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Using the precis of hip assessment as shown below create your own differential diagnosis and

management plan for a 45 year old male patient brought in for assessment. He walks with a limp
and complains of anterior hip and buttock pain after his weekly soccer game that is becoming
incresingly worse throughout the season.

FAI OA
History Questions - LODCTRAPPA - LODCTRAPPA –
- Where is the pain? - Do you have any stiffness in
- What aggravates the pain? the morning? How long does
i.e. squatting? it normally last?
- Have they had any - What type of pain is it?
previous trauma? - Is it difficult for you to walk?
- What brought you in - What is your medical history?
today? - Do you have family history of
- When does the pain bother OA?
you – day or night? - Does the pain go away at
- Does the pain refer rest?
anywhere?
- How does the pain impact
on your life?
- Do you get any pain when
running or changing
direction?
- Are they sedentary for long
period of time?

Observations - Pain - Antalgic gait


- Antalgic gait - Shortened stride
- Shortened stride - Contracture of the muscles
- Contracture of the muscles - Decrease in internal rotation
- Decrease in internal
rotation and flexion
adduction

Active Movements - Reduction in flexion and - Reduction in flexion


internal rotation - Restriction on extension and
- External rotation may also internal rotation
be affected

Passive - Pain in flexion at 90 - Pain in internal and external


Movements degrees rotation of the hip

Resisted Isometric - All movements will basically


Movements be restricted
Special Tests - Hip scour test - Flexion Adduction Test
- FADDIR test - Hip Scour Test
- Patrick FABER test - Yeomans Test
- SIJ distraction provocation - Patrick FABER Test
test - Craig’s Test
- Thigh thrust SIJ - Hibbs Test
provocation test - Sign of the buttock
- Gaenslen’s provocation
SIJ test
- Compression provocation
SIJ test
- Sacral thrust provocation
SIJ test
- Sign of the buttock
- Thomas test
Sensation Dermatomes Dermatomes
- L1 - L1
- L2 - L2
- S3 - S3
- S4 - S4
Cutaneous distribution Cutaneous distribution
- Subcostal N. - Subcostal N.
- Genitofemoral N. - Genitofemoral N.
- Ilioinguinal N. - Ilioinguinal N.
- Obturator N. - Obturator N.
- Lateral cutaneous N. - Lateral cutaneous N.
- Iliohypogastric N. - Iliohypogastric N.
Reflexes - No reflexes associated - No reflexes associated

Diagnostic Imaging - X-ray - X-ray

Management Plan:

Lifestyle changes – dietary, incorporate activity into daily life, lose weight
Non-weight bearing exercises
Soft tissue therapy
trigger point therapy
PNF stretches
Chiropractic adjustments

Case Study 3

Robert is a 30-year-old solicitor.

Presenting Complaint

Robert complains of right hip pain.


History of Presenting Complaint

There has no previous history of hip pain, and his medical history is unremarkable. He reports a
gradual onset of pain that started approximately two months ago and is now felt more often,
whereas before he would feel it only when lying down on his right side. Robert, unfortunately,
cannot recall any incident that may have caused his hip pain. He rates it at a level of 5/10,
describing it as being very sore and tender.

He also mentions that he occasionally gets pain in his right shoulder, which is not related to
movement or physical activity. This shoulder pain has been present for about six months.

Physical Examination

Robert walks into your office with no visible limitations.

Active right hip ROM: 30 degrees of abduction with pain, 20 degrees of external rotation with pain.
All other ranges of motion of the right hip are normal.

Lumbar ROM: Flexion is reduced by 50% due to hamstring tightness. All other movements are
unremarkable.

Muscle strength: 4/5 on the abductors and external rotators; other muscles are normal.

Patrick Fabere test is negative

Right Sign of Buttock test reproduces the pain in the right hip

Right Ober’s test reproduces the pain in the right hip.

Palpation: Robert exhibits increased tenderness on the right greater trochanter with slight
tenderness on the middle portion of the buttock on the right side.

