Physiotherapy Hip Ax

Keywords: Subjective Ax, objective Ax, Hip Assessment, Passive ROM, Active ROM, Hip pain, osteoarthritis, Strength Tests, Special tests, Differential Diagnosis, Red flags.

Physiotherapy Hip Assessment (Ax)

 

A good hip assessment is necessary to accurately diagnose the source of pain.  The best way to learn good assessment skills is through hands on practice and watching experts. Try to spend a day with a consultant or extended scope practitioner to see how they perform an assessment. Visit the student room to  find preparation notes for work experience days.

Subjective Assessment

  • HPC –Trauma/insidious onset
  • History
  • Mechanism of injury
  • PMH
  • Is pain in a dermatomal region? (Pain in the knee can be referred from the back)
  • Is there knee pain? (Knee pain can be referred from the hip)
  • Is there a snapping/pop/click/grinding?
  • Did the hip swell? How quickly? Where is the swelling? ( lateral swelling may be seen over the greater trochanter in trochanteric bursitis).
  • Was there bruising? (Immediate bruising indicates significant trauma
  • Cough/sneeze cause pain?(?Referral from lumbar spine)
  • Age – The following conditions are not exclusive  to these age groups but a higher prevalence is noted in these populations (elderly – OA?,  middle aged- labral tear).

What does this tell you?

Knowing the history gives clues as to the structures affected. Mechanism of injury is extremely important. If you can work out the force of the injury this gives you clues on likely stretched/ damaged structures. Large traumas where a subluxation/ dislocation or fracture has occurred with have also caused significant damage to the surrounding soft tissue which must be considered in treatment. If your patient is known to have a high falls risk you should be formulating a prevention plan alongside treatment (ie teaching the backward chain to help people get off the floor or balance exercises). Think holistically find the cause of the floor and address this.
Immediate swelling and bruising usually indicates significant trauma and may require X-Ray to rule out neck of femur fractures, bone bruises or an MRI to identify labral tears or soft tissue impingement.

Mechanism Of Injury and Differential Diagnosis

 

Muscle strain (Groin, Quadriceps, Hamstrings)

  • Sudden onset of pain following large muscle contraction/contusion or force.
  • Often running,jumping, sport.
  • Pain on contraction of muscle, weakness, tenderness over site of tear.

 

Quadricep Contusion

  • H/o blunt trauma to thigh (ie rugby tackle)
  • Bruise/oedema.
  • Decreased AROM knee/Hip.

 

Iliac Crest contusion

  • Direct trauma to iliac crest.
  • Can result from fall/ tackle in rugby/football.

 

Osteitis Pubis

  • Result of repetitive trauma.
  • C/o pain in pubic symphysis region.
  • Pain with kicking, running, jumping, twisting.
  • Seen in swimmers/runners/lacrosse players.
Trochanteric Bursitis
  • H/O direct blow to hip.
  • Can also be insidious onset.
  • Lateral hip pain.
  • Aggravated by side lying/stairs.

 

Femoral shaft stress fracture

  • Deep thigh pain (Anterior)
  • Aggravated by activity, eased with rest.
  • Recent increase in activity
  • High milage/intensive training.

 

Gilmore’s groin

  • Seen in those with repetitive loading/twisting.
  • Unilateral groin pain
  • Insidious onset

 

Acetabular labral tear

  • C/o ‘catching’ pain following slipping injury.
  • Symptoms may increase over time with nil H/o trauma.
  • Groin pain
  • audible click
  • Mild limitation ROM
Also consider:
  • Degenerative Joint Disease
  • Iliopectineal Bursitis (Internal snapping hip syndrome)
  • Piriformis syndrome
  • Legg-Calve-Perthes disease
  • Slipped capital femoral epiphysis.
  • Meralgia paresthetica
  • Pubic ramus stress fracture
  • Femoral neck stress fracture

RED FLAGS

These are the special questions which may indicate that something more sinister may be going on. Patients should be referred immediately back to the GP with your concerns noted. Ask a seniors advice on the severity of these symptoms and whether and A and E referral is more appropriate. Mechanism of Injury is important here, what force was exerted through the leg? Was it enough for a pelvic/femoral fracture? Loss of pulses in the foot may indicate vascular compromise due to  a fracture. Fractures can lead to fatty embolisms therefore warrant immediate A and E referral.

  • Bilateral pins and needles or numbness in the LL.
  • Problems with bowel and bladder function where the patient is unable to feel themselves going to the toilet.
  • Incontinence.
  • Paraesthesia in the groin region.
  • Loss of pulses in the LL (Vascular compromise).
  • Obvious deformity.

Objective Examinations

 The objective examination gives you quantifiable measures to rule out what structures are involved and to reassess after treatment to determine improvement/deterioration. For example documenting that a lady has 90 degrees knee flexion will allow you to re-assess at her next treatment session and monitor improvement or deterioration. This should help guide you on whether a treatment has been effective and  can help confirm a diagnosis.

  • Observation (leg length/gait/posture)
  • AROM – Hip flexion(120-130degrees), Hip extension(10-20 degrees) MR (40-50 degrees) LR(35-45degrees) ~Hip Abd(40-45 degrees) Hip add(20-30degrees).
  • PROM
  • Myotomes
  • Reflexes (Patella; L3-4, Ankle Jerk; S1, Babinski, Clonus).
  • Sensation (Dermatomes)
  • Palpation (ASIS/PSIS/Inguinal ligament/Pubic tubercles)
  • PA Spinous processes (To r/o back pathology)
  • PA Tranverse processes (To r/o back pathology)
  • Strength (Quads/Hamstrings/Gluts/Hip external rotators)
What does this tell you?

 

  • Try to establish the structure involved. Pain at the end of the day after work may suggest structures that are stressed as the day goes on. Pain in morning could be due to inflammation (ie OA) however if the pain is easier in the morning this could be due to reduced swelling  due to rest and elevation overnight .
  • Poor Quality of movement – Is the muscle jerking or shaky which could indicate pain inhibition or fatigue.
  • Throughout movements where does the patent feel their pain? Is the patient weak in a specific range or does the pain increase with soft tissue impingement ie end of range flexion?
  • Does the patient present with significant guarding and unwillingness to move.
  • Pins and needles of paraesthesia (numbness) in the lower limb? This normally suggests a neural element which maybe coming from the lumbar spine or compression of the nerve somewhere along its course.
  • If you press on a structure and this reproduces the patients symptoms this may suggest referred pain is occurring.

 

 

Special Tests

To see all tests click here

Mark Hutchingson’s examinations

Hip and Groin

Also check out Dr. Mark Hutchinson’s podcasts. 
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