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What nerve root levels receive afferent input from the anterior pubic symphysis?
L2 to L4 leading to groin pain.
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What nerve root levels receive afferent input from the posterior pubic symphysis?
S3 to S5 leading to genital pain.
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Describe the 3 dimensional movement of the hip during flexion.
Femoral head flex, abduct, IR
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Describe the 3 dimensional movement of the hip during extension.
Femoral head extension, adduction, ER
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Describe the 3 dimensional movement of the hip during abduction.
Femoral head abduction, extension, ER.
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Describe the 3 dimensional movement of the hip during adduction.
Femoral head adduction, flexion, ER.
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What patholgies may be present in a 4-10 yo with hip pain?
- Transient synovitis
- Legg-Calve-Perthes disease
- Juvenile RA
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What age for epiphysolysis?
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Age for articular osteochondritis dissecans?
15-25
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Age for ischemic femoral necrosis and synovial osteochondromatosis?
Between 35-50
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Age for hip labral lesions?
18-40
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Age for labral cysts, sacral pathologies, and stress fractures of the femur or pelvis?
Greater than 40 yo, especially in men.
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Who is at risk for stress fractures in the proximal femoral region?
Young, athletic females with the female triad (eating disorder, amenorrhea, and osteoporosis).
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What conditions are associated with aching pain?
- Bursitis
- Tendopathy
- Arthritis
- Arthrosis
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What conditions are associated with sharp pain?
- Labral tears
- Articular loose bodies and pt may complain of giving way or locking
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What conditions are associated with burning pain?
Nerve entrapments in the femoral, lateral femoral cutaneous, ilioinguinal, genitofemoral, obturator, and sciatic nerves
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What conditions are associated with groin pain?
- Affliction of the hip and labrum
- Symphysis pubis lesion
- Adductor tendopathy
- Iliopectineal bursitis
- Incompetent abdominal wall
- Urological
- Gynecological
- Neurovascular
- Organic lesions of the abdominal cavity and plvic region
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What conditions are associated with buttock pain?
- SIJ dysfunction
- Gluteal bursitis
- Hamstring tendopathy
- Hamstring syndrome
- Lumbar spine
- DJD or labrum
- Posterior symphysis pubis
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What conditions are associated with posterolateral pain?
- Trochanteric bursitis
- Gluteal insertion tendopathy or disruption
- Component loosening of THA
- Lumbar spine
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What conditions are associated with groin pain with coughing or sneezing?
- Hernia
- Pubic symphyseal affliction
- Tendopathy of the adductor longus or rectus abdominus
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What is the capsular pattern of the hip?
Flexion, abduction, and IR
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A non-traumatic capsular pattern of the hip in younger individuals may be related to what conditions?
- RA
- Gout
- Reiter syndromme
- Psoriasis
- AS
- Legg-Calve-Perthes disease
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What is the best treatment for traumatic synovitis of the hip?
Early mobilization including joint-specific low-velocity mobs into traction.
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What is transient synovitis?
It emerges from a viral, autoimmune, or microtraumatic origin and i more common in boys under 6 yo and rare in adults.
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Describe the onset of slipped capital femoral epiphysis.
- Boys 2:1 over girls, usually overwieght and underdevelped.
- Acute will have significant groin pain that prohibits wt bearing.
- If gradual, will begin with mild groin or anterior knee pain and muscle guarding will increase with limited IR, increased ER, and Drehman sign.
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What is the treatment for slipped capital femoral epiphysis?
Percutaneus pinning in situ followed by partial weight bearing for 4-6 weeks.
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What is Legg-Calve-Perthes disease?
Aseptic bone necrosis of the femoral head.
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What is the stagging of Legg-Calve-Perthes disease?
- Stage I: 25%
- Stage II: 50%
- Stage III: 75%
- Stage IV: 100%
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What conditions can lead to articular loose bodies?
- Osteochondritis dissecans
- Synovial osteochondromatosis
- Villonodular synovitis
- Flake fracture
- OA
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What are extra-articular causes of snapping hip?
- Thickening of the IT tract at the greater trochanter
- Ilipsoas at the pectin pubis
- Gluteus maximus fibrosis in the posterior hip
- Adventitios bursal formation
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What are the areas most likely to have an avulsion?
- Adductors
- Sartorius
- Rectus femoris
- Iliopsoas
- Biceps femoris
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What areas are most likely to devolop a tendopathy?
- Groin
- Hamstrings at the ischial tuberosity
- Rectus femoris at the AIIS
- Sartorius at the ASIS
- Ilipsoas over the iliopectineal eminence
- Gluteal muscles at and around the greater trochanter
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What position will cause pain with trochanteric (gluteal) bursitis?
Full flexion, adduction, and ER or IR.
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What conditions are painful with resisted hip adduction?
- Acute adductor tendopathy
- Chronic adductor tendopathy
- Rectus abdominus
- Obturator nerve
- Osteitis pubis
- Ossifying myositis
- Symphysitis
- SI joint
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What is the most common cause of groin pain?
Increased tendon load during directional change type sports.
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Describe the positions where a tendonapathy will be most painful.
Adductor longus and brevis
Gracilis
Pectineus
- Adductor longus and brevis: hip in neutral
- Gracilis: hip in neutral along with painful resisted knee flexion
- Pectineus: hip flexion and adduction with hip in 90deg flexion
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What should reproduce true symphyseal pain?
Resisted hip adduction with the hip in 45deg flexion.
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What type of treatment is usually needed for osteitis pubis?
- Repeated injections (prolotherapy) or surgical stabilization.
- Conservative treatment typically fails.
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What is the best treatment of a sports hernia?
Surgery with open mesh repair appearing superior to laparoscopic repair.
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This can produce referred pain in the groin that is difficlt or impossible to clinicall reproduce.
Sacroilitis
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What is typically the type of traumatic labral tear? Degenerative?
- Traumatic: vertical - full substance or partial substance with avulsion
- Degenerative: horizontal - detachment of the fibrocartilaginous labrum from the transition zone at the acetabular cartilage or separation of cartilaginous planes within the substance of the labrum
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With what condition may a patient have a completely unremarkable exam other than pain with weigth bearing and maybe the fulcrum test?
Stress fracture in the proximal third of the femur and femoral neck or the pubic ramus.
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What condition is likely to be painful with passive hip ER in full flexion?
Iliopectineal bursits
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