fi test for hip pin is logrolling of the hip k nd forth (Fig ). This moves only the femorl hed in reltion to the etulum nd the surrounding psule. There is no signi fi nt exursion or stress on myotendinous strutures or nerves. Asene of positive logroll test does not prelude the hip s soure of symptoms, ut its presene gretly rises the suspiion. Fored flexion, ddution nd internl rottion is one mnuever. Tht my eliit symptoms ssoited with even sutle hip pthology (Fig ). This is often referred to s n impingement test in referene to testing for FAI [ 9 ]. However, we hve found tht this test is not spei fi for impingement s most irritle hips will e pinful with this mneuver regrdless of the etiology of the intr-rtiulr pthology. This mneuver my normlly e unomfortle, so it is importnt to ompre the response on the symptomti nd symptomti sides.

11 2 Ptient Seletion nd Physil Exmintion 17 d e f g Fig Lterl plption inludes the following strutures. ( ) Greter trohnter nd trohnteri urs. ( ) Posterior trohnter nd trohnteri urs. ( ) Insertion site of the gluteus mximus. ( d ) Proximl tip of the trohnter nd insertion of the gluteus medius. ( e ) Musle elly of the gluteus medius. ( f ) Tensor fsi lt originting from the nterior mrgin of the ili rest. ( g ) Ili rest. (All rights re retined y Dr. Byrd)

12 18 J.W.T. Byrd d e f g Fig Posterior plption inludes the following strutures. ( ) Posterior ili rest. ( ) Posterior superior ili spine. ( ) Sroili joint. ( d ) Siti noth. ( e ) Region of the piriformis nd overlying gluteus mximus. ( f ) The ishium is est plpted in the lterl deuitus position with the hip fl exed. ( g ) The origin of the hmstrings is plpted prone with resisted ontrtion of the hmstring musle group. (All rights re retined y Dr. Byrd)

13 2 Ptient Seletion nd Physil Exmintion 19 d e Fig ( ) Resisted hip fl exion with the knee fl exed isoltes the iliopsos tendon. Contriution from the srtorius is miniml s this is very wek musle. ( ) Resisted hip fl exion omined with knee extension reruits the retus femoris, whih rosses oth joints s hip fl exor nd knee extensor. ( ) Resisted hip extension n e tested with the ptient prone. ( d ) Another useful test for extensor wekness is to simply hve the ptient rise from the seted position with the rms rossed. This is dif fi ult when signi fi nt extensor musle wekness is present. ( e ) Mnul testing of dutor strength is most esily performed in the lterl position. Resistne testing ross the extended knee reruits the tensor fsi lt. ( f ) Resistne testing with the knee fl exed isoltes the gluteus medius. ( g ) The Trendelenurg test is nother dynmi method for ssessing dutor strength. Lifting the unffeted leg off of the ground, with norml dutor strength, the ptient should e le to mintin level pelvis. ( h ) If the dutors re wek, the ptient is unle to mintin level pelvis, nd it drops towrd the unffeted side with the rised leg. ( i ) Mnul testing of ddutor strength n similrly e tested ut with the ptient supine. (All rights re retined y Dr. Byrd)

14 20 J.W.T. Byrd f g h i Fig (ontinued)

