REIDER PART 221

Chapter 5_Pelvis, Hip, and Thigh 181

When the Patient Complains of Hip Pain

Pain Located Anteriorly or "in the Groin"

If the pain is reproduced by active straight leg raise (Stinchfield's test) primary hip pathology is likely.

• lliopsoas tendonitis

- Pain with FABER (Patrick's test)

- Pain with resisted hip flexion

• Rectus femoris injury

- No pain with FABER (Patrick's test)

- Pain with resisted hip flexion

- Pain or tightness to Ely test

• Osteoarthritis of hip

-Tenderness of anterior hip capsule

- Restricted rangę of motion

- Pain reproduced by passive rotation of the hip

- Abductor limp (morę severe cases)

- Apparent leg length discrepancy (if abduction or adduction contracture is present)

• Inflammatory arthritis of hip

- Finding similar to osteoarthritis but signs of multiple joint invo!vement often present

• Septic arthritis of the hip

- Finding similar to osteoarthritis but onset usually morę sudden and pain morę severe

• Avascular necrosis of femoral head

- Finding similar to osteoarthritis; diagnosis usually madę by imaging studies

• Hip fracture or stress fracture

-Tenderness of anterior hip capsule or greater trochanter

- Externally rotated position of lower limb (displaced fractures)

Pain Located Laterally (Greater Trochanter)

• lliotibial band contracture

-Tightness to Ober's test -Crepitation or snapping of iliotibial band

• Trochanteric bursitis

-Tenderness over great trochanter with deep palpation

-Crepitation with hip flexion (variable)

• Gluteus medius tendonitis

-Tenderness just proximal to the greater trochanter

- Pain reproduced by resisted abduction of the hip

Pain Located Posteriorly

• Piriformis tendonitis or syndrome

-Tenderness to deep palpation near the hook of the greater trochanter

- Pain reproduced by the piriformis test

• Gluteus maximus tendonitis

-Tenderness near the gluteal fold at the inferior aspect of the gluteus maximus

- Pain reproduced by Yeoman's test

• Herniated lumbar disc

- Sciatic notch tenderness

- Reproduction of pain with nerve tension test (straight-leg raising, seated-leg raising, Lasegue's test, slump test, bowstring sign)

• Spinał stenosis

- Reproduction of pain with extension of the lumbar spine

- Loss of normal lumbar lordosis

- Sciatic notch tenderness

• Sacroiliac joint disfunction

-Tenderness over the sacroiliac joint

- Pain reproduced by FABER (Patrick's) test or Gaenslen's test

In a normal patient, the extending thigh should be able to touch the examination table. This is considered neutral or 0° of extension. If the hip being tcsted is unable to extend enough to allow the thigh to reach the table, a flexion contracture (loss of cxtcnsion) is said to be present (see Fig. 5-27C). The flexion contracture can be quantitated by estimating or measuring with a goniome-ter the angle formed by the central axis of the thigh and the top of the examining table.

To measure flexion, both knees are again positioned against the patient’s chest. The contralateral thigh is now allowcd to fali to the examination table whilc the thigh of the hip being testcd is kept in maximal flexion. The angle between the table and the midline of the thigh being examined represents the maximal amount of flexion and can be measured or cstimated (see Fig. 5-27D). In normal patients, at least 110° of hip flexion should be present.

During the Thomas test, one hip is positioned in maximal flexion whilc the other is positioned in maximal extension. Bccause it is customary to measure the ROM in both hips, the maximal flexion of one hip can be measured at the same time that the extension of the opposite hip is being gauged, thus minimizing the number of maneuvcrs necessary to test the flexion and extension of both hips.

Extension past 0° may be assessed with the patient lying prone (Fig. 5-28). In this position, it is important to guard against the patient’s natural tendency to augment true hip extension by hyperextending the lumbar spine. Abduction and Adduction. Abduction and adduction may be assessed in two positions: (1) with the hips extended and (2) with the hips flexed. For both these assessments, the patient is positioned supine on the examination table. Because the pelvis is capable of motion in a fashion that would supplement abduction and adduction, the examiner must observe for such com-plementary motion of the pelvis when assessing these movements.

To test abduction in extension, the examiner stands at the side of the examination table facing the supine patient. One of ihe examiner s hands grasps the patient’s ankle while the examiner^łs other hand is placcd lightly on