Week 6

Group 1 - Hip Osteoarthritis

What is a classic history or capsule summary for this presentation? Specifically, a typical
mechanism of injury and the typical aggravating and relieving factors.

The development of OA at any joint site depends on a generalized predisposition to the condition
and abnormalities of biomechanical loading, which act at specific joints. Individual risk factors,
which may be associated with a generalized vulnerability to the disorder, include amily history,
obesity, and hypermobility of the joint.

In primary OA a middle-aged or elderly patient presents with hip and possibly buttock,
groin, or knee pain that was insidious in onset. Additionally, the patient notes a slow
stiffening (specifically internal rotation). This often results in the patient’s walking with the
hip held in external rotation. The patient may complain of low back pain due to excessive
extension with weight-bearing to compensate for limited hip extension. In secondary OA,
the presentation may be similar; however, there may be a history of trauma to the hip, or the
patient may have other joint involvement if crystal deposition (i.e., gout) is a factor

There is restriction to passive internal rotation and extension of the hip. Eventually, abductor
or adductor contracture may develop. Pain may be produced by axially compressing the
femur into the acetabulum. (Souza, 2014)

Capsular pattern – Cyriax and Russell described a typical capsular pattern of motion loss of the
hip that included flexion, abduction, and internal rotation. However, more recent literature has
challenged this concept of capsular pattern motion loss that is associated with OA. The most
common losses of motion seen with hip OA are internal rotation and flexion.

According to Vizniak (Vizniak, 2015);

Patients with arthritis often describe a gradual onset of pain, though some may remain
asymptomatic until the later stages of disease and experience onset of pain after a particular injury
or activity.
Typical location of pain - Intra-articular hip pain is often localized to the deep anterior groin.
Patients often use the “C” sign when describing the location of their symptoms. Mechanical
symptoms such as catching, clicking, or locking may be experienced, and may represent the
presence of loose bodies or chondral injuries, or alternatively snapping of musculotendinous
structures. Patients with hip arthritis often report associated stiffness. Substantial limitations in
motion may be a sign of later stages of arthritis.

Aggravating factors - The pain often worsens as the day progresses and can persist as an aching
pain at night. Patients typically report worsened pain with increased activity such as walking,
standing, running, or playing a sport, and improved pain with rest. Sitting with the hip flexed, such
as during an extended car or plane ride, or entering or exiting a low vehicle may also aggravate
symptoms. Pain is relieved by resting and reduced weight bearing to the affected hip

Tenderness over the anterior hip capsule pain reproduced by passive rotation of the hip
Restricted range of motion (rotation is usually first affected)
Pain reproduced by Stinch eld's test
Abductor limp (more severe cases)
Functional leg-length discrepancy (abduction contracture has developed)

What red flags and other conditions you need to eliminate? (include systemic and
peripheral presentations.

• Fracture – femoral neck, head

• Ankylosing spondylitis
• Avascular necrosis
• Septic arthritis

What outcome assessments would you use?

 • Hip disability and osteoarthritis outcome score
• SF36
• Oxford hip score
• ROM
• Resisted ROM strength

If there is a grading scale, can you briefly describe it?

What imaging techniques would you use and why?

Nonuniform loss of joint space is found radiographically. Superior joint space narrowing with
associated findings of subchondral cysts and osteophytes is the hallmark of OA. It is important to
note that many patients receive the diagnosis of OA when in fact there are no radiographic findings
to support this diagnosis (Souza, 2014).

• X-ray – joint space narrowing, osteophyte formation, subchondral sclerosis, subchondral

cyst; usually first imaging investigation done
• MRI – can be used to see early signs of bone change

On the provided Images, please indicate the pathology and describe it?
Asymmetric loss of joint space
severe osteophytes formation in the supra-acetabular margin and the lateral inferomedial surface of
the femoral head
widening and flattening of the femoral head
Axial migration of the femoral head
Severe degenerative changes noticed on the left femoroacetbular joint
Severe subchondral sclerosis on the acetabular margin of the ilium and superior femoral head
Cortical buttressing
Thickened weightbearing trabeculae
Enthesopathy of rectus femoris, iliopsoas, and sartorius muscles +/- tensor fascia lata
 What relevant orthopaedic, quantitative and qualitative tests would you use?
Demonstrate one of each on the patient to the class.

• ROM
• Trendelenburg
• FABER
• FADIR
• Scour test
• Anvil’s test
•

Outline your management strategy including chiropractic and other techniques, treatment
plan; including your visit schedule, home advice, exercises and progressions. Include
expectations of what they can achieve at relevant time frames and what exercises you
would use in the relevant time frames.
principal aim of treatment for osteoarthritis is to control pain, improve mobility, increase
muscle function, minimize disability, educate patients and their families about the disease,
and maintain activities of daily living
Modes of intervention
• Patient education
• Functional, gait and balance training
• Manual therapy
• Manipulative therapy
• Weight loss
• Flexibility, strengthening and endurance exercises
Management strategy (12 week management plan)
• Treatment
o Observation (this is important to monitor functional movement status and to
note progression of changes)
o NSAIDS for pain management
o Myofascial release
 o HVLA and mobilisations – the nature of hip OA can affect the SIJ, Lumbo
sacral junction and low back. Methods of correcting joint misalignment can
help re-distribute load appropriately, correcting compensatory movements
of other joints. Knee, ankle and foot should also be evaluated and adjusted if
necessary to help with lower limb biomechanics, consider orthotics.
• Rehabilitation
o General measures to help with weight loss, strengthening of lower back
muscles, yoga to help with mobility and flexibility, hydrotherapy to assist
with strengthening, light aerobic movements.
• Progression
o For patients who are overweight or obese, a weight loss program can help
significantly with pain and progression management, as well as controlled
physical therapy. Hip OA is a progressive condition, pain and disability will
continue, however if a well structure rehabilitation program is followed, as
well as rehab compliance is maintained, it has been noted that 1 in 3 patients
can have improvement of symptoms. General measure for progression is
observation.
• PROM’s and Home Advice
o VAS, HOOS Prom, avoidance of activities which exacerbate the pain or
overload the joint, NSAIDS for pain management, weight loss program

Souza, T. A. (2014). Differential Diagnosis and Management for Chiropractors. Jones &
Bartlett Learning, LLC. http://ebookcentral.proquest.com/lib/cqu/detail.action?docI
D=4441398
Vizniak, N. A. (2015). Quick reference evidence informed orthopedic conditions. Canada
: Professional Health Systems Inc.