15 2 Ptient Seletion nd Physil Exmintion 21 Fig Fored fl exion omined with ddution nd internl rottion is often very unomfortle nd usully eliits symptoms ssoited with even sutle degrees of hip pthology. (All rights re retined y Dr. Byrd) Fig The logroll test is the single most spei fi test for hip pthology. With the ptient supine ( ), gently rolling the thigh internlly ( ) nd externlly ( ) moves the rtiulr surfe of the femorl hed in reltion to the etulum ut does not stress ny of the surrounding extr-rtiulr strutures. (All rights re retined y Dr. Byrd) Fored dution with externl rottion my lso rete symptoms with hip joint prolem (Fig ). The fist test is useful method for quntitting the mount of restrition in dution nd externl rottion [ 10 ]. This is usully present to lesser extent thn pin with fl exion nd internl rottion in ses of degenertive disese or severe impingement. Isolted tightness nd pin with dution nd externl rottion our in the presene of posterior impingement or dhesive psulitis [ 11, 12 ]. Glol over overge of the etulum n our due to n ossi fi ed lrum resulting in pinful restrited motion in ll plnes nd wht hs een termed s ptured hip. With dhesive psulitis, externl rottion is more restrited nd pinful thn internl rottion. Both of these onditions fi nd their highest prevlene mong middle-ged femles. Isolted posterior impingement is not ommon. It n e heked y foring the extended hip into externl rottion eliiting pinful posterior impingement symptoms (Fig ). This sme mneuver n e used testing for nterior instility s the femorl hed n trnslte nteriorly with fored externl rottion. An tive stright leg rise or stright leg rise ginst resistne tests the hip fl exors ut n lso eliit joint symptoms (Fig ). This mneuver genertes fore of severl times ody weight ross the rtiulr surfes nd is more thn the norml fores of wlking [ 13 ]. A onventionl stright leg rise test is importnt for ssessing signs of lumr nerve root irrittion (Fig ). The Ptrik or Fer test ( fl exion, dution, externl rottion) hs een desried for stressing the SI joint looking for symptoms lolized to this re nd for isolting symptoms to the hip (Fig ). Differentition etween pin lolized to the SI joint in the hip is usully esy. Osionlly, this my lso eliit symptoms referle to the symphysis puis.

16 22 J.W.T. Byrd Fig Supine, the ptient is positioned lose to the edge of the tle so the hip n e extended long with mximl externl rottion. This n eliit symptoms of pinful posterior impingement. However, nterior trnsltion of the femorl hed in this position my lso evoke symptoms of nterior instility or possily eliit pin trpping n nterior lrl ter. Thus, the mneuver my e positive for vrious forms of hip joint pthology. (All rights re retined y Dr. Byrd) Fig ( ) Flexion omined with dution nd externl rottion my e unomfortle nd n produe thing-type senstions ssoited with lrl nd hondrl lesions. ( ) Restrition in dution nd externl rottion is quntitted y mesuring knee elevtion off of the exmintion tle. ( ) Estimting the numer of fi st widths provides quik method of ssessment. (All rights re retined y Dr. Byrd) The Dil test hs een desried s n ssessment of nterior psulr lxity nd possile instility (Fig ) [ 14 ]. It is hrterized y inresed externl rottion of the ffeted lim when resting in extension. Also, sujetively, there is loss of the norml springy endpoint with externl rottion whih n e inditive of ompromise of the Fig (, ) An tive stright leg rise, or espeilly leg rise ginst resistne, genertes ompressive fores of multiple times ody weight ross the hip joint. Consequently, this is often pinful, espeilly when there is even mild degree of underlying degenertive disese. (All rights re retined y Dr. Byrd)

