Week 9 PCP Question

Case 2 

Using the precis of hip assessment as shown below  create your own differential diagnosis
and management plan  for a 45 year old male patient brought in for assessment. He walks
with a limp and complains of anterior hip and buttock pain after his weekly soccer game
that is becoming increasingly worse throughout the season.

 Differential Diagnosis of Hip OA Osteoarthritis verses FAI Femoral Acetabular

Impingement

Differential Diagnosis Femoral Acetabular Impingement and Osteoarthritis

Osteoarthritis – degeneration of the articular cartilage with subsequent narrowing of

the joint space and osteophytes

Femoroacetabular Impingement – motion related disorder of the hip. Characterised by

early abnormal contact between skeletal prominences of the acetabulum and femur. Two
types: Camp type or Pincer type (86% have both)

Ask the questions about what pain activity causes the pain?

  FAI OA
History Questions Is there any groin pain –  Insidious onset of anterior hip,
impingement? thigh and groin pain with stiffness

Can you squat without pain? Pain may radiate to the gluts

Is there pain when running straight Symptoms (stiffness) worse in the

or changing directions? morning (~30mins-hr)

Slow onset intermittent groin pain in With advanced changed, may

active young adults, often starting develop nocturnal pain and
after minor tumour.   discomfort lying on the affected hip

Recurrent episodes of sharp hip and

groin pain
Is it difficult to walk, go from sitting
Pain may be out of proportion to to standing, getting in and out of a
radiographic findings car?

Pain exacerbated on weight bearing (OA pain reduces on non-movement)

and with hip flexion such as walking
uphill, sitting or jumping
Pain increases with loadbearing such
as running
Have you had any previous accidents
that cause a similar pain?
Have you had any blood tests? – could
 indicate inflammatory arthritis (RA)

Observations  Walking uphill,  Gait may be antalgic, shortened

stride and an abductor limp may be
present
Active Movements  Limited ROM, particularly flexion Restriction in all motions
and internal rotation
Passive Movements Decreased by pain, particularly
internal rotation and external
rotation
Test with knee bend (90o) and knee
straight

 
Resisted Isometric  Pain on flexion, inter/external  Pain generally on all movements
Movements rotation
Special Tests  Positive impingement provocation  Faeber Patrick – differentiates
test – pain on flexion plus internal between hip SI and other pathologies
  rotation
3 out of 5
  Hip Scour Test
1. Hip Scour Test =Ve
FADDIR 2. Hip internal Rotation
<25degrees
3. Pain on squatting
4. Pain on hip flexion
5. Pain on Hip Extension
(Yohman’s)

Sensitivity 75%-91%
Specificity 43%

Sensation  L1/ L2 or S3, S4 high and groin
dermatome sensation
Reflexes  Normal
Joint Play Movements  Flexion and internal and external
rotation restriction
Long axis distraction – may feel good
Diagnostic Imaging  X-ray for both types
  Pincer – diagnosis of acetabular
retroversion may be made by
observing a ‘crossover’ sign on x-ray
films; the posterior and anterior walls MRI – gold standard
of the acetabulum cross each other
  L1/ L2 or S3, S4 high and groin
dermatome sensation
Normal
 All could be restricted
 Radiographs demonstrate loss of joint
space (particularly superior)
osteophytes and other degenerative
changed
 

Management Plan:

OA

1. When pain is dominant, mobilisation, soft tissue work, PMF stretches, Trp therapy
of the hip joint should at first use small-amplitude movements without provoking
any further pain. As pain settles, treatment is progressed by using rotational
movements and the amplitude of these movements Is gradually progressed until
a full rocking from medial to lateral can be done.
2. When pain and stiffness are major problems, the hip is first treated in flexion and
adduction and accessory movements are used at the end of the range
3. Glucosamine and other supplements may be useful.

FAI

 Activity modification
 Non-weight bearing (short term)
 Muscle strengthening to relieve stress
 Non-loadbearing activities (cycle, swimming)
 Accelerates cartilage healing
 Or simply deep water walking focusing on all the different movements

Case Study 3

Robert is a 30-year-old solicitor.

Presenting Complaint

Robert complains of right hip pain.

History of Presenting Complaint

There has no previous history of hip pain, and his medical history is unremarkable. He
reports a gradual onset of pain that started approximately two months ago and is now
felt more often, whereas before he would feel it only when lying down on his right side. 
Robert, unfortunately, cannot recall any incident that may have caused his hip pain.  He
rates it at a level of 5/10, describing it as being very sore and tender.

He also mentions that he occasionally gets pain in his right shoulder, which is not related
to movement or physical activity. This shoulder pain has been present for about six
months.
 

Physical Examination

Robert walks into your office with no visible limitations.

Active right hip ROM:  30 degrees of abduction with pain (Normal is 30-50degrees), 20
degrees of external rotation with pain (Normal is ~40-60degrees).  All other ranges of
motion of the right hip are normal.

Lumbar ROM:  Flexion is reduced by 50% due to hamstring tightness.  All other
movements are unremarkable.

Muscle strength:  4/5 on the abductors and external rotators; other muscles are normal.

Patrick Fabere test is negative – indicates that the hip may not be affected and the pain
experienced in the hip is referred pain.

Right Sign of Buttock test reproduces the pain in the right hip -

Right Ober’s test reproduces the pain in the right hip.

Palpation:  Robert exhibits increased tenderness on the right greater trochanter with
slight tenderness on the middle portion of the buttock on the right side.

