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Hip, Pelvis and Thigh Problems: Anatomy, Evaluation and Management

Hip, Pelvis and Thigh Problems: Anatomy, Evaluation and Management. Kevin deWeber, MD, FAAFP Director, Sports Medicine Fellowship USUHS Family Medicine (credits to LTC Erik A. Dahl MD for some slides). Objectives. Review pertinent hip, pelvis and thigh anatomy

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Hip, Pelvis and Thigh Problems: Anatomy, Evaluation and Management

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  1. Hip, Pelvis and Thigh Problems: Anatomy, Evaluation and Management Kevin deWeber, MD, FAAFP Director, Sports Medicine Fellowship USUHS Family Medicine (credits to LTC Erik A. Dahl MD for some slides)

  2. Objectives • Review pertinent hip, pelvis and thigh anatomy • Describe clinical presentation of injuries • Review best examination techniques for the hip • Briefly outline treatment for common conditions

  3. Hip Examination • Anatomy • History • Physical Examination • Radiology and Laboratory

  4. BONY ANATOMY

  5. Hip Capsule Ligaments Iliopsoas bursa

  6. Bursae • Trochanteric bursa • Between the greater trochanter and ITB • Ischial bursa • Between the ischial tuberosity and the overlying gluteus muscle • Iliopsoas bursa • Between the iliopsoas tendon and the lesser trochanter, extending upward into the iliac fossa beneath the iliacus muscle • Largest bursa in the body

  7. Hip - Anatomy • Multiaxial ball & socket joint • Acetabulum1/2 sphere • Femoral head2/3 sphere • Strong ligaments & capsule • Maximally stable

  8. History • Age • infancy: congenital hip dysplasia • 3-12 year old boys: Legg-Calve-Perthes, SCFE, acute synovitis • middle age & elderly: osteoarthritis • Mechanism of injury • land on outside hip • land on knee • repetitive loading

  9. History • Pain details • location • snapping • progression of symptoms • exacerbating factors • alleviating factors • Weakness • Occupation, Sport

  10. Observation • Gait • Posture • Balance • Limb position • shortened, adducted, medially rotated • abducted, laterally rotated • shortened, laterally rotated • Leg shortening

  11. Inspection Pelvic unleveling (iliac crest levels) Pelvic rotation (PSIS levels) If asymmetric, measure leg lengths

  12. Leg Length Measurements Eyeball method Measurement method

  13. Anterior Palpation Iliopsoas bursa

  14. Posterior Palpation

  15. Sciatic nerve palpation

  16. Range of Motion: pearls • Quick screen w/ Log-roll IR/ER: • pain may be from intra-articular fracture, synovitis, or infection • Decreased IR: • First plane to be painful in OA

  17. Range of Motion • Flexion: 110 to 120 degrees • Extension: 10 to 15 degrees

  18. Abduction: 30 to 50 degrees • Adduction: 30 degrees

  19. External rotation: 40 to 60 degrees • Internal rotation: 30 to 40 degrees

  20. Examination • Strength testing • isometric • eccentric • knee extension • knee flexion

  21. Hip Flexion Strength Iliopsoas, rectus femoris, sartorius, tensor fascia lata, pectineus

  22. Hip Extension Strength • Hamstrings, gluteus maximus

  23. Hip Adduction Strength • Adductor longus, adductor brevis, adductor magnus, gracilis, pectineus, oburator externus

  24. Hip Abduction Testing • Gluteus medius, gluteus minimus, tensor fascia lata

  25. Internal Rotation Strength • Gluteus medius, gluteus minimus, tensor fascia lata

  26. External Rotation Strength • Piriformis, Obturator internus & externus, Superior/inferior Gemelli, Quadratus femoris, Gluteus maximus

  27. Abdominal strength

  28. Special Tests • Patrick’s Test(FAbER) • hip joint • SI joint

  29. Gaenslen’s Sign Pain at ipsilateral SIJ is positive test

  30. Special Tests • modified Thomas Test • hip flexor and quad flexibility

  31. Special Tests • Ober Test • iliotibial band flexibility

  32. Special Tests • Piriformis Test • Piriformis flexibility or pain

  33. Special Tests • Popliteal Angle • Hamstring flexibilty

  34. Special Tests • Labral Injury • FAdAxL: flexion, Adduction, Axial Load + some IR/ER • pain +/- click

  35. True Hip Pain Misdiagnosis Common • The patients studied by Lesher's team received hip injections for pain. Prior to hip injecton, patients told doctors where they felt pain: • Buttocks: 71% • Thigh: 57% • Groin: 55% • Lower leg: 22% • Foot: 6% • Knee: 2% SOURCE: John Lesher, M.D. 22nd Annual Meeting of the American Academy of Pain Medicine, San Diego, Feb. 22-25, 2006. News release, American Academy of Pain Medicine.

  36. Think outside the pelvis! • Abdominal exam • Obturator and Iliopsoas signs • Back exam • Pelvic exam in females • Hip joint problems can radiate to KNEE

  37. Diagnostic Imaging • Radiographs • Anterior-Posterior view • Frog leg view • STANDING films to r/o early OA • Bone scan: stress fxs • CT: subtle fractures • MRI: soft tissue, stress fx • Arthrogram: labral tears

  38. Approach to hip problems • Better anatomy knowledge  better diagnoses • Differentiate Anterior, Lateral, and Posterior Hip Pain • Develop an appropriate differential based on the location and the exam • Consider AGE in DDx

  39. Margo K, et al. Evaluation and management of hip pain: An algorithmic approach J Fam Pract. 2003, 52:8

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