17 2 Ptient Seletion nd Physil Exmintion 23 Fig The lssi stright leg rise (SLR) test is performed to ssess tension signs of lumr nerve root irrittion. A positive interprettion is hrterized y reprodution of rditing pin long dermtoml distriution of the lower extremity. It my lso re-rete disomfort from strething of the hmstring tendons. (All rights re retined y Dr. Byrd) Fig A positive Dil test is sried to nterior psulr lxity. ( ) In the resting position, the ffeted hip tends to lie in exessive externl rottion. ( ) Pssively externlly rotting the lim, soft end point is enountered. (All rights re retined y Dr. Byrd) Fig With the ptient supine, the Ptrik of Fer test is performed y rossing the nkle over the front of the ontrlterl knee nd then foring the knee of the involved extremity down on the tle while pplying ounterfore to the ontrlterl ili rest. This omintion of fl exion, dution, nd externl rottion stresses the sroili (SI) joint, nd when injury or in fl mmtion is present, this movement my exerte symptoms lolized to the SI re. This sme mneuver n irritte the hip joint s well ut with distintly different loliztion of symptoms. Osionlly, it my lso eliit symptoms emnting from the symphysis puis. (All rights re retined y Dr. Byrd) struturl integrity of the nterior psule. Fored externl rottion of the extended hip trnsltes the femorl hed nteriorly nd my evoke symptoms of nterior instility (Fig ). Assessing for pthologil lxity in the hip is ided y looking for generlized signs of exessive lxity (Fig ) [ 15 ]. Athleti pulgi ( sports herni ) n mimi or oexist with hip joint prolem [ 16, 17 ]. Groin tenderness to plption is eliited over the puis t the tendinous on fl uene of the insertion of the retus dominis nd origin of the ddutors (Fig ). Hip fl exor soreness my e present (Fig ). Tenderness is isolted y plpting the ddutor origin during resisted ontrtion (Fig ). Similrly, tenderness is lolized plpting the insertion of the retus dominis during resisted sit-ups (Fig ). These mneuvers re normlly not pinful with isolted joint pthology. Conversely, pssive fl exion with internl rottion should exerte hip joint prolem nd not e pinful with thleti pulgi. Keep in mind tht vrious elements of oth prolems my oexist. Symptoms of osteitis puis, hrterized y point tenderness over the symphysis, my our s n isolted entity or in onjuntion with thleti pulgi used y exessive miromotion tht n our with ompromise of the pelvi stilizers. Snpping of the iliopsos tendon is ommon ondition [3 ]. The exmintion fi ndings nd symptoms when pinful n e hllenging to differentite from n intr-rtiulr prolem. The snpping ours s the iliopsos trnsiently lodges on the nterior spet of the hip psule or petinel eminene (Fig ). It my e udile nd sometimes plple. The hrteristi mneuver for reting this type of

18 24 J.W.T. Byrd Fig Beighton desried five exmintion fetures of generlized lxity. ( ) Fifth finger hyperextension greter thn 90. ( ) Aility to pproximte the thum ginst the proximl forerm. ( ) Elow hyperextension greter thn 10. ( d ) Knee hyperextension greter thn 10. ( e ) Aility to ple plms fl t on the floor with knees extended. (All rights re retined y Dr. Byrd) d e snp is ringing the hip from fl exed, duted, externlly rotted position into extension with internl rottion (Fig ). Applying diret pressure over the front of the hip my lok the snpping. Often the snpping phenomenon is etter demonstrted y the ptient thn n e deteted on exmintion. This my vriously e shown stnding, sitting, or lying, ut onsistent feture is the snpping lmost lwys ours going from fl exion to extension. With lose questioning, the ptient n usully tell you whether the snpping is the use of their pin or just oinidentl finding. Snpping of the iliotiil nd is not likely to e onfused with joint prolem sine the fi ndings re loted lterlly [ 3 ]. However, these re ptients who frequently present with sense tht their hip is suluxing. They n dynmilly perform mneuver tht suggests hip instility. This visul pperne is uniformly reted y the tensor fsi lt fl ipping k nd forth ross the greter trohnter (Fig ). The ptient is exmined on their side, fl exing nd extending nd rotting the hip to ssess the snpping (Fig ). Oer testing is lso performed s routine ssessment for tightness of the iliotiil nd (Fig ). However, this snpping phenomenon is gin etter demonstrted y the ptient thn eliited y the exminer. Typilly, the ptient will stnd internlly nd externlly rotting the hip reting the visul snpping. Rdiogrphs will demonstrte tht the hip remins onentrilly redued regrdless of the visul positionl ltertions. Piriformis syndrome is unommon ut is likely one of the most ommon uses of non-spinl origin siti [ 18 ]. This

