CHIR12007

Clinical Assessment and Diagnosis

Portfolio Exercises Week 9 & 10

Exercise 1

Differential Chart

Please create a chart that lists as many differential diagnoses for hip pain as you can, including but
not limited to the following conditions (where possible, note those factors that help to differentiate
the condition – historical, physical finding, specific testing or any other factor that may be helpful

LOCATION DDx HIP PAIN DESCRIPTION

Child Perthes 4-8; males; insidious onset
pain; associated risk factors;
groin/hip/thigh/knee pain;
limp; LLD
Slipped Epiphysis 10-15 years old; generally over
weight compared to age0-
matched; males; 50/50
trauma/atraumatic; knee pain
Developmental hip dysplasia newborn
Infection Nothing makes it better; fever;
generally unwell; rapid
progressive
Synovitis Nothing makes it better; low
grade fever; cranky and
uncomfortable
Joint Degenerative arthritis/OA Age; previous injury or hip
disease or other risk factors;
insidious onset
Inflammatory arthritis/RA and
others
FAI Positive impingement test –
pain on flexion/internal
rotation; groin pain/anterior
hip pain; fluctuates between
dull and sharp; usually athletic;
weightbearing pain with
activities-
uphill/squatting/jumping;
generally younger than OA
Labral tears Non-specific; clicking or
clucking with orthopaedic tests
Infection Fever; generally unwell;
progressive; positive lab
values; rapid progression
Bursa Iliopsoas Anterior medial thigh pain,
radiates to the knees,
 snapping sensation; pain hip
flexion and internal rotation;
worse with activity
Trochanteric Tenderness directly over
trochanter; difficulty
Ischial Buttock pain, posterior upper
thigh pain; tender on palpation
of ischial tuberosity, difficulty
sitting
Bone Fracture (overt/stress or Mechanism of injury; high
insufficiency) velocity- younger; low velocity
– older; associated fall; may be
less symptomatic
Dislocation Mechanism of injury;
posterior-dashboard; anterior-
blow rom behind
Avascular necrosis 10-35; 80% bilateral;
associated risk actors;
insidious onset similar to OA
but at younger age usually
Infection Fever; generally unwell;
progressive; positive lab
values; rapid progression
Tumour Discussed later date
Groin Osteitis pubis Groin pain; athlete; pain on
palpation of pubic symphysis
Muscle Adductor longus Stabbing groin pain; external
rotation & abduction force
Rectus femoris Pain anterior to acetabulum;
inability to extend the knee;
pain resisted hip flexion/knee
extension
Glutes Pain over the greater
trochanter and lateral thigh
referral; increases with sitting,
crossed legs, may interfere
with sleep
Psoas LB, groin, medial thigh pain;
difficulty walking and upright
posture
Rectus abdominis Groin pain and lower
abdominal pain; pain wit
contraction (sit-up)
Hamstrings Posterior thig pain
Piriformis Buttock pain, SI pain
Tendon As above
Calcific tendonitis
Nerve Radiculopathy Associated LBP
Maigne’s Referred from thoracolumbar
junction
 Ilioinguinal Burning, shooting pain to
medial thigh, tender at ASIS;
exacerbated by
hyperextension
Obturator Medial thigh pain; previous
surgery; altered sensation at
adductor origin
Genitofemoral Elliptical area on medial thigh;
chronic burning pain
Sciatic Posterior leg pain to knee
Other Snapping hip
Hernia Tissue bulge; inguinal pain
Referred
Myofascial pain syndrome

Exercise 2

Osteonecrosis will be presented in lecture in week 10 however, this can occur in locations other than
the hip.

Please create a table/ chart that lists the locations where Osteonecrosis can occur.

LOCATIONS WHERE OSTEONECROSIS/AVASCULAR

OSTEONECROSIS CAN OCCUR NECROSIS (AVN)
Knees Classically medial - a painful condition that occurs
femoral condyle; when the blood supply to the
medial knee pain bone is disrupted
mimics meniscal lesion - bone cells need a steady
Wrist (Lunate) Collapse of the carpal supply of blood to stay
lunate; repetitive healthy, osteonecrosis can
trauma, ultimately lead to destruction
biomechanical factors of joints and severe arthritis
Ankles (talus) Increased incidence - It is not always known what
with dislocations causes the lack of blood
Upper arm (humeral head) Usually trauma; supply, but doctors have
subarticular, end stage identified a number of risk
flattening of the factors that can make
humeral head someone more likely to
Thigh (femoral head) Trauma/atraumatic; develop osteonecrosis
superior aspect of the - 1. Injury
femoral head; 80% - 2. Excessive alcohol use
bilateral; end stage - 3. Corticosteroid medicines
femoral head - 4. Medical conditions -
flattening and collapse including Caisson disease
(diver's disease or "the
bends"), sickle cell disease,
myeloproliferative disorders,
Gaucher's disease, systemic
 lupus erythematosus, Crohn's
disease, arterial embolism,
thrombosis, and vasculitis.
- It may take from several
months to over a year for the
disease to progress. It is
important to diagnose
osteonecrosis early, because
some studies show that early
treatment is associated with
better outcomes.

Exercise 3

There are 4 major conditions that can affect the paediatric hip and may present with hip pain. Please
list these, nothing the main clinical features and identify those features which may help to
differentiate these.

4 MAJOR CONDITIONS CLINICAL DIFFERENTIATING

AFFECTING THE PAEDIATRIC
HIP
Congenital dislocation of the
hip and acetabular dysplasia
Perthes’ disorder
Slipped upper femoral
epiphysis
Stress fractures of the femoral
neck
FEATURES FEATURES
Gestational and infancy; Gestational and infancy,
female > male; positive family female > male
history; sleepless nights &
avoid walking or crawling;
limping, toe walking, waddling
‘duck like’ gait; LLD
4-8; males; insidious onset 4-8 years old, males
pain; associated risk factors;
groin/hip/thigh/knee pain;
limp; LLD
12-16 years old; generally over 10-15 years old,
weight compared to age - males>females 2/1, obese,
matched; males > females 2/1;
trauma/atraumatic; knee pain

Exercise 4

Self directed learning:

Please research ‘Myositis ossificans’ and present the history, clinical findings and importance of this
condition. Note: this does not solely apply to the hip!
CONDITION HISTORY CLINICAL FINDINGS IMPORTANCE OF
CONDITION
Myositis ossificans Causes bone to form Aching pain within the The common concern
deep within muscles of muscle that persists when abnormal bone
the body longer than expected is seen on an x-ray is
Often this condition is for a normal muscle that there could be a
found in young contusion tumor within the soft-
athletes who sustain a Limited mobility of tissues
traumatic injury, or joints surrounding the
sometimes as a result injured muscle
of repetitive injury to Swelling of the muscle
the muscle group, and sometimes
Most commonly found extending throughout
in the thigh, and the extremity
sometimes in the
forearm
Often occurs in
athletes such as
football or soccer
players.