00:01
When considering hip pathologies,
there are several special tests
that we could utilize
to help narrow down our differential.
00:08
So we could perform a Trendelenburg test
to check for gluteus medius weakness,
straight leg raising to check
for lumbar radiculopathy,
Stinchfield tests for intra-articular
hip pathology,
FABERE test or Patrick’s tests
to check for range of motion
restrictions in the hip,
Fadir also will check for range of
motion restrictions in the hip,
the Thomas test will check for
iliopsoas contraction,
Erichsen’s for any sacroiliac restrictions,
Ober’s test for contracture of IT band,
and the hip drop test will
check for any lumbar
involvement with back pain and hip pains.
00:47
So the Trendelenburg test is a special test
that tests for gluteus medius weakness.
00:53
And so, if we have a patient
complaining of back pain,
buttock pain,
feeling unstable when they’re ambulating,
or weakness in the hip,
what we could do is to perform
the Trendelenburg test to see
if there’s gluteus medius weakness.
01:08
And so, what you’re going to do is to
ask the patient to pretty much stand
and then try to stand on one leg.
01:14
So in the image here, you could see how
the patient is picking up their left foot,
and when you lift the left foot,
the right gluteus medius has to fire
so it stabilizes the hip
and allows the hip to stay level.
01:31
An abnormal test is when you have
someone trying to lift up their leg
and that hip actually drops.
So the iliac crest will drop
because the gluteus medius on
the opposite side cannot fire
and hold the pelvis more level.
01:46
So a positive Trendelenburg test
will give you a positive gluteus
medius on the standing leg
or the side opposite
the leg you’re lifting.
01:59
Straight leg test is a test to check for
any lumbar radiculopathy or sciatica.
02:06
What you’re doing here is
with the leg straight,
you’re slowly flexing the hip.
02:12
So the patient is supine,
you’re going to passively—
with the leg straight—
slowly flex the hip to about 70°.
02:24
And what this does, is this puts
a stretch on the sciatic nerve.
02:30
If the patient has pain recreated
that shoots down the leg
then that is a positive test.
02:37
So when you’re stretching that nerve,
if someone has some sort of compression,
inflammation, or irritation,
the patient will complain of pain
when you’re flexing the leg.
02:49
You could confirm also by slowly
lowering the leg, maybe 5°,
then dorsiflexing the toes.
02:56
If you do that and the patient
has pain again,
that helps to confirm the positive
straight leg raise.
03:03
You could also perform this
on the opposite side,
or the side that the patient is
not complaining about,
because usually if you have a lumbar
radiculopathy or sciatica,
it effects one side.
03:13
But if you perform the test
on the opposite side,
and the patient gets the pain on the
side where it originally hurt,
that also confirms your suspicion.
03:24
So test both sides when you’re
performing the test
to see if the patient has
lumbar radiculopathy.
03:30
And so a positive straight leg test
is indicative of some sort of
sciatic or radicular pain.
03:39
Stinchfield’s test is a test for
intra-articular hip pathology.
03:43
So if the patient complains of hip pain
and you’re suspecting possible
osteoarthritis
or some sort of degenerative
change in the hip itself,
you could perform this test.
03:52
So for this test, the patient is supine
and here you’re going to have the patient
actively try to raise the leg off the table
while you provide resistance.
04:01
Pain within the joint would
be a positive test
for a possible intra-articular hip pathology.
04:11
Patrick’s test or FABERE’s test is a
range of motion test for the hip.
04:15
So FABERE actually stands for the motions
that you’re going to put the hip through.
04:22
So the motion that you
engage the patient in
is you’re going to take the hip into flexion,
abduct by letting the knee
come out to the side,
externally rotate and extension.
04:32
So usually you’re going to feel
for possible range of motion,
if there’s restriction.
04:38
If the patient can’t get into that position,
could indicate that there’s a problem
with the SI joint, the hip,
or some sort of muscle imbalance
or muscle problem.
04:48
So it’s a positive test
if you’re unable to kind of create
that figure 4 with the leg,
and then you have to motion
test each individual one
to try to distinguish what
is the key problem.
05:04
FADIR test here or FAIR test
what you’re doing is
here you’re moving the hip into flexion,
adduction, and internal rotation.
05:14
So again, we’re looking for
the quality, quantity,
and symmetry of motion on both sides.
05:19
It could indicate a problem
with the hip joint itself
or muscular problems such
as a piriformis spasm.
05:24
And so again, a positive test is
if you’re unable to move the hip
through its full range of motion.
05:32
The Thomas test is a special test to check
for psoas muscle hypertonicity.
05:37
So the psoas muscle is a very
important hip flexor,
and when that muscle is
irritated or inflamed,
that could cause a lot of hip pain
and even lower back pain
because remember the psoas attaches from
the anterior bodies of the lumbar spine
and comes down and attaches
to the lesser trochanter.
05:54
So when we have a psoas muscle spasm,
that could cause hip and lower back pain,
and sometimes patients may complain
of like an anterior groin pain from it.