19 2 Ptient Seletion nd Physil Exmintion 25 Fig Illustrtion of the iliopsos tendon fl ipping k nd forth ross the nterior hip psule nd petinel eminene. ( ) With flexion of the hip, the iliopsos tendon lies lterl to the enter of the femorl hed. ( ) With extension of the hip, the iliopsos shifts medil to the enter of the femorl hed. (All rights re retined y Dr. Byrd) Fig Findings ssoited with thleti pulgi. ( ) Hip flexor soreness is eliited y plption during resisted ontrtion. ( ) Tenderness is eliited t the origin of the ddutors y plption during resisted ontrtion. ( ) The insertion of the retus dominis is plpted for tenderness during resisted ontrtion. Counter pressure is pplied to the ontrlterl shoulder using seletive reruitment nd ontrtion on the involved side. (All rights re retined y Dr. Byrd) ondition is proly overlooked nd overdignosed in equl proportions. Piriformis funtion hnges with hip position. Provotive exm mneuvers inlude pssive internl (Freierg s test) nd resisted externl rottion of the extended hip, resisted dution of the fl exed hip (Pe s sign), nd strething in fl exion, ddution, nd internl rottion (Fig ). Posterior tenderness to plption is present, ut the piriformis is osured y the overlying mss of the Fig The hrteristi exmintion mneuver for snpping of the iliopsos is performed with the ptient lying supine. The hip is pled in position of fl exion, dution, nd externl rottion ( ) nd then rotted down into extension with internl rottion ( ) reting the snp. (All rights re retined y Dr. Byrd)

20 26 J.W.T. Byrd Fig Snpping of the iliotiil nd n our either s the tendinous portion fl ips k nd forth ross the trohnter with fl exion nd extension, or the trohnter my move k nd forth underneth the sttionry tendon with internl nd externl rottion. (All rights re retined y Dr. Byrd) gluteus mximus (Fig ); nd for relitrnt ses, the most spei fi exmintion mneuver is retl or vginl plption of the piriformis from inside the pelvis. There re lso other less well-de fi ned uses of extrspinl siti. Rdiology In the pst, with the emergene of dvned imging suh s mgneti resonne studies, the importne of plin rdiogrphy in the ssessment of hip prolems hs een overlooked. Fortuntely, the interest in FAI nd other morphologil onditions hs led to resurgene in ppreition for wht plin x-rys offer [ 19 ]. A well-entered AP pelvis x-ry is importnt for ssessing vrious rdiogrphi indies s well s simply looking t losely relted surrounding strutures nd providing omprison view of the ontrlterl hip tht n help in ssessing sutle vritions (Figs nd 2.39 ). A lterl view of the ffeted hip is lso needed. A frog lterl is not true lterl of the hip ut provides perpendiulr view of the proximl femorl ntomy (Fig ). It hs good utility nd is esily otined in onsistent fshion [20 ]. There is muh disussion out other optiml lterl rdiogrphs for ssessing FAI, ut none of these re preditly relile in ll ses [ 21 ]. A flse pro fi le view n e Fig With the ptient on the side, the lim is supported ( ) s it is moved k ( ) nd forth ( ) in order to eliit snpping of the iliotiil nd. (All rights re retined y Dr. Byrd) helpful looking for de fi ienies of the nterior etulum s well s ssessing the nterior ontour of the proximl femur.