Shoulder examination: Unremarkable. Pain cannot be reproduced during your consultation.

1. List the statements (clues) in the case history that aligns with the diagnosis of hip pain. Use
the script concordance.
 Trochanteric bursitis- positive sign of the buttock and inability to sleep on that
side.
 ITB contracture- positive Obers test and decreased abduction
 SIJ dysfunction
 Lower cross syndrome

2. The above case history is incomplete. What further questions or what information would you
need to acquire?
 Is the pain relieved by sitting?
 Is it worse going up and down stairs?
 Do you have any past history or trauma to that area?
 Are there any aggravating factors e.g. what makes it worse?
 Is the pain intermittent or constant?
 Have you had any previous treatment and did it help?
 Does anything relieve the pain?
 Previous medical history (is there anything I need to know)

3. Based on the given information from the case history and physical examination, do you think
Robert has a hip problem, facet syndrome or muscle strain? Give reasons for your answer.
 Hip pathology – ruled in due to positive special tests
 Muscular strain – ruled out because its been going on for 2 Months.
 Facet strain – ruled out because facet’s refer (knee) and chiropractic treatment
resolves this pretty quickly

4. For the above case history alone, give 3 possibilities (differential diagnoses) for his hip pain.
Explain each answer.
 SI joint strain or sprain
 Facet joint synovitis
 Trochanteric bursitis

5. Your colleague thinks that Robert as an ischiogluteal bursitis (weaver’s bottom). Do you
agree with your colleague?
 Possibly

6. Using the information from the above case history and physical examination, what is the
more likely diagnosis for

i. His hip pain – sub trochanteric bursitis


ii. His shoulder pain – could be postural due to his job

Case Study 4

Joey is a 45-year-old computer programmer

Presenting Complaint:

Joey presents to your office with right low back pain which occasionally radiates into the right
buttock.

History of Presenting Complaint and Onset: The pain had been present for three weeks. It
started one day after he played a game of golf. He has no history of back pain, and he denies any
medical history of significance. X-rays are unremarkable.

Aggravating Activities

Running, prolonged fast walking of more than a mile. When the symptoms are at its worst, he is
unable to stand or walk without pain. Joey also finds it difficult to stand from a seated position.
When the pain is present, he is unable to sleep, waking him as he rolls over in bed.
Physical Examination

Observation: Standing on the right foot reproduced his pain in the right low back area. He also
has a right flat foot.

Trunk extension was full range but reproduced his pain. All other movements were pain-free and
full range.

Neurological: Unremarkable.

SLR: Full range but mildly painful in the right low back at 70 degrees.

Nachlas and Ely’s: Unremarkable

Lumbar Compression/distraction: Unremarkable.

Standing on the right leg only reproduced the pain in the right low back however, if the sacro-iliac
joints were supported (as in supported Adams or the belt test) the pain disappeared.

NB If the question incorporates ‘Based on the information in the case history and/or physical
examination’ assume that all other tests are unremarkable.

1. List the statements (clues) in the case history that aligns with the diagnosis sacro-iliac pain.
Use the script concordance.
 Sacroiliac joint pathology – strain/sprain
 Facet synovitis
 Trochanteric bursitis – unable to sleep on his side
 SLR with pain in the 70 degrees range is suggestive of lumbar disc herniation
 Possible Glute muscle strain

2. The above case history is incomplete. What further questions or what information would
you need to acquire?

3. Based on the given information from the case history and physical examination, do you
think Joey has a sacro-iliac problem, hip problem, facet syndrome or muscle strain? Give
reasons for your answer.
4. For the above case history alone, give 3 possibilities (differential diagnoses) for his back
and buttock pain? Explain each answer.
 SI joint strain or sprain
 Facet joint synovitis
 Trochanteric bursitis

5. What other tests would you like to perform?

 Nachlas test
 Oberes test
 Trendelenburg test
 Patrick faber test
 Gaenslen’s test

6. Joey presents with the x-ray below: Would this change your diagnosis?

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