MSK- HIP for GP’s Dr Tim Hughes GP Kirkbymoorside Surgery

What you will be able to accurately diagnose by the end of the day Osteoarthitis of hip Rule out spine as cause hip pain Bursitis- trochanteric, gluteal, psoas, ischial Groin strain Hamstring strain Meralgia parasthetica 2

What you will be able to accurately diagnose by the end of the day Perthes disease Slipped upper femoral epiphysis 3

Session plan Principles of orthropaedic medicine- 5 mins Examination sequence – 15 mins 7 common presentations and examination patterns- 45 mins Children's hip disorders- 5mins Summary- 5 mins 4

James Cyriax- principles of orthopaedic medicine All pain has a source All treatment must reach the source 5

Sources of pain The joint itself- joint surface, joint capsule Structures around the joint that move the joint- tendons, muscles. Inert structures around the joint- ligaments, bursae Referred pain 6

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Exercise 1 -Surface anatomy Anterior superior iliac spine Posterior superior iliac spines Iliac crests Greater trochanter Ischial tuberosity- origin of hamstring Pubic tubercle- origin of adductor longus Position of L2,3,4 dermatomes 9

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Passive movements Test inert structures- joint capsule, ligaments, bursa, fascia, nerve root Capsular pattern- varies from joint to joint- passive range of movement patterns Hip joint capsular pattern- most limitation of medial rotation, less limitation of flexion and abduction, least limitation extension 12

Resisted movements Test contractile structures- tendons and muscles Pain and power Test joint in mid position 13

Palpation Localising precise site of tenderness at end of examination. 14

History Age and occupation Site and spread of pain Onset and duration Symptoms: twinges, night pain, pain on activity, cough/sneeze Behaviour- effect on life Other joints PMH Medications 15

Inspection Bony deformity- spinal curvatures,pelvic position, leg length Wasting Swelling 16

Examination- eliminate spine Eliminate lumbar spine- active lumbar extension with and without hip in flexion- stool. Active side flexion Supine lying- SLR Exercise 2 - everyone rule out the spine! 17 Make sure you have a small stool in your room!

Examination of hip- after ruling out spine Supine lying Passive flexion, medial rotation,lateral rotation, abduction, adduction Resisted flexion, medial rotation,lateral rotation, abduction, adduction Prone lying Femoral stretch test- rule out spine Passive Medial and lateral rotation Knee flexion and extension Resisted Lateral rotation- small deep muscles hip- piriformis Medial rotation- gluteus medius Knee flexion- hamstrings Knee extension- quadriceps 18

Special tests Psoas bursa test Sign of buttock test Trendelenberg test Thomas's test 19

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Exercise 3 Run through the examination sequence 21

Scenarios In groups each take turn to role play the patient and do the examination.Tell the story and replicate examination findings. 7 cases 22

Patient 1 Age 77 Increase ache pain around hip on walking and now at night. Sudden sharp pains groin on getting up Using paracetamol 23 Limp Pain on extension Lumbar Spine that goes with hip In flexion Restriction medial rotation

24 Osteoarthritis of hip

Patient 2 Age 67 Laying a new patio 3m ago Ache pain buttock around hip to groin. No neuro symptoms Worse with walking and at night. Using ibuprofen. 'FH - everyone's got a new hip' Want referral hip surgery 25 Pain on extension Lumbar spine Pain remains with extension With hip in flexion SLR normal Normal hip examination Normal neuro exam

26 Referred pain from lumbar spine

Patient 3 Age 38 Zumba class started Ache lateral hip, worse at night when lies on that side and when she walks 27 Pain on passive abduction and adduction and a little on hip flexion Pain on resisted hip abduction Tender over Trochanteric Bursa

28 Trochanteric bursitis

Patient 4 A 40 year old solicitor who is training for the London Marathon complains of pain in his right hip and buttock It is particularly painful getting out of bed in the morning and on hills and stairs. He also has difficulty getting out of the car. 29 Painful passive straight leg raise- buttock Painful resisted knee extension Very tender over ischial Tuberosity

30 Hamstrings

Patient 5 Age 77 Started regular 40 minute a day walks to get fitter 6 weeks ago Ache pain right buttock more she walks and now when she sits down I think I might have arthritis Paracetamol helps a bit 31 Point to upper outer buttock As site of pain Painful passive flexion, abduction and Adduction Painful resisted abduction And extension. Tender point upper outer Buttock

32 Gluteal bursitis

Patient 6 22 year old footballer Slide tackle Severe pain right groin not settled rest 3 weeks 33 Point to right groin as site Of pain Painful passive adduction Painful resisted Adduction Tender pubic tubercle

34 Groin strain

Patient 7 Age 38 Keen footballer Lorry driver Ache pain groin all time- terrible when driving 35 Point diffuse area around groin as site pain Normal lumbar spine Pain passive flexion, adduction and abduction Pain resisted flexion and adduction Positive psoas bursa test

36 Psoas bursitis

Two children's conditions to cover Perthes SUFE 37

SUFE Groin, hip, thigh or knee pain. Some people only have knee pain, even though the condition affects the hip. Adolescent males- 2:1. Obesity. Limp Limited movement of the hip joint There may be slight shortening of the affected leg. 38

Perthes disease Children with Perthes' disease usually complain of pain in the groin, the thigh or the knee - particularly after physical activity. They limp and have a restricted range of movement (stiffness) of the hip joint. These symptoms may persist on and off for many months. The disease itself lasts for a few years. Age 4 to 8 most common Can occur 2 to 15 yrs 39

40 ConditionHistory Exam findings Management OsteoarthritisAge Capsular pattern- loss medial rotation Oxford hip score Analgesia Physio/aids Lumbar spine Quality of pain Radiation Pain remains spine extension hip flexed Exercises Physio Trochanteric bursa Fall Overuse Mixed picture Tender over bursa Exercises Injection Groin strain Overuse Trauma Pain resisted adduction Tender insertion Exercises Injection

41 ConditionHistory Exam findings Treatment Hamstring Overuse Trauma Resisted knee flexion Tenderness Exercises Gluteal bursa Overuse Trauma Mixed passive/resisted pain Tenderness Exercises Injection Ischial bursa Overuse Trauma Mixed passive/resisted pain Tenderness Exercises Injection Psoas bursa Overuse Mixed passive/resisted pain Positive test Injection Exercises