Diagnosing Hip Pain Causes
Hip pain can have various causes, and diagnosing the underlying issue requires a comprehensive evaluation by a physiotherapist/healthcare professional. Diagnosing the exact cause of hip pain mainly the posterolateral aspect is important so proper treatment plan can be prescribed by physiotherapist.
- Physical Examination: The physiotherapist will examine the hip joint, looking for signs of swelling, tenderness, or deformity.
- Imaging Tests: X-rays, MRI scans, or CT scans may be ordered to get detailed images of the hip joint and surrounding structures.
- Blood Tests: These can help identify inflammatory or autoimmune conditions.
- Joint Aspiration: Removing a small sample of fluid from the joint for analysis can help diagnose certain conditions.
- Bone Scan: This can detect abnormalities in bone metabolism and help identify fractures or bone diseases.
Differential Diagnosis of Hip Pain(Posterolateral Aspect)
Piriformis Syndrome
Freiberg Test:
It is used to diagnose involvement of piriformis or
gluteus muscle. Patient complains of not sitting for prolonged period of time
i.e. 30min, paresthesia and limping gait is common. Pain intensity increases at night.
The patient is in supine lying position with flexion at
hip and extension at knee. The physiotherapist internally rotates the hip joint, which
may reproduce pain if the piriformis muscle is involved.
FAIR Test (Flexion, Adduction, and Internal Rotation):
The patient is in side lying position on unaffected side,
with the hip and knee flexed at 90 degrees and adduction. The physiotherapist applies upward and lateral force with knee in internal rotation at 45 degree, it may
elicit pain if the piriformis muscle is compressing the sciatic nerve.
Piriformis Stretch Test:
The patient is seated with the affected leg crossed over
the opposite knee. The physiotherapist gently applies pressure to the knee, creating
external rotation of the hip. This may reproduce symptoms if the piriformis
muscle is tight or inflamed.
Beatty's Test:
The patient lies on the unaffected side, and the physiotherapist lifts the affected leg while the patient is in a side-lying position. This is
done with the hip and knee in slight flexion, which may provoke pain if
piriformis syndrome is present.
Sciatic Nerve Entrapment
Straight Leg Raise (SLR) Test:
The patient is in a supine position, and the physiotherapist lifts the patient's straightened leg. This test can provoke pain along the
sciatic nerve and may indicate nerve root irritation.
Crossed Straight Leg Raise Test:
Similar to the SLR test, but performed on the opposite
side. If raising the unaffected leg, 60 to 70 degree, reproduces symptoms in the
affected leg, it may suggest nerve root involvement or disc protrusion.
Slump Test:
The patient sits on the edge of a table and slumps
forward i.e. active neck flexion. This test can stress
the sciatic nerve and may reproduce symptoms when patient actively extends the
knee, if there is nerve compression.
Ischiofemoral Impingement
Ischial Tuberosity Palpation:
The physiotherapist palpates the ischial tuberosity to assess
for tenderness, swelling, or other signs of irritation.
Ischiofemoral Impingement Test
The patient is side lying on unaffected side. The
physiotherapist brings hip in extension and adduction, which provokes pain.
Resisted Hip External Rotation Test:
The patient is positioned in a seated or side-lying
position, and the physiotherapist resists hip external rotation. Pain or discomfort
during this maneuver may indicate ischiofemoral impingement.
Long Stride Walk Test:
The patient complains of pain during Long Stride,
particularly in toe-off phase of gait cycle.
Proximal Hamstring Tendinopathy
Proximal
hamstring tendinopathy (PHT) is common among distance runners and athletes
involving activities like sprinting, hurdling, football and hockey.
Characteristics of PHT include
- deep, localized pain around the ischial tuberosity
- pain worsens during or after running, lunging, squatting and sitting
- history of repetitive loading in flexion
- pain during running, the peak force occurs in late swing, with a second peak reported in early stance
Test to Diagnose:
Palpation:
The physiotherapist palpates the affected area to identify tenderness, swelling, or irregularities in the soft tissue around the hamstring attachment sites.
Load Test Assessment:
- low-load clinical test - Single-leg bent-knee bridge
- moderate-load clinical test - Long-lever bridge
- high-load clinical test - Arabesque
Active Range of Motion (ROM) and Strength Testing:
Assessing the active range of motion and strength of the hamstring muscles may reveal limitations and weakness, which could be indicative of a hamstring avulsion.
Straight Leg Raise (SLR) Test:
While SLR is commonly associated with sciatic nerve irritation, it can also be used to assess hamstring function. Pain or weakness during SLR, around 60 degree, may suggest hamstring involvement.
Sacroiliac Joint Dysfunction
Patrick's (FABER) Test:
The patient lies on their back, and the physiotherapist flexes,
abducts, and externally rotates the hip with the knee bent. Pain at the
sacroiliac joint during this maneuver may suggest dysfunction.
Gaenslen's Test:
The patient lies on their back at the edge of the table,
with one hip and knee flexed toward the chest and the other leg extended off
the table. The therapist then hyperextends the extended leg, stressing the
sacroiliac joint.
Fortin Finger Test:
The patient points to the area of pain with one finger
while sitting or standing. This test helps localize the pain to the sacroiliac
joint region.
Greater Trochanteric Bursitis
Trendelenburg Test:
The patient stands on one leg, and the physiotherapist observes
for pelvic drop on the unsupported side. A positive test may indicate weakness
in the hip abductor muscles, which can contribute to greater trochanteric
bursitis.
Ober's Test:
The patient lies on their side with the unaffected hip
and knee flexed. The physiotherapist passively abducts and extends the affected hip,
and then attempts to lower the leg toward the table. A positive test may
suggest tightness or contracture of the iliotibial band, potentially
contributing to bursitis.
Hip Range of Motion Assessment:
Evaluating the range of motion of the hip joint,
including internal and external rotation, flexion, and abduction, to identify
any limitations or pain associated with bursitis.
Resisted External Rotation Test:
Other Conditions Include
Gluteus Maximus Claudication
Claudication typically refers to pain or cramping in the
legs, especially during physical activity, and is commonly associated with
conditions like peripheral artery disease (PAD).
Gluteus Maximus Tendonitis
Gluteus maximus tendonitis, also known as gluteal
tendonitis, is a condition characterized by inflammation or irritation of the
tendons of the gluteus maximus muscle. Limping is seen after prolonged sitting
Obturator Externus/Internus Tear
Obturator externus and internus muscular tears are
uncommon injuries. It is prevalent in high intensity sports activities like
soccer.
Pudendal Nerve Entrapment
Pudendal Nerve Entrapment causes Pudendal Neuralgia. It
causes perineal pain exacerbated by sitting, which is relieved by standing or
lying, along with painful bowel movement.
Pudendal Nerve Compression/ Entrapment Classification
- Type I - Entrapment occurs below the piriformis muscle
- Type II - Entrapment between sacrospinous and sacrotuberous ligaments
- Type III - Entrapment in the Alcock canal
- Type IV - Entrapment of terminal branches
It is common in athletes and preset as chronic groin pain,
hip stiffness and pain with active leg adduction. It occurs due to overuse
activity which aggravates with sporting activity. Pain increases with adduction
of the thigh against resistance and with passive stretching of the adductors.
Physiotherapy treatment includes R.I.C.E that is rest, ice, and compression. The goal is to reduce soft tissue swelling initially. It is then incorporated with range-of-motion and strengthening exercises.
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