WHEN THE HIP IS NOT THE HIP M Cusí MBBS, FACSP, FFSEM (UK)
Conditions that can be confused with hip pain 1. Referred pain lumbar spine
Conditions that can be confused with hip pain 1. Referred pain lumbar spine 1. L1 2 groin 2. L4/5, S1 buttock / thigh
Conditions that can be confused with hip pain 1. Referred pain lumbar spine 2. Pelvic girdle pain
SIJ pain distribution Never above L5 Typically over sacrum Frequent radiation to buttock Leg(pseudo sciatica) Groin
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
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
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
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
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.
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
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
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
Conditions that can be confused with hip pain 1. Referred pain lumbar spine 2. Pelvic girdle pain 3. Trochanteric pain
Trochanteric pain Trochanteric bursitis Gluteus medius bursitis TFL / ITB pain Usually the passenger LOOK FOR THE DRIVER
Quadratus lumborum Psoas TFL / ITB Gmed + P Adductors
Erector Spinae Psoas Anterior abdominal wall Gluteus major Pelvic floor Hamstrings
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
Quadratus lumborum Psoas TFL / ITB Gmed + P Adductors
Erector Spinae Psoas Anterior abdominal wall Gluteus major Pelvic floor Hamstrings
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
In summary A complex area Coexistence of multiple causes Think biomechanics Look beyond the obvious Find the driver, do not stay with the passenger
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