21 2 Ptient Seletion nd Physil Exmintion Fig The ptient is in the lterl deuitus position with the ffeted side up. ( ) Clssi Oer testing is desried, lowering the knee towrd the tle ssessing for tightness of the iliotiil nd. ( ) The tensor fsi lt nd iliotiil nd re isolted heking for tightness in ddution with the hip nd knee extended. ( ) Tightness of the gluteus mximus is heked in ddution with the hip fl exed nd the shoulders squred on the exmintion tle. (All rights re retined y Dr. Byrd) 27 Numerous mesurements n e otined to quntitte the vritions of hip morphology tht exist on spetrum from dysplsi to impingement [ 19 ]. Mny of these vritions my exist mong symptomti individuls. Thus, it is importnt not to se tretment strtegy solely on rdiogrphi normlities. However, it is eqully importnt to interpret the ontriution of hip morphology with joint dmge. This hs gret implition in the strtegy of rthrosopi mngement nd lso knowing when rthrosopy my not e pproprite. Two importnt onsidertions regrding plin rdiogrphy re offered. First, the dmge inside the joint must e dvned efore strting to notie ny rdiogrphi hnges (Fig ). Thus, sutle rdiogrphi normlities my hve gret signi fi ne regrding the severity of intr-rtiulr pthology. Seond, x-ry hnges my our in short period of time (Fig ). Thus, in the ourse of treting ptients with hip joint prolem, when the symptoms do not suside, repet plin fi lms efore emrking on surgil intervention. Espeilly mong middle-ged nd older ptients, degenertive hnges my strt to our t n elerted rte. You my e inititing tretment on the eginning of steep downhill slope tht nnot e reversed. Progressive rdiogrphi hnges with joint spe loss my explin the severity of symptoms nd void potentilly reommending n unsuessful rthrosopi proedure. Lstly re few omments regrding mgneti resonne imging (MRI) nd MRI with gdolinium rthrogrphy (MRA) [22 ]. Not ll MRIs re the sme. Low-resolution studies (smll mgnets nd open snners) re unrelile t ssessing hip joint pthology. High-resolution studies with smll- fi eld-of-view imges nd dedited surfe oils re etter ut still imperfet. Gdolinium rthrogrphy n provide more sensitivity ut is not lwys neessry, nd there re vets. Any mgneti resonne study should inlude minimum of the following: oronl nd xil lrge- fi eld-ofview imges of the pelvis showing oth hips, nd smll- fi eldof-view xil, oronl, sgittl, nd olique xil imges of the ffeted hip. Anything less is n inomplete study. The literture will support high reliility of MRIs nd MRAs in sensitivity nd spei fi ity [ 23, 24 ]. However, in linil prtie, it is est not to put too muh fith solely in these studies. They re pretty good t showing lrl pthology ut will usully underestimte the severity of ompnying rtiulr dmge tht is present. You must simply ntiipte tht it is likely tht the rtiulr dmge enountered t the time of rthrosopy will e more extensive, nd prepre your ptients with this possiility in mind sine this n in fl uene the suess of rthrosopy. Contrsted imges osure whether n effusion my hve een present, whih is vlule inditor of linilly relevnt hip pthology (Fig ). Also, ontrsted imges n osure edem in the suhondrl one nd surrounding

22 28 J.W.T. Byrd d Fig Tests for piriformis syndrome. ( ) Pssive internl rottion of the extended hip pling tension on the piriformis is referred to s Freierg s test. ( ) Resisted externl rottion of the extended hip with ontrtion of the piriformis my lso re-rete symptoms. ( ) Resisted dution of the fl exed hip uses ontrtion of the piriformis in soft tissues (Fig ). Thus, our strtegy hs een to perform limited series of pre-ontrst MRI followed y more detiled post-ontrst study. Historilly, we hve relied mostly simply on the response to fl uorosopilly guided intr-rtiulr injetion of nestheti to determine whether the hip ws the prinipl pin genertor [22 ]. As ontrsted imges eme more populr, different hip position nd is referred to s Pe s sign. ( d ) The piriformis streth test is performed with pssive fl exion, ddution, nd internl rottion. This my streth the piriformis provoking posterior symptoms ut n lso rete nterior disomfort if the hip joint is irritle. (All rights re retined y Dr. Byrd) we simply injeted the nestheti long with the ontrst. For linil relevne, we rely more on the response to the injetion thn simply fi ndings on the imges. However, there hs een nedotl experiene y numerous experiened hip speilists tht the ontrst my somehow negte some of the nestheti effet using flse-negtive interprettion. Presently, we hve trnsitioned more to ultrsound-guided

