Common Causes of Hip Pain Abnormal Posture Trochanteric Bursitis Osteoarthritis Referral Pain Fracture Osteonecrosis

According to the British Chiropractic Association 32% of the population spends more than 10 hours per day sitting.

That is most of our waking hours. With that much time of our lives sitting with our

hips flexed to around 90 degrees, it is no wonder why we have muscle imbalance.

When these muscles lengthen and shorten, it leads to abnormal hip joint bio mechanics, which leads to abnormal wear and tear, causing early degeneration and HIP PAIN.

How can you tell if it is just abnormal posture, and not something more serious such as AVN of the femoral head, or Cancer?

History

First, start with a thorough history. A wise man once said that a good

history is worth 90% of a diagnosis. A good history should uncover red flags

if any. It is recommended to take imaging if

warranted.

Ask simple questions

What do you do for a living and what percentage of your time at work is spent in the seated position?

How long is your daily commute? How much television do you watch on

average per day?

“Sitter”

If we know that they are a “sitter”, then we know what is happening to the muscles around the hip.

Through the process of hysteresis and creep, many of the muscles are elongated and because many of the muscle spindles are not firing the muscle shortens so that it takes less stretch to fire.

CreepCreep

When a constant force is applied to a When a constant force is applied to a collagenous structure for a prolonged collagenous structure for a prolonged period of time the initial range of period of time the initial range of movement increases – this increase in movement increases – this increase in motion is known as motion is known as creepcreepIt is believed that creep is due to the gradual It is believed that creep is due to the gradual

rearrangement of collagen fibers, rearrangement of collagen fibers, proteoglycans and water in the tissue being proteoglycans and water in the tissue being stressedstressed

Creep Graphically creep is

seen as continued displacement at some point in a stress-strain curve

HysteresisHysteresis All tissues exhibit differences in mechanical All tissues exhibit differences in mechanical

behavior during loading vs. unloading (stress-behavior during loading vs. unloading (stress-strain curve) – this difference in behavior is strain curve) – this difference in behavior is referred to as referred to as hysteresishysteresis Restoration of the initial length of a collagenous structure Restoration of the initial length of a collagenous structure

occurs at a lesser rate and extent than did the occurs at a lesser rate and extent than did the deformationdeformation

The difference between the initial and final length of a The difference between the initial and final length of a collagenous structure after loading and unloading is called collagenous structure after loading and unloading is called the the “set”“set”

Since the muscle spindles are not firing certain muscles shorten so that it takes less stretch to fire.

Muscle Groups Affected

The hip flexors are contracted and shortened

The gluteal muscles are inhibited The quads are lengthened The hamstring muscles are shortened

The body is always adapting to its environment.

If you spend the majority of the day in a seated position, the body will do what it can to make that position the most energy efficient.

The problem with that is when you attempt to stand up and walk.

What does it feel like when after several hours of sitting you immediately want to jump up and go for a run?

It hurts! You are unable to straiten your legs and

extend your knees fully. Weaknesses in these muscles leads to

an abnormal Q-angle and makes you more prone to not only have hip pain and problems, but knee problems as well.

Orthopedic Tests

There are several orthopedic tests that you could perform to rule in/out hip pathology from something similar such as an SI joint problem or lumbar problem.

Ely’s Heel to Buttock

A classical positive finding is the inability of the patient to touch their heel to their buttock. This could be interpreted as a Hip joint lesion.

Going back to our sitting patient, this could be explained by tight hip flexors or anterior hip capsule.

Femoral Nerve Traction Test The classical response is pain in the

anterior thigh due to femoral nerve tractioning.

You may interpret this test as positive for a person who may have entrapment of the femoral nerve by the anterior hip muscles.

As mentioned before, these muscles contract and shorten during prolonged sitting.

Thomas Test

A positive Thomas test will confirm the anterior hip muscle contracture, especially from rectus femoris.

Lesegue’s and Kemp’s

Performing a Lesegue’s Strait Leg and Kemp’s Test will aid in the ruling out of a lesion further up the axial anatomy.

