WHEN THE HIP IS NOT THE HIP

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Toby Newman
5 years ago
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1 WHEN THE HIP IS NOT THE HIP M Cusí MBBS, FACSP, FFSEM (UK)

2 Conditions that can be confused with hip pain 1. Referred pain lumbar spine

3 Conditions that can be confused with hip pain 1. Referred pain lumbar spine 1. L1 2 groin 2. L4/5, S1 buttock / thigh

4 Conditions that can be confused with hip pain 1. Referred pain lumbar spine 2. Pelvic girdle pain

5 SIJ pain distribution Never above L5 Typically over sacrum Frequent radiation to buttock Leg(pseudo sciatica) Groin

6 Assessment of the SIJ History Typically post pregnancy or trauma (fall) Worse in loading situations Standing Walking, running Stairs Sitting In and out of car Turning in bed

7 Assessment of the SIJ History Clinical examination Stork test (Hungerford) Posterior pelvic pain provocation test (Ostgaard, Sturesson) Active SLR (Mens) Palpation of LDSIL, all evidence based SIJ glide (D Lee), useful adjunct

8 Stork test There are two phases to the Stork test; a hip flexion phase and a stance phase In the hip flexion phase, movement between the innominate and sacrum is examined during a non-weight bearing movement The stance phase examines the ability of the weight bearing SIJ to transfer loads

9 Posterior Pelvic Pain Provocation Test (P4) Patient supine Passively flex hip to 90º Exert gentle pressure through femur Reproduction of SIJ pain is a positive test

Ask patient to hold leg up for 5 secs. Lower leg.

10 Active Straight Leg Raise test Patient lies supine (ASLR) Instruct patient to lift L leg off plinth keeping the leg straight. Ask patient to hold leg up for 5 secs. Lower leg. Inquire of level of pain or any difficulty to lift the leg. Compare with R ASLR test. Compare height & ease of lift.

11 SIJ Glides passive articular glide assessment Passive articular gliding of the innominate relative to the sacrum evaluates the relative stiffness of the joints. Squish test SIJ Passive articular glide

12 Hip abductors Gluteus medius and gluteus minimus may become weak or ineffectively activated due to altered lumbo-pelvic posture, altered pelvic mechanics involvement of the L4 / L5 nerve roots

13 Assessment of the SIJ History Clinical examination Stork test (Hungerford) Posterior pelvic pain provocation test (Ostgaard, Sturesson) Active SLR (Mens) Palpation of LDSIL, all evidence based SIJ glide (D Lee), useful adjunct Imaging SPECT CT, new technique

14 Conditions that can be confused with hip pain 1. Referred pain lumbar spine 2. Pelvic girdle pain 3. Trochanteric pain

15 Trochanteric pain Trochanteric bursitis Gluteus medius bursitis TFL / ITB pain Usually the passenger LOOK FOR THE DRIVER

16 Quadratus lumborum Psoas TFL / ITB Gmed + P Adductors

18 Erector Spinae Psoas Anterior abdominal wall Gluteus major Pelvic floor Hamstrings

19 The Unstable Platform Gluteus Medius Quadratus lumborum TFL / ITB Adductors Glut med: weak, tight, tender Compensation mechanisms Tight QL, TFL /ITB Trochanteric bursitis Facet joint strain Unopposed adductors

20 Quadratus lumborum Psoas TFL / ITB Gmed + P Adductors

22 Erector Spinae Psoas Anterior abdominal wall Gluteus major Pelvic floor Hamstrings

23 The Unstable Platform Gluteus Medius Quadratus lumborum TFL / ITB Adductors Glut med: weak, tight, tender Compensation mechanisms Tight QL, TFL /ITB Trochanteric bursitis Facet joint strain Unopposed adductors

25 In summary A complex area Coexistence of multiple causes Think biomechanics Look beyond the obvious Find the driver, do not stay with the passenger

26 THANK YOU

Burwood Road, Concord 160 Belmore Road, Randwick Dora Street, Hurstville

www.orthosports.com.au 47 49 Burwood Road, Concord 160 Belmore Road, Randwick 29 31 Dora Street, Hurstville WHEN SCIATICA IS NOT SCIATICA, WHAT DO YOU LOOK FOR? What do you look for, where? Low Back pain