23 2 Ptient Seletion nd Physil Exmintion 29 Fig A properly entered AP rdiogrph must e ontrolled for rottion nd tilt. Proper rottion is on fi rmed y lignment of the oyx over the symphysis puis ( vertil line ). Proper tilt is ontrolled y mintining the distne etween the tip of the oyx nd the superior order of the symphysis puis t 1 2 m. (All rights re retined y Dr. Byrd) Fig A frog lterl rdiogrph is useful s routine sreening fi lm. It is esy to otin in reproduile fshion. (All rights re retined y Dr. Byrd) ultrsound-guided injetions, we usully otin only highresolution onventionl MRI. It is importnt to keep in mind tht some of the gretest vlue of the MRI is in ssessing disorders tht would not e evident during rthrosopy suh s stress frtures, AVN, trnsient regionl osteoporosis, tumors, nd vrious extrrtiulr soft tissue disorders. The indition for rthrosopy is most often determined y the presene of relitrnt hip joint pin tht hs filed onservtive tretment, whih my or my not e supported y ovious imging fi ndings of the nture of the pthology. Summry Fig AP pelvis rdiogrph of 50-yer-old womn with hief omplint of right hip pin. Chroni ony hnges re pprent round oth hips, ut n ggressive lyti lesion is identi fi ed in the right srum ( rrows ). (All rights re retined y Dr. Byrd) dignosti injetions whih n e onveniently performed for the ptient in the of fi e setting. It lso llows rel-time ssessment of the ptient s response, testing the hip oth prend postinjetion to determine the level of pin relief. Offiesed ultrsonogrphy now offers mny new dignosti nd interventionl options for ptients nd these re detiled in hpter 34. With the dvntge nd ptient onveniene of This hpter hs detiled prtil pproh to the ssessment of ptients presenting with omplint of hip pin. The evlution inludes the history nd exmintion nd how to interpret the linil relevne of vrious imging studies. This strtegy evolved s diret onsequene of rthrosopy, whih egn minly with the removl of loose odies then grdully the tretment of other previously unreognized soures of hip pin suh s lrl ters. This evolution hs inluded reognizing the existene of tretle hip disorders, lerning how to interpret the history nd symptoms, developing exmintion skills, nd susequently understnding the vlue nd limittions of imging studies. It is hoped tht this prtil pproh n e useful for ll liniins hllenged with the evlution of hip prolems. Others hve ttempted to ddress this in n evidene-sed fshion, whih my omplement the prtil experienes expressed here [ 25 ].

24 30 J.W.T. Byrd Fig ( ) AP pelvis rdiogrph of 74-yer-old womn with hroni rheumtoid rthritis who presented with reent onset of intrtle mehnil hip pin. Rdiogrphs were reported s super fi illy norml with only modest evidene of in fl mmtory degenertive hnges, insuf fi ient to solely explin the mgnitude of her symptoms. ( ) Arthrosopi view of the left hip from the nterolterl portl reveling extensive rtiulr surfe erosion of oth the femorl hed ( F ) nd etulum ( A ) with res of exposed one ( * ) nd extensive synovil disese ( ** ). (All rights re retined y Dr. Byrd) Fig A 54-yer-old orthopedi surgeon s wife experienes spontneous onset of worsening mehnil right hip pin. ( ) An AP rdiogrph demonstrtes joint spe preservtion, nd she ws sheduled for rthrosopi surgery with MRI evidene of lrl dmge. ( ) A repet AP rdiogrph the dy prior to surgery nd only 1 month sine her previous film demonstrtes omplete joint spe loss. Arthrosopi surgery ws neled s this ptient demonstrted rpidly progressive degenertive disese wrrnting totl hip rthroplsty. (All rights re retined y Dr. Byrd) Fig ( ) A oronl MRA imge demonstrtes ontrst seprting the lterl lrum ( rrow ), whih ould e inditive of pthologil ter or norml lrl left. ( ) Pre-ontrst oronl T2-weighted lrge-field-of-view pelvis imge demonstrtes n effusion ( rrows ) of the right hip whih is signi fi nt indiret evidene of joint pthology. (All rights re retined y Dr. Byrd)

25 2 Ptient Seletion nd Physil Exmintion 31 Fig Pre-ontrst oronl ( ) nd sgittl ( ) MRI imges demonstrte suhondrl signl hnges of the femorl hed ( rrows ). Post-ontrst oronl ( ) nd sgittl ( d ) imges sustntilly osure the suhondrl hnges. (All rights re retined y Dr. Byrd) d Referenes 1. MCrory P, Bell S. Nerve entrpment syndromes s use of pin in the hip, groin nd uttok. Sports Med. 1999;27(4): Byrd JWT, Jones KS. Hip rthrosopy in thletes. Clin Sports Med. 2001;20(4): Byrd JWT. Snpping hip. Oper Teh Sports Med. 2005;13(1): Byrd JWT, Jones KS. Prospetive nlysis of hip rthrosopy with 10-yer follow up. Clin Orthop Relt Res. 2010;468(3): Byrd JWT, Jones KS. Prospetive nlysis of hip rthrosopy with two yer follow up. Arthrosopy. 2000;16(6): O Lery JA, Berend K, Vil TP. The reltionship etween dignosis nd outome in rthrosopy of the hip. Arthrosopy. 2001;17(2): Aufrn OE. The ptient with hip prolem. In: Aufrn OE, editor. Construtive surgery of the hip. St. Louis: CV Mosy; p Hilton J. Rest nd pin. London: Bell; Gnz R, Prvizi J, Bek M, Leunig M, Notzli H, Sieenrok KA. Femoroetulr impingement: use for osteorthritis in the hip. Clin Orthop. 2003;417:

26 32 J.W.T. Byrd 10. Philippon MJ. New frontiers in hip rthrosopy: the role of rthrosopi repir nd psulorrhphy in the tretment of hip disorders. Instr Course Let. 2006;55: Sierr RJ, Trousdle RT, Gnz R, Leunig M. Hip disese in the young, tive ptient: evlution nd nonrthroplsty surgil options. J Am Ad Orthop Surg. 2008;16: Byrd JWT. Adhesive psulitis of the hip. Arthrosopy. 2006;22(1): Rydell NW. Fores ting on the femorl hed-prosthesis. Deprtment of Orthop Surgery, University of Goteorg, Sweden, Munksgrd, Copenhgen p Philippon MJ, Shenker ML. Athleti hip injuries nd psulr lxity. Oper Teh Orthop. 2005;15: Beighton P, Horn F. Orthopedi spets of the Ehlers-Dnlos syndrome. J Bone Joint Surg Br. 1969;51(3): Tior LM, Sekiy JK. Differentil dignosis of pin round the hip joint. Arthrosopy. 2008;24(12): Meyers WC, MKehnie A, Philippon MJ, Horner MA, et l. Experiene with sports herni spnning two dedes. Ann Surg. 2008;248(4): Byrd JWT. Piriformis syndrome. Oper Teh Sports Med. 2005;13(1): Clohisy JC, Crlisle JC, Beule PE, et l. A systemti pproh to the plin rdiogrphi evlution of the young dult hip. J Bone Joint Surg Am. 2008;90: Clohisy JC, Nunley RM, Otto RJ, Shoeneker PL. The frog-leg lterl rdiogrph urtely visulized hip m impingement normlities. Clin Orthop. 2007;472: Meyer DC, Bek M, Ellis T, et l. Comprison of six rdiogrphi projetions to ssess femorl hed/nek spheriity. Clin Orthop Relt Res. 2006;445: Byrd JWT, Jones KS. Dignosti ury of linil ssessment, MRI, gdolinium MRI, nd intrrtiulr injetion in hip rthrosopy ptients. Am J Sports Med. 2004;32(7): Mintz DN, Hooper T, Connell D, et l. Mgneti resonne imging of the hip: detetion of lrl nd hondrl normlities using nonontrst imging. Arthrosopy. 2005;21(4): Ziegert AL, et l. Comprison of stndrd hip MR rthrogrphi imging plnes nd sequenes for detetion of rthrosopilly proven lrl ters. Am J Roentgenol. 2009;192(5): Mrtin HD, Kelly BT, Leunig M, et l. The pttern nd tehnique in the linil evlution of the dult hip: the ommon physil exmintion tests of hip speilists. Arthrosopy. 2010;26(2):

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