Shoulder examination: Unremarkable. Pain cannot be reproduced during your

consultation.

1. List the statements (clues) in the case history that aligns with the diagnosis of hip
pain.  Use the script concordance.

Pain lying down on his side +0

Slight decreased external rotation and +1
extension muscle strength
Ober’s test which assesses the tensor +1
fasciae later for contracture reproduces
pain in the right hip
Tenderness on the greater trochanter +1
Right Sign of Buttock test reproduces +1
pain in the right hip

2. The above case history is incomplete.  What further questions or what

information would you need to acquire?
L – tenderness on greater trochanter? – is this main location of pain?
O – gradual onset
D – two months
C – intermittent
T – sore and tender
R – does the pain radiate at all down the leg?
A – increased pain when lying down. What else aggravates/ relieves the pain?
P – Is this the first time you have experienced this pain?
P – What you received any previous treatment to help with the pain? What type of
treatment? What is affective?
A – Do you notice any other associated signs/ symptoms when you

3. Based on the given information from the case history and physical examination,
do you think Robert has a hip problem, facet syndrome or muscle strain?  Give
reasons for your answer.

Hip problem – pain on the right side when he lies on it, positive sign of the buttocks

As his lumbar ROM is normal, besides flexion restriction due to hamstring weakness, he
doesn’t have facet syndrome. Chiropractic is really effective at treating facet problems
and resolution is fast. Facets refer because inflammation which is different to a nerve
compression pain or a muscle trigger point referral.

Muscle sprain don’t last for two months (better within a matter of days, one to two
weeks max) but this pain has been going on for two months and is getting worse.
Muscle just needs rest, and muscles test mostly normal even the abductors and
extensors were only marginally limited.

4. For the above case history alone, give 3 possibilities (differential diagnoses) for
his hip pain.  Explain each answer.

Glut muscle sprain

Trochanteric bursitis

SI joint problem

ITB contracture

5. Your colleague thinks that Robert as an ischiogluteal bursitis (weaver’s bottom).

Do you agree with your colleague?
 Possible: Ischiogluteal bursitis - can’t sleep on affected hip, there is swelling and
limited mobility – could be aggrevated by long periods of sitting because he is a
soliticer

Ischiogluteal bursitis (gluteal tendinopathy) usually experience pain, tenderness

and stiffness around the ischial tuberosity/ in the area where the buttock normally
meets a chair. But Robert has pain around the right greater trochanter with only
slight tenderness on the middle portion of the buttock.

While the sign of the buttock was positive for reproduction of right hip pain, in
the cases of a bursitis, tumour or abscess the patient should also exhibit a non-
capsular pattern of the hip. However, Robert does exhibit a capsular pattern with
extension and abduction.

No reported discomfort when sitting.

6. Using the information from the above case history and physical examination,
what is the more likely diagnosis for

i. His hip pain -> trochanteric bursitis

ii. ii.    His shoulder pain -> don’t have enough information to make this decision
-> shoulder examination was unremarkable.

Case Study 4

Joey is a 45-year-old computer programmer

Presenting Complaint:

Joey presents to your office with right low back pain which occasionally radiates into the
right buttock. 

History of Presenting Complaint and Onset:  The pain had been present for three
weeks.  It started one day after he played a game of golf.  He has no history of back pain,
and he denies any medical history of significance. X-rays are unremarkable.

Aggravating Activities

Running, prolonged fast walking of more than a mile.  When the symptoms are at its
worst, he is unable to stand or walk without pain.  Joey also finds it difficult to stand
from a seated position.  When the pain is present, he is unable to sleep, waking him as
he rolls over in bed.

Physical Examination

Observation:  Standing on the right foot reproduced his pain in the right low back area. 
He also has a right flat foot.

 Trunk extension was full range but reproduced his pain.  All other movements were
pain-free and full range.

Neurological:  Unremarkable.

SLR: Full range but mildly painful in the right low back at 70 degrees.

Nachlas and Ely’s: Unremarkable – no femoral nerve compression or radicular pain

Lumbar Compression/distraction: Unremarkable.

Standing on the right leg only reproduced the pain in the right low back however, if the
sacro-iliac joints were supported (as in supported Adams or the belt test) the pain
disappeared.

NB If the question incorporates ‘Based on the information in the case history and/or
physical examination’ assume that all other tests are unremarkable.

1. List the statements (clues) in the case history that aligns with the diagnosis sacro-
iliac pain.  Use the script concordance.

SI Joint Dysfunction sprain/strain -> Positive Belt test -> +2

Possible gluteal muscle sprain (gluts extend hip and propel when running) ->
can’t run -> +1

Facet issue -> trunk extension reproduces pain -> 1

Bursitis -> low back pain, inability to run, compression through area could irritate
burse, can’t sleep at night on the side -> 0/+1

Nachlas and Ely’s

2. The above case history is incomplete.  What further questions or what

information would you need to acquire?
 3. Based on the given information from the case history and physical examination,
do you think Joey has a sacro-iliac problem, hip problem, facet syndrome or
muscle strain?  Give reasons for your answer.

Sacroiliac problem

4. For the above case history alone, give 3 possibilities (differential diagnoses) for
his back and buttock pain? Explain each answer.
5. What other tests would you like to perform?

Facets can be compressed or stretching the tissues

Kemp’s test –load facets

Prone springing

Slump – to stretch neuromeningeal tissue

SI joint sprain/ strain

Thigh thrust

SI joint compression

Patrick Faber test

Hibbs test

Test for trochanteric bursitis – ober’s test, Scour test