DIFFERENTITATING BACK AND HIP PAIN

Transcription

1 DIFFERENTITATING BACK AND HIP PAIN MANAGEING LATERAL HIP PAIN DR ANGIE FEARON PHD, M(PTHY), B(APP)SC(PHTY) Effective treatment of lateral hip pain relies on the correct diagnosis; understanding the aetiology and pathology; recognising, understanding and addressing the modifiable risk factors; identifying and evaluating the contribution of biomechanical deficiencies and the contribution of pain; and then prescribing, modifying and progressing the most appropriate

2 DIFFERENTIATING BACK AND HIP PAIN & MANAGING LATERAL HIP PAIN TABLE OF CONTENTS Table of Contents... 2 Case study On examination:...4 What would hip OA look like?...5 Differentiation back and hip pain... 6 Visa G Development of the VISA G (13) Completing the VISA G VISA G Questionnaire UNDERSTANDING LATERAL HIP PAIN management of Lateral hip pain Principles: Address the risk factors Address the pain Address the muscle imbalances Exercise prescription 101 (29) Exercise therapy (mechanotherapy) ISOMetrics (30, 31) Exercise therapy (mechanotherapy) Muscle hypertrophy Exercise therapy (mechanotherapy) Effective treatment relies on What doesn t help Not improving? References... 25

3 Case study CASE STUDY Wendy is a 59 year old woman who works full time in job with significant responsibilities - she works long hours. She has a large family, and 12 grandchildren. She comes to see you because she has lateral hip pain. Prior to her attendance her GP arranged for her to have an MRI of her right and left hips. The report states that there is bilateral tendinopathy of the Gluteus medius and gluteus minimus tendons, with associated tears in both tendons bilaterally. Her GP has sent her in for Physio. If this fails, the GP wants her to have surgery. Phx: Intermittent pain over the R > L lateral hip over five + years. Wendy reports no obvious past or present trauma that has contributed to the current presentation. She had one cortico-steroid injection 18 months ago. This resulted in good pain relief for six months. She did not undertake any rehabilitation following the injection. The pain returned 12 months ago and she doesn t want to have another injection. She has had some physio already which hurt. Chx: No significant medical co-morbidities (diabetes, cancer, hypertension), BMI ~ 27 kg/m 2 Musculoskeletal co-morbidities: Wendy reports OA in the mid foot and great toe (R > L); patellofemoral pain (R > L); hand OA; low back pain (R), and SIJ pain (R). Medications: Intermittent NSAID, paracetamol. Nil else reported. 24/24 behaviour: Night: Difficulty sleeping at night - wakes 3 to 4 times. Is able to go back to sleep but is unable to lie on R side for any length of time. This can be a problem in L side lying also.

4 CASE STUDY AM: hip is OK, feet very sore. Day: Hip has near constant ache; feet increasingly sore as day progresses, knees - activity dependent. Wendy finds it difficult to articulate what makes the hip pain worse. She says they varies on a day to day basis for no reason. Aggs: Hips: walking, lying on side, stairs (ascend and descend) Knees: stairs (ascend and descend) Feet: pain through midfoot (tarso-metatarsal joints) with weight bearing Back: lying, sit to stand Ease: Hips: near constant ache, Pt reports nothing eases; Knees: not climbing stairs; Feet: Not weight bearing; Back: sitting, slight movement (not extremes) VISA-G score: 30/100 ON EXAMINATION: Gait: Positive Trendelenburg with R stance (trunk lean to R), prolonged stance on R. Lack of push off bilaterally. Reduced step length bilaterally. (Pain in hips R>L and feet) Sit to stand: Uses hands to push up with, when asked to refrain weight bears on L > R, MR/Add of hips bilaterally (reproduces lateral hip and knee pain) Lunge: MR/Add R>L, pronated feet (pain in hip, knee and feet R>L) Step up: MR/Add, (pain in hip, knee and feet R>L) SLS: Pain reproduced on R after 10 seconds, in hip adduction which she can correct with advice. L pain free for 20 seconds. R and L very poor control/balance Lx: Flexion: NAD; Extension: ½ pain on L4 L5 SIJ; Side Flexion R - 5 cm AK pain reproduced in back; L 5cm above knee, P 0, stretch on right; Rotation R ¾ slight L4 L5; L 4/4, P 0 SIJ: Stork negative, AP compression negative, ASLR negative Hip: ROM: MR, LR, Flex, Ext, Add, Abd, Faddir. All = NAD 4

