question

PMH Red Flags

answer

PREVIOUS Hx of CANCER - prostate, reproductive, breast Previous hx of renal or urologic disease (kidney stones, UTIs) Trauma/assault Femoral artery catheterization Hx of infectious or inflammatory condition Hx of gynecologic conditions Hx of alcoholism (hip osteonecrosis) Long term use of immunosuppressants

question

PMH HX RED Flags part deux

answer

Hx of heart disease Receiving anticoagulation therapy (risk factor for hemarthrosis) Hx of AIDs-related TB Hx of hematologic disease such as sickle cell anemia or hemophilia Hx of joint replacement Pain with wear debris from hip arthroplasty

question

Polyethylene wear debris can also result in:

answer

DVT, LE edema, ureteral or bladder compression, or sciatic neuropathy

question

Polyethylene wear debris can be caused by:

answer

Caused by loose components, improper implant size, mm imbalance, infection

question

Hip and Buttock: Pain pattern

answer

True hip pain is usually felt posteriorly deep within the buttock or anteriorly in the groin, sometimes radiating down the anterior thigh Pain located on the lateral or posterior hip is usually not caused by an intraarticular problem, but more likely results from trigger points, bursitis, knee, SI, or back problems

question

With joint disease, when does pain occur?

answer

Pain will occur during AROM and PROM and increase with WB Pt will lean away from affected side and shorten swing phase to avoid WB

question

With soft tissue disease, pt will lean toward the ______ side to compensate for downward rotation of the pelvis.

answer

affected; If bursa are involved, pain may radiate from the buttock, greater troch, and/or lateral thigh

question

Pain with IR and decreased hip medial ROM is associated with?

answer

hip OA

question

Sign of the Buttock (RED FLAG):

answer

Used to differentiate between hip and lumbar spine (CNS) involvement Presence of any of the signs may indicate osteomyelitis, neoplasm, fracture, abscess, or other infection NEED TO REFER

question

Signs of the Buttock:

answer

Primary sign: passive hip flexion more limited and painful than SLR Limited (and painful) SLR Trunk FLX limited to the same extent as hip FLX Painful and weak hip EXT Non-capsular pattern of restriction at the hip Swelling (and tenderness) in the buttocks region Empty end feel with hip FLX

question

Pain can be referred FROM the hip to other structures..

answer

low back, SI or sacral area, groin, anterior thigh, knee, or ankle

question

Pain can be referred TO the hip from other structures..

answer

Pain from upper lumbar vertebrae can radiate into anterior thigh Pain from lower lumbar vertebrae and sacrum can be felt in the gluteal region, with radiation down the back or outer thigh

question

Pain caused by component instability following a THA will be felt with activity, at rest, or both.

answer

"Start up" pain may indicate a loose component - After 5-10 steps groin pain subsides Groin/thigh pain is most common with micromotion at the bone-prosthesis interface or other loose component, periosteal irritation, or undersized femoral stem Pain is usually dull/achy and is localized to the prosthetic hip with no systemic symptoms

question

Hip and buttock: Systemic presentation

answer

Noncapsular pattern restricