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

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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)

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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

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Hip Examination

• Anatomy
• History
• Physical Examination
• Radiology and Laboratory

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BONY ANATOMY
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Hip Capsule Ligaments
Iliopsoas bursa
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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

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Hip - Anatomy

• Multiaxial ball socket joint
• Acetabulum1/2 sphere
• Femoral head2/3 sphere
• Strong ligaments capsule
• Maximally stable

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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

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History

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

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Observation

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

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Inspection

• Pelvic unleveling (iliac crest levels)
• Pelvic rotation (PSIS levels)
• If asymmetric, measure leg lengths

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Leg Length Measurements

• Eyeball method

• Measurement method

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Anterior Palpation
Iliopsoas bursa
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Posterior Palpation
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Sciatic nerve palpation
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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

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Range of Motion

• Flexion 110 to 120 degrees
• Extension 10 to 15 degrees

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• Abduction 30 to 50 degrees
• Adduction 30 degrees

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• External rotation 40 to 60 degrees
• Internal rotation 30 to 40 degrees

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Examination

• Strength testing
• isometric
• eccentric
• knee extension
• knee flexion

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Hip Flexion Strength
Iliopsoas, rectus femoris, sartorius, tensor
fascia lata, pectineus
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Hip Extension Strength
Hamstrings, gluteus maximus
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Hip Adduction Strength
Adductor longus, adductor brevis, adductor
magnus, gracilis, pectineus, oburator externus
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Hip Abduction Testing
Gluteus medius, gluteus minimus, tensor fascia
lata
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Internal Rotation Strength
Gluteus medius, gluteus minimus, tensor fascia
lata
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External Rotation Strength
Piriformis, Obturator internus externus,
Superior/inferior Gemelli, Quadratus femoris,
Gluteus maximus
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Abdominal strength
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Special Tests

• Patricks Test(FAbER)
• hip joint
• SI joint

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Gaenslens Sign
Pain at ipsilateral SIJ is positive test
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Special Tests

• modified Thomas Test
• hip flexor and quad flexibility

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Special Tests

• Ober Test
• iliotibial band flexibility

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Special Tests

• Piriformis Test
• Piriformis flexibility or pain

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Special Tests

• Popliteal Angle
• Hamstring flexibilty

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Special Tests

• Labral Injury
• FAdAxL flexion, Adduction, Axial Load some
  IR/ER
• pain /- click

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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.

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Think outside the pelvis!

• Abdominal exam
• Obturator and Iliopsoas signs
• Back exam
• Pelvic exam in females
• Hip joint problems can radiate to KNEE

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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

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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

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Margo K, et al. Evaluation and management of hip
pain An algorithmic approach J Fam Pract. 2003,
528
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Common Hip Problems by Age

• Newborn Congenital dislcation of hip
• Age 2-8 AVN of hip (Legg-Calve-Perthes),
  sysnovitis
• Age10-14 Slipped Cap Fem Epiphysis
• Age 14-25 Stress Fracture
• Age 20-40 Labral Tear
• Age gt40 Osteoarthritis

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Anterior Hip Pain

• Differential Dx
• Osteoarthritis
• Muscle strains or tendinopathy
• Stress fracture (femoral neck, pubis)
• Sports hernia
• Osteitis pubis
• Acetabular labral tears
• Obturator or ilioinguinal nerve entrapment
• Meralgia paresthetica (may be lateral)
• Inflammatory arthritis
• Iliac crest apophysitis
• AVN of femoral head

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Lateral Hip Pain

• Differential Dx
• Greater trochanteric bursitis
• ITB
• Meralgia paresthetica
• OA, labral tear, AVN
• TFL or gluteus medius strain

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Posterior Hip Pain

• Differential Dx
• Lumbar spine disease and radicolopathy
• Eval for red flags
• Sacroiliac joint disorders
• Hip extensor strain or tendinopathy
• Glut max, hamstrings
• External rotator strain
• Piriformis strain or syndrome
• Aortoiliac vascular occlusive disease (rare)

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Specific Conditions
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Osteitis Pubis

• Repetitive trauma to pubic symphysis due to
  overuse
• Running/cutting, esp soccer, football,
  basketball
• S/Sx insidious onset dull anterior groin pain
  may radiate TTP over PS /- pain w/ resisted
  Adduction or passive Abduction
• Xrays helpful
• Tx relative rest, brief NSAID, cross-tng,
  stretching/strength rehab,
• consider steroid injection

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Hip Pointer

• Contusion to the iliac crest
• S/Sx pain, swelling, and ecchymosis
• severe limit to motion
• /- palpable hematoma
• Xrays to r/o fractures
• TX rest, ice, compression, ?benefit from
  steroid/lido inj after acute phase, progressive
  ROM, strength rehab
• RTP padding over area

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Piriformis Syndrome

• Pain due to sciatic nerve compression at
  piriformis
• Cause trauma, prolonged sitting, overuse
  anomalies in 15-20
• S/Sx
• dull buttock pain /- radiation into leg
• TTP over mid-buttock
• Pain worse with passive IR or resisted ER
• -Tx relative rest, ER stretching, /- steroid
  injection

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Trochanteric bursitis

• Causes
• friction between IT band, glut medius/minimus/max
  and greater trochanter common in running w/
  improper biomechanics and overtraining
• direct blows
• S/Sx
• local pain, tenderness over the greater
  trochanter
• Eval for leg length discrep, adductor/abductor
  muscle imbalance, hyperpronation
• Tx relative rest, ice, brief NSAID, ITB
  stretching, /- steroid injection
• Address biomechanical defects above

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Ischial bursitis

• Cause excessive friction over ischial
  tuberosity, or direct blow (hematoma, scarring)
• S/Sx pain with sitting, TTP over ischial
  tuberosity, pain w/ passive hip flexion and
  active/resistive hip extension
• Xray to r/o fractures in traumatic hx
• Tx
• Ice, padding, brief NSAID
• Prolonged steroid injection
• Refractory surgical excision

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Iliopsoas bursitis

• Cause overuse of hip flexors
• S/Sx
• anterior hip pain, /- snap
• preferred position of hip in flex/ER,
• TTP to deep palpation anteriorly,
• pain with passive hip extension
• Tx relative rest, ice, brief NSAID, stretching
  of iliopsoas,
• /- steroid injection (preferably w/ guidance)

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Sports hernia

• TTP lower abd wall
• No palpable hernias
• Co-incident injuries
• Adductor tendinopathy
• Osteitis pubis
• Imaging consider MRI to r/o other conditions
• Dynamic US helpful?
• Tx relative rest, flexibility, strength ?
  surgery if refractory

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Muscle strains

• Adductors, gluteals, quads, hamstring tears
  usually from overstretching during eccentric
  contraction, esp when muscle fatigued
• Risk factors
• Early in season
• Muscle imbalance, inflexibility, inadequate
  warmup
• S/Sx localized pain and TTP, /- swelling or
  ecchymosis , rarely palpable muscle defect, and
  decreased ROM
• Graded I, II, III similar to sprains
• Xrays to r/o avulsion fxs if near muscle origins
  MRI if suspected complete tear
• Tx PRICEMM, Rehab (ROM?strength?cardio?sport-spe
  cific tng)

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Quadriceps Contusions

• Direct blow to muscle causes tissue damage
• S/Sx localized TTP, /-ecchymosis
• Grade I knee flexion gt90
• Grade II knee flexion 45-90
• Grade III knee flexion lt45
• Tx PRICE avoid NSAID 48 hrs
• Max knee flexion, wrap in place 24 hrs
• Crutches, gradual WB, rehab (ROM?strength)
• RTP when FROM, 90 strength, activity w/o pain
• Complications
• Compartment syndrome (acute)
• Myositis ossificans (chronic)
• Slowly enlarging mass, redness, increasing pain
• Xrays 3-4 weeks, BS/US sooner

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Stress Fractures

• Caused by repetitive overuse stresses
• RFs training errors, females, inadequate
  footwear, intrinsic factors
• Pelvic, femoral neck, femoral shaft
• S/Sx insidious pain w/ activity /- local TTP
  or pain w/ hop test, /- decreased ROM
• Xrays first, MRI or BS if neg but suspected
• Tx
• Femoral immediate NWB, Ortho referral
• Tension side?surgery
• Pelvic/femoral shaft painless relative rest
  graduated WB, strength/stretching rehab, address
  other RFs

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Hip fractures

• Most common through femoral neck, various
  traumatic causes
• S/Sx pain, swelling, and loss of function
• Involved leg shortened and externally rotated
• Tx Ortho referral, surgery

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Hip Dislocation

• Femoral head usually goes posteriorly
• common mechanism knee to dashboard during
  traffic collision
• S/Sx extreme pain, obvious deformity, unwilling
  to move the extremity position typically
  flexion, adduction, and internal rotation (FAdIR)
• Tx emergent reduction in ER under sedation
  (Ortho STAT!)