06:02
Remember that the psoas
muscle is a hip flexor
so things that patients usually
complain about
when they come in with a complaint
of psoas pain,
is that they were sitting for a long
time and suddenly got up,
or they were in a crouch or crawling
position or gardening position
and suddenly get up,
and that sometimes can cause
that psoas spasm.
06:22
And when the psoas is spasmed,
they complain about not being
able to fully stand up straight
or potentially having more pain
when they’re lying down flat.
06:30
So to perform the Thomas test,
we have the patient supine.
06:34
And first, the patient kind of grabs
both of their knees to their chest
and then they allow one leg to extend.
06:42
What the physician does then is
to measure the distance
between that extended leg and the table.
06:49
Really, the popliteal crease should get down
to the table without any problems.
06:55
Sometimes patients might kind of
arch their back a little bit more
to let the leg come down.
06:59
So you want to make sure
that they’re not arching
to allow their leg to reach the table.
07:03
And then you do the same for the other side.
07:05
A positive test really is when you note
that the hip does not extend all the
down onto the table on one side
because that’s psoas contracture or spasm
is preventing that hip from
going into extension.
07:16
So a positive Thomas test
signals a potential psoas spasm
on the affected side.
07:25
Erichsen’s test.
07:26
So Erichsen’s test is a
test for sacroiliitis.
07:29
So if you have inflammation
of the sacroiliac joints,
patients will complain of tenderness
and pain in their sacroiliac joints.
07:40
So to perform this test,
the patient is supine.
07:42
The physician is going to place both your
hands on the ASIS on the innominates
and then you’re going to apply
a medial pressure—
kind of medial and a little bit
towards the table.
07:53
And as you compress at the ASIS bilaterally,
what you’re doing is you are gapping
the SI joints posteriorly.
08:02
Patient’s that have pain when
you perform that maneuver
would be a positive test
on that particular side.
08:09
So the Erichsen’s test screens
for sacroiliitis,
and again, a positive test would
be pain on the side
when you’re adding the compression
to the ASIS.
08:22
Ober’s test.
08:23
So Ober’s test is a test to check
for IT band contracture.
08:26
This is more common with patients
that are runners or marathon runners.
08:32
Patients that have these contractures
will usually complain about
perhaps lateral knee pain.
08:37
So remember the iliotibial band
comes down and attaches
along the lateral aspect of the
leg into the fibular head
and so patients might have
lateral knee pain
or pain along the lateral aspect
of their leg into the hip.
08:50
So to perform the test, what we do is
we have the patient lying on their
sides so the affected side is up.
08:57
The physician is going to take
the knee and abduct the hip
and so as you abduct the hip
you shorten the IT band.
09:09
And when you release the hip to
let the leg fall towards the table,
someone with a contracted IT band
will have like a delayed drop
or ratcheting motion
as it comes down.
09:22
So Ober’s test is testing for iliotibial
band spasm or contractures.
09:27
And again, as you’re releasing the leg,
if there’s a decrease in the
rate of how it drops
or ratcheting as you move and let
the leg fall towards the table
then that would be a positive test.
09:40
The hip drop test
or lateral lumbar flexion test
could help to discern whether or not there’s
some sort of lumbar involvement
with back pain and hip pains.
09:50
So lateral lumbar flexion is also known
as sidebending of the lumbar spine,
so what we’re looking at
here overall is to see
if someone drops their hip
whether or not the lumbar spine
side bends accordingly.
10:02
So to perform the test, we’re going to
start with the patient standing
with their feet about 4 to 6 inches apart.
10:08
As a physician, you want to get about
eye level to the lumbar spine to see
if there is changes
and how much the hip is dropping.
10:17
You’re going to ask the patient
to bend one knee
while both feet are flat on the ground
and you’re going to look at how
the lumbar spine shifts and whether
or not it shifts smoothly.
10:27
So you want to look at how
much the hips drop
so if I ask the patient to bend
their right knee
you are going to note how
much that right hip drops
and see how fluid that movement is.
10:38
And so you’re going to compare
the side that drops more
is going to be opposite to the side of
the greatest lumbar sidebending.
10:46
Or in other words, the lumbar convexity
on the side as the side of the
greatest amount of drop.
10:54
So your lumbar will be convex on the
side of the greater hip drop.
10:58
There’s some additional musculoskeletal
disorders that we need to be aware of
in children and adolescents.
11:05
There are certain diseases that you
have to kind of keep in mind.
11:08
Congenital hip dislocation
or developmental dysplasia of the hip
are some things to be concerned
about with kids.
11:18
Legg-Calve-Perthes is also
another hip problem
that you should be aware of.
11:22
Slipped capital femoral epiphysis
and also transient synovitis
are all more prevalent and
common in children.
11:32
Whereas in adults
due to aging, wear and tear, and trauma,
adults have a different
set of differentials.
11:42
Keep in mind avascular necrosis.
11:43
Remember we talked about how the femoral
head doesn’t receive as much blood supply
so patients might complain about hip pain
and you can’t find anything going
on musculoskeletally.
11:55
Sometimes x-rays or CT will help pick up
on avascular necrosis.
12:01
Ischiogluteal bursitis.
12:02
So the different bursas that lie
close to the hip joint itself
sometimes become inflamed.