Additional Tests

Manual muscle strength tests Hip and lumbar ranges of motion

Which are?

Soft tissue mobility Gait analysis Palpation for spasm, trigger points,

fascitis, or atrophy

Treatment Options

Chiropractic care…DUH!!!

History

Inflammation of the bursa, which is lateral to the greater trochanter.

More common in women and in middle-aged or elderly people.

Symptoms

Pain on the outside of the hip and thigh or in the buttocks

Pain when lying on the affected side Pain that gets worse during activities,

such as getting up from a deep chair, getting out of a car

Pain with walking up stairs

Causes Abnormal posture

ScoliosisSubluxation

Bone spurs and calcium deposits Overuse injuries

Running up stairsClimbingStanding for long periods of time

Unknown

Things to Look For

Overweight Flexibility of hip muscles History of repetitive activities Pro-inflammatory diet History of blunt trauma to the hip History of infection, arthritis or

autoimmune conditions

History Middle or Older Aged Think Over Use

AthletesObeseTrauma

Signs and SymptomsWeight bearing painJoint stiffnessCrepitusPresent in flexion, adbuction and external

rotation (open-packed)

Examination

Range-of-Motion Limited Might be painful

Neurologic Exam WNL

Examination

+ Orthopedic TestsNot definitive

ImagingConclusiveKey Characteristic

Ranges of Motion

Flexion: >100o Extension: 0o

Abduction: >25o Adduction: >15o Internal Rotation: >20o External Rotation: >30o

Orthopedic Tests

+ Anvil Test + Hopping + Hibb’s Test

Imaging

Non-Uniform Erosion Superior Migration Buttressing Osteophytes Subchondral Cysts

Possible Causes

Facet Joint Syndrome Discal Lesion Foraminal stenosis Spondylolisthesis Spinal stenosis

Facet Joint Syndrome Back ache Worse after sitting and standing still for long

periods Usually better keeping on the move Provoked by spinal extension Hyperlordosis

Discal Lesion

History:TraumaInsidious

NeurologyLMN Lesion

OrthopedicValsalva’sDejerine’sEngel’s

Foraminal Stenosis

Spondylolisthesis

Spinal Stenosis

Patient Presentation

76 yr old white female presents with acute onset of severe anterior hip pain on left radiating into the groin with antalgic limp.

She is assisted with a walker. Pain started after she fell while mopping

the floor.

Physical Exam

Bruising is noted on left hip Marked left short leg Externally rotated left leg +3 MMS@ L3, L4, L5 on left All other neuro tests are unremarkable + Laguerre Test, + Fabere-Patricks

Test, + Anvil Test

Imaging

A-P Frog Leg projection,

Imaging

Intertrochanteric Fracture

Lab Test

Complete blood cell (CBC) count Urinalysis All tests are unremarkable

Treatment

Refer to Orthopedist Co manage once fracture is stable

Patient Presentation 47 yr old white male presents with gradual onset

of groin pain on left leg, pain in hip upon movement, low back pain, and difficulty walking .

He is a recovering alcoholic and has been on corticosteroids for the past 2 yrs to treat O.A.

He jumped off of a 6 ft roof a month ago and landed on his feet

Symptoms are aggravated by walking and stair climbing

Physical Exam

Pt has a noticeable limp on left leg and slight limp on right leg.

Marked difficulty when moving from seated to standing position.

+ jump sign upon palpation on left greater throchanter

Extremely tender left glut max upon palpation

Physical Exam

+ Rhombergs to left All other neuro tests were unremarkable + Anvil Test, + Elys heel to buttock, +

Fabere- Patricks test Limited ROM and painful in all ranges Most painful on abduction and internal

rotation

Imaging• Anteroposterior radiograph showing Ficat stage

III disease

Ficat Scale

Lab Test

CBC - moderately elevated ESR - moderate elevation Lipid Profile - lipid necrosis

Treatment

Refer to orthopedic surgeon Co manage with Chiropractic Care