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AVN of Femoral Head

• Causes
• Trauma fxs, hip dislocation, surgery
• Medical conditions (numerous)
• S/Sx nonspecific hip pain, may radiate to knee
  exam may be relatively unremarkable, with decr
  IR/ER as dz advances
• Xrays usually diagnostic gt3mo duration MRI or BS
  if normal
• Tx make pt NWB and refer to Ortho
• Conservative tx vs hip replacement depending on
  severity

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Conditions in adolescents and children
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Pelvic Apophysitis
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Pelvic Apophysitis

• Cause overuse at tendinous insertion at
  apophysis
• Iliac crest gt ASIS, AIIS, lesser troch, greater
  troch, ischial tuberosity
• S/Sx localized pain, TTP, pain w/ passive
  stretch of attached muscle
• Xrays to r/o avulsion fxs
• Tx relative rest (rare crutches), ice, brief
  NSAID?, cross training, strength rehab,
  flexibility

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Pelvic Avulsion Fractures

• Caused by violent contraction of the attaching
  muscle in skeletally immature athlete
• Sprint, jump, soccer, gymnast, dancer, football
• Ischial tuberosity gt AIIS gt ASIS gt iliac crest,
  lesser troch, greater troch
• S/Sx sudden pain /- pop, poor ROM, local pain
  and TTP /- muscle bulging away from the
  attachment
• Xrays needed to eval size/displacement
• Tx PRICEMM, progressive rehab
• Ortho referral if displacement gt2 cm

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Slipped Capital Femoral Epiphysis (SCFE)

• Slippage of femoral epiphysis laterally off
  femoral head
• Most prevalent ages 9-15, esp overweight
• Bilateral up to 50
• S/Sx insidious poorly localized hip/groin pain
  /- radiation to knee, worse w/ activ
• May have limited IR
• Xrays usually diagnostic MRI early if neg but dz
  suspected
• Tx immed NWB, Ortho referral, surgery

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Klines Line tangent to superior femoral neck on
AP view
Abnormal Less or no transsection of physis
Normal transsection of physis
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Legg-Calve-Perthes Dz

• Avascular necrosis of proximal femoral epiphysis
• Most prevalent ages 4-9, males 41
• Develops slowly
• S/Sx intermittent deep hip pain worse w/
  activity, /- radiating to groin, ant/med thigh,
  knee
• limping, decreased ROM, and hip flexor tightness
  may be noted
• Xrays usually diagnostic MRI or BS early if xray
  neg but AVN suspected
• Tx Ortho referral crutches, pain meds

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Acute Transient (Toxic) Synovitis

• inflammatory process of hip w/ chronic irritation
  and excess secretion of synovial fluid within the
  capsule ? cause
• Most common dx in limping child lt10, but its a
  Dx of exclusion
• r/o septic arthritis, SCFE, stress fx, etc.
• Xrays normal MRI helpful ruling out other causes
• Labs normal CBC, CRP
• S/Sx pain w/ walking, low-grade fever
• Tx relative rest, analgesics

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Conclusion

• Know your anatomy
• Know why youre doing an exam

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References

• Birrer R. and OConnor F. Sports Medicine for the
  Primary Care Physician. Boca Raton CRC Press,
  2004.
• Greene W. Essentials of Musculoskeletal Care.
  Rosemont American Academy of Orthopaedic
  Surgeons, 2001.
• Hoppenfeld S. Physical Examination of the Spine
  and Extremities. East Norwalk Appleton-Century-Cr
  ofts, 197659-74.
• Lillegard W. Evaluation of Knee Injuries. In W
  Lillegard (ed), Handbook of Sports Medicine.
  Boston Butterworth-Heinemann, 1999 233-249.
• Netter F. Atlas of Human Anatomy. West Caldwell
  CIBA-Geigy, 1989.
• Tandeter H. et al. Acute Knee Injuries Use of
  Decision Rules for Selective Radiograph Ordering.
  American Family Physician. Dec 1999 60
  2599-608. (For Radiograph Images)