12:10
The trochanteric bursa also could become
inflamed and cause hip pains.
12:14
The iliopsoas also has a bursa
and also the iliopsoas could
also have a tendonitis
that could cause that anterior groin pain.
12:22
Psoas syndrome—we discussed a little bit
about how the psoas muscle
could become spasmed
but then that also leads
to a whole syndrome
where there’s compensatory
changes that could occur.
12:33
Piriformis syndrome—
the piriformis could be spasmed
and also cause
pain in the hip and also pain
shooting down the leg.
12:41
And osteoarthritis is another common
thing on your differential list
you should think about for adults that
complain about hip pains.
12:51
So iliopsoas bursitis and tendonitis,
also known as “snapping hip syndrome.”
Patients may complain of
a snapping sensation
or sound with hip flexion.
13:03
Usually the patient will present
with like a psoas gait
which is more of like a kind
of a staggering,
waddling gait
and a positive Thomas test.
13:15
Patient will have pain kind of
in that anterior groin
and femoral triangle region.
13:21
They will have a pelvic shift
to the opposite side
and it could be associated with
visceral somatic dysfunctions.
13:28
Your psoas muscle is in close
proximity to your appendix.
13:33
You also have the kidneys and the ureters
that travels kind of over the psoas muscle.
13:40
So visceral dysfunction or problems
could potentially irritate the psoas muscle.
13:46
So it’s something to kind of think about.
13:49
Psoas syndrome usually starts with a
somatic dysfunction of the psoas.
13:54
So the psoas is spasmed, and what happens
when the psoas muscle is spasmed,
is based on its attachments
to the lumbar spine.
14:01
It usually causes a non-neutral,
usually a flex dysfunction of L1-L2
on the side of spasm.
14:09
Usually you also have a sacral dysfunction—
a right on right or left on left—
based on the side of spasm and the
pelvis will shift to the opposite side.
14:19
Usually you’ll also have involvement
of the opposite piriformis.
14:23
So if you see someone with a piriformis
syndrome or piriformis spasm
that isn’t resolving with treatment,
make sure that you check the psoas
on the opposite side.
14:35
Piriformis syndrome.
14:36
Piriformis syndrome is a
syndrome that occurs
when patients might complain about shooting
pain radiating down their leg.
14:43
And you need to distinguish this from
lumbar radiculopathy
because the pain is due to
compression of the nerve
or inflammation of the nerve
as it passes close or through
the piriformis muscle.
14:56
So the sciatic nerve could have two
different anatomical variations.
15:01
It could pass through the piriformis
or sometimes it could actually
bisect the piriformis
because the piriformis could arise
from two tendinous origins.
15:11
And so you can see how spasm
of that muscle
could compress that nerve
causing pain to shoot down the posterior
lateral aspect of the leg.
15:22
So usually patients might complain
about piriformis muscle spasms
which could arise from a sudden fall
on the buttock region or
the sacroiliac region.
15:33
Sometimes patients don’t have to
necessarily fall and hit something
but it’s almost have a slip and a near fall
where they catch themselves
and that piriformis muscle fires
to try to stabilize their hip
and they could have that spasm
that could occur.
15:47
Sometimes prolonged sitting
could irritate that region
or sometimes overuse of the
muscles of the hip
could also irritate that muscle leading
to irritation of the nerve.
15:59
Having items in the back pocket,
where you’re kind of sitting
on your wallet for men,
could also irritate the nerve
and the muscle.
16:08
And sometimes,
the pain is worsened by sitting and walking.
16:12
It could effect stride, your gait
and also lead to decreased
internal rotation,
that positive FADIR special test,
and sometimes you could develop
a piriformis tender point
where you’re pushing along the muscle
and the muscle belly
and the patient cries in pain as you’re
palpating in that area
without any other significant lower
back pain in the lumbar spine.
16:36
Osteoarthritis is also an important
consideration of the hip.
16:40
You could have wear and
tear of the hip joint
where you have degeneration of the
femoral head or the acetabulum.
16:50
Usually on x-ray,
you can see some degenerative changes,
narrowing of the joint space,
or bone spurs,
or a non-smooth appearance
of the actual femoral head
and the acetabulum.
17:04
Usually, your symptoms could be so severe
that they may require total
hip replacement.
17:11
Osteopathic manipulation could
potentially help treat
some of the muscle spasms
and pain in the area
and help delay some of the surgeries
that need to occur.
17:22
Osteoarthritis of the hip could affect
anywhere up to 85% to 90% of the population
that is greater than 65 years old
and is really the most common
form of articular degeneration.
17:34
So osteoarthritis is graded on a scale
of 1 to 4 based on imaging.
17:39
So on imaging, if you see some
minor chondral changes
that might be a grade 1 and it becomes
as severe as a grade 4
when you have additional changes
to the bony surface
and also to the femoral head.
17:53
Usually on examination, patients might have
decreased internal rotation of the hip.
17:58
Patient might also have a
positive Stinchfield test
which was a test that tests for
intra-articular hip pathology.
18:07
So with that knowledge of
anatomy and physiology
and these different examination
skills and special tests,
it could help you determine
the different hip pathologies that your
patients may present with.