Week 9 Workbook questions

Study Guide Questions: 9.4

The questions for this week will focus on a case study that will require students
to formulate a series of questions in the history and complete the table below
with details to assist you with your diagnosis for this patient, similar to Table
11-16 from Magee D, Orthopedic Physical Assessment, 6th Edition (2014),
page 759- 759 provided as an exemplar

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 incresingly worse throughout the season.

Differential Diagnosis of Hip OA Osteoarthritis verses FAI Femoral Acetabular

Impingement
Differential Diagnosis Femoral Acetabular Impingement and Osteoarthritis

FAI OA
History Questions Where is the pain? Where is the pain?
Does the pain radiate? Does the pain refer/or localised?
What are your ADL’s? (To find rel/agg What are your ADL’s? (To find rel/
factors). agg factors).
Do you have pain when squatting? Do you have pain when squatting?
Have you had any previous Have you had any previous
surgeries? surgeries?
Any current or previous medications? Any current or previous
Do you have any stiffness in the medications?
morning for the first 30-60minutes. Do you have any stiffness in the
morning for the first 30-60minutes.
Observations Crepitus Crepitus and antalgic gait
(shortened stride)
Active Movements Pain on flexion Pain on restriction
Passive Movements Restriction and pain in flexion and IR Restriction, and ?
of Hip
Resisted Isometric Pain on Pain on
Movements
Special Tests Thomas test -ve -ve/+ve (rule out/in Thomas test -ve/+ve (rule out/in
muscle contracture) muscle contracture)
Patrick Faber +ve Patrick Faber +ve
Anterior/Posterior labral tear (ADDIR Slide: “Hip OA cluster of Sutlive”
test) +ve Springing Sx/Lx tests
Scour test +ve Hibb’s test +ve for Hip lesions
Sign of the buttock +ve for hip
pathology
Springing Sx/Lx tests
Hibb’s test +ve for Hip lesions
Sensation NAD Same
Reflexes NAD Same
Joint Play May cause pain, or relief NAD
Movements

Diagnostic Imaging X-ray: Deformity of acetabular or X-rays: Joint space narrowing and
femoral head observed. possible osteophyte formations
observed.

Management Plan:

Lifestyle changes: Diet, exercise,

Soft-tissue therapy: MFR, TrP to surrounding muscles such as Hamstrings, Mobilisations
within limitation,
Eventual adjustment if suitable.
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, 20 degrees of external rotation
with pain. 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

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.

A: All highlighted above in red/pink.

2. The above case history is incomplete. What further questions or what information
would you need to acquire?
A: Is there any groin pain? Is there any radiation/referral? What rel/agg the pain?

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.

A: Hip pathology: his pain is in his right hip, pain when lying on right side, local soreness/
tenderness of Hip, Limited Hip Flex, Lumbar is reduced by hamstrings during ROM testing,
but is otherwise unremarkable, Sign of Buttock +ve, Obers test +ve.

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

A: Shoulder-related or systemic pathology -2, SIJ dysfunction -1, Snapping hip syndrome
0, Sub-trochanteric bursitis +1, Ischial-gluteal bursitis 2+.

5. Your colleague thinks that Robert as an ischio-gluteal bursitis (weaver’s bottom). Do

you agree with your colleague?
A: Yes.

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

i. His hip pain

A: Ischial-gluteal bursitis 2+

ii. His shoulder pain

A: Unknown, more investigation needed. Not a priority over the Hip,

most likely unrelated.

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.

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.

A: Bursitis -2, Muscle strain -1, Lumbar disc lesion 0, facet syndrome +1, muscle strain
Muscle strain +1, SIJ pathology +2.

2. The above case history is incomplete. What further questions or what information
would you need to acquire?

A: Previous or current medications? Previous operations? Can you describe the current
pain? What do you find relieves the pain? Is there anything else in your health or your life
that you feel could be contributing to this pain?

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.

A: Based on the supported belt/Adam’s test, and no neuro-findings (unremarkable ortho

tests and SRM), yes.

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

A: SIJ pathology, facet joint syndrome, muscle strain.

 5. What other tests would you like to perform?

A:

Facet cluster: Kemps test, Prone springing test, SLR test, Adam’s Belt test, Nachlas test.

SIJ cluster: Adams belt test, SIJ: compression, distraction, thigh thrust, Gaenlen’s SIJ test,
Hibb’s.

Muscle strain: muscle testing the surrounding region.