5 CASE STUDY Faber: Reproduces lateral hip pain, R and L Resisted de-rotation from Flex/add: Reproduces lateral hip pain, R, not L Knee: ROM NAD; ligaments NAD; meniscus NAD; patellofemoral joint: medial glide R =1/3 VMO = concave, reduced in size and does not activate with static quads. Feet: Bony hyperplasia about mid foot = likely tarso-metatarsal OA; reduced active arch unable to control in w/b. Wt bearing pain eased with supportive taping Palpation: Lx ms sp through Lx R>>L, L5/S1 painful on R SIJ - R slightly painful, sacrotuberous ligament painful Hip Gluteal ms (mid buttock) painful and muscle spasm GT pain anterior>posterior, R>L WHAT WOULD HIP OA LOOK LIKE? - Hip joint can refer to buttock, GT, groin, anterior thigh (and foot) (2, 3) - Restricted ROM in hip joint (4) - Groin or anterior pain with MR (4) - Difficulty with shoes and socks (5) - Groin/anterior pain with Faber (5) 5

6 Differentiation back and hip pain DIFFERENTIATION BACK AND HIP PAIN

7 DIFFERENTIATION BACK AND HIP PAIN Adapted from Brukner and Khan, 2015, Sports Anatomy (1) 7

8 DIFFERENTIATION BACK AND HIP PAIN Adapted from Reiman, 2014 (6), with (7-11) 8

9 DIFFERENTIATION BACK AND HIP PAIN Confirmed on MRI Compared to Asymptomatic people(12) Clinically compared to people with OA(5) 9

10 VISA G VISA G DEVELOPMENT OF THE VISA G (13) The VISA-G was developed to evaluate the severity of impact of gluteal tendinopathy. The VISA G was constructed and tested with the intention that it should be used as a whole, although segments of it may provide clinicians with insight in to how their clients are progressing. The minimal significant difference is currently being calculated. We expect that changes would be seen over weeks, rather than days. The clinical diagnosis that this score is valid for is (14) : 1. Pain over the lateral aspect of the greater trochanter (GT) 2. Pain on palpation of the GT 3. Reproduction of GT pain with the FABER test 4. No difficulty with putting on shoes or socks The score is valid for those with concurrent low back pain. It has not been tested on those with concurrent hip osteoarthritis. If the FABER test reproduced groin pain the person probably has an intra-articular problem (14). COMPLETING THE VISA G When asking a client to complete this on the first occasion it is best to show them each question. In particular, clients may stumble on question 8. Question 8 has three sections, A, B and C. Clients should only respond to one of A, B or C. Which section they respond to depends on their pain level with weight bearing activities see the definition attached to each section. Question 8 is particularly important as it provides weighting for levels of activity. For example, someone with no pain with walking, shopping or weight bearing activities (Section C, score=6) but who only moves about the house, scores lower than someone who has pain with these activities but that pain doesn t prevent them from participating in 20 to 29 mins of these activities each day (Section B, score=15). Once all the questions are answered, calculate the score out of 100. If someone fails to answer a questions (try to avoid this), mark the score out of the total available scores this has not been tested for robustness, but it is a clinically reasonable thing to do. If the person answers all three sections of question 8 use the worst case activity scenario (Section C, score=6). 10

11 VISA G Down load the VISA G and the instructions from ResearchGate Go to the Contributions Tab. 11

12 VISA G Questionnaire VISA G QUESTIONNAIRE

13 VISA G QUESTIONNAIRE 13

14 VISA G QUESTIONNAIRE 14

15 UNDERSTANDING LATERAL HIP PAIN UNDERSTANDING LATERAL HIP PAIN Increased compression of the gluteal tendons on the GT, via the ITB. (15) Grimaldi and Fearon 2015, (16, 17)

