Study Guide Questions: 9.

The questions for this week will focus on a case study that will require students to
formulate a series of questions in the history and complete the table below with details to
assist you with your diagnosis for this patient, similar to Table 11-16 from Magee D,
Orthopedic Physical Assessment, 6th Edition (2014), page 759- 759 provided as an
exemplar

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.

Differential Diagnosis of Hip OA Osteoarthritis verses FAI Femoral Acetabular Impingement

Differential Diagnosis Femoral Acetabular Impingement and Osteoarthritis

FAI OA
History - Have you had any deep in the hip (Over 50 and males more common)
Questions and groin - Pain in any particular movements
- How did it start (does it radiate etc) - Any pain at night
- Do you have any pain when moving - Any pan when lying down
you led during activities like walking - Does the pain Radiate
sitting or jumping - Does it hurt in the morning
- Does it hurt when you put weight on - Does it affect both sides
your leg - Any previous history of injury
(level of athleticism- more in athletic
people)
Observations - Pain when walking - Gait can be antalgic
- Abnormal gait (strained leg - Abductor limb (if present)
movement on affected side) - Pain during limb movement (or
decreased ROM)
Active - Pain on flexion and internal rotation - Pain in most direction in particular
Movements internal rotation
Passive - Pain on flexion and internal rotation - Pain in most direction in particular
Movements internal rotation
Resisted - Resisted flexion and internal rotation - Pain in most direction in particular
Isometric will be painful internal rotation
Movements
Note: Due to type of joint (ball and socket) Due to type of joint (ball and socket)
there will most likely be some level of there will most likely be some level of
restriction and pain in all movements restriction and pain in all movements
Special Tests - Hip scour test - Flexion Adduction Test
 - FADDIR test - Hip Scour Test
- Patrick FABER test - Yeomans Test
- SIJ distraction provocation test - Patrick FABER Test
- Thigh thrust SIJ provocation test - Craig’s Test
- Gaenslen’s provocation SIJ test - Hibbs Test
- Compression provocation SIJ
test
- Sacral thrust provocation SIJ
test
- Sign of the buttock
Sensation - Dermatomes thigh/groin L1-2, S3 Loss of joint space, osteophytes and
- Obturator nerve L2-L4 other degenerative changes it may
- Femoral nerve L2-L4 interfere with surrounding nerves and
muscle but loss on sensation and
reflexes in not common clinical
presentation (Test gluteal nerve – as
pain may radiate to gluts)
Reflexes “ ” “ ”
Joint Play - There will be pain in inferior glide in Pain in internal rotation (most likely a
Movements flexion and internal rotation (most likely level of pain in most movement)
a level of pain in most movement)
Diagnostic - X-ray - X-ray
Imaging - CAM - MRI
- Pincer
 Management Plan:

- Nutrition
- Lifestyle, movement habits (Active care plan)
- Posture hygiene
- Water activities
- PIR
- Mobilisation Soft tissue work
- Stretching exercises PNF
- Trigger points therapy work (correction of factors that perpetuate trigger `
points)
- Manipulation Long-axis distraction techniques
- Activator work
- Drop table 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.
- Right hip pain
- Gradual onset but originally only hurt when lying down on his right side
- Right sign on the buttock positive
- Tenderness on right greater trochanter
- Tenderness in middle portion of buttock on right
- Tight hamstrings
- Painful abduction and external rotation
- Positive ober’s test
- Sub-trochanteric bursitis ( pain when lying down on right side) 1+
- Contracture ITB, avulsion fracture (positive Ober’s test) 1+
- Muscle Strain Tight Hamstrings (50% reduced flexion, hamstring
tightness) 1+
- SIJ disfunction (positive sign off the buttock) 1+
2. The above case history is incomplete. What further questions or what information
would you need to acquire?

- Have you had any previous injuries or surgery’s

- Previous treatment for it
- How active is he (stretching and or sports he undertakes)
- Does anything relive it
- Does it radiate anywhere
-
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.

- Positive sign on the buttock does suggest possible bursitis however the decreased and
painful abduction and external rotation with a positive obers does suggest tensor fascia
lata involvement. Pain also started when lying down on his right side and now is
constant with tenderness over greater trochanter. (negative fabere test)

4. For the above case history alone, give 3 possibilities (differential diagnoses) for his hip
pain. Explain each answer.

- Sub-trochanteric bursitis ( pain when lying down on right side)

- Tight or strained tensor fasci lata
- SIJ disfunction (positive sign off the buttock)

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

- It is a possibility due to the positive right sign of the buttock however he would most
likely had previous pain with sitting
- It also doesn’t account for decreased and painful abduction and external rotation with a
positive obers and the fact that the pain started when lying down on his right side and
now is constant with tenderness over greater trochanter

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

i. His hip pain

- Tight or strained tensor fasciae latae and possible glute medius

ii. His shoulder pain

- Pain due to tight hamstrings and iliotibial band (body compensating and putting strain
on other body components)
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.

- Low back pain that radiates to ipsilateral buttock

- supported Adams or the belt test the pain disappeared
- mildly painful in the right low back at 70 degrees

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

- Does anything relieve the pain

- Associated pain
- Is there any history of any previous medical history, operations etc.

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.

- Can be facet problem = due to radiating nature of pain and increased pain with
movement (extension) and onset of pain
- SIJ joint – Adams forward bending test, and single leg raise above 70 degrees

4. For the above case history alone, give 3 possibilities (differential diagnoses) for his
back and buttock pain? Explain each answer.

- Disc herniation
- Facet syndrome
- Muscle strain (QL, Iliopsoas)

5. What other tests would you like to perform?

- SI compression
- Slump
- Kemp’s
- Prone springing

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