16 MANAGEMENT OF LATERAL HIP PAIN MANAGEMENT OF LATERAL HIP PAIN PRINCIPLES: 1. Address the modifiable risk factors 2. Address the pain (by managing the load 24/7) 3. Address the muscle imbalances and weakness 4. Address the neuromucsular control 5. Address the co-morbidities Stop the compression Address the risk factors Control the load Improve the strength Improve N/M patterns Treat the co-morbidities 16

17 MANAGEMENT OF LATERAL HIP PAIN ADDRESS THE RISK FACTORS (1, 18, 19) Reduce the adduction and MR Increase the quadriceps strength 17

18 MANAGEMENT OF LATERAL HIP PAIN ADDRESS THE PAIN Stop the compression (STOP these)(20) Do these Grimaldi and Fearon (2015) Add a pillow Limited evidence Rolled up blanket in a pillow case 18

19 MANAGEMENT OF LATERAL HIP PAIN Manage the 24/7 load bearing (17, 21-23) Isometrics (24) Tape (anecdotal evidence) Massage ECSW therapy (controversial) (25) CSI (last option in my opinion) (26, 27) ADDRESS THE MUSCLE IMBALANCES Motor control? True strength? Pain inhibition? Trunk vs hip vs thigh (quads) Might be all of these (28) 19

20 MANAGEMENT OF LATERAL HIP PAIN EXERCISE PRESCRIPTION 101 (29) Frequency of exercises for a) Strengthening (3 x week) b) pain relief (3-4 x day) (dose not optimised) c) Ms activation (> 3 x day) d) Stretching Ms (daily) e) Stretching joints (daily) EXERCISE THERAPY (MECHANOTHERAPY) 1 ISOMETRICS (30, 31) Low intensity Long holds (as the patient can cope) (32, 33) Lifelonglegging Accessed 25 June 2016 Consider doing this as an isometric hold. 20

21 MANAGEMENT OF LATERAL HIP PAIN EXERCISE THERAPY (MECHANOTHERAPY) 2 MUSCLE HYPERTROPHY Low speed, high load Weight bearing Better feedback (manage the load) EXERCISE THERAPY (MECHANOTHERAPY) 3 G med activation (34) 1. Side lying (with MR) (med and min) (32, 33) 2. Single leg squat 3. Lateral band walking 4. Single leg dead lift 5. Transverse hop 6. Forward hop 7. Forward lunge c.f. static lunge (35, 36) 8. Clam (30 ) (NOTE least effective for activation) You can vary how the stabilising leg is pushing with abduction, or stabilised In neutral (with more knee flexion). 21

22 MANAGEMENT OF LATERAL HIP PAIN Any lower limb pain issue (e.g. OA knee, foot). Back pain (37) Diabetes and adiposity (38) Address the co-morbidities EFFECTIVE TREATMENT RELIES ON Correct diagnosis Understanding the aetiology and pathology Recognising, understanding and addressing the modifiable risk factors Identifying and evaluating the contribution of biomechanical deficiencies Identifying and evaluating the contribution of pain And then Prescribing, modifying, progressing the most appropriate interventions WHAT DOESN T HELP High load drill Exercise without recover (3 days) Working people in to pain Isolated eccentric exercises US and frictions 22

23 Not improving? NOT IMPROVING? 1. Re-assess clinically Ms/joints/strength balance 2. Re-visit with the person a. What activities they are doing / not doing? b. Are they doing the exercises? i. At all? ii. Correctly (technique)? iii. Enough? iv. Too much? v. Have they added some extra ones in? 3. Monitoring the total tendon loading 4. Re-consider the diagnosis 5. Re-consider the treatment options 6. Consider referral

24 Look after your self be active, many times during the day, and eat well. Acknowledgements: Jill Cook, Jennie Scarvell, Teresa Neeman, Mike Reiman, Alison Grimaldi and Paul Smith. University of Canberra and The Australian National University The Trauma and Orthopaedic Research Unit at the Canberra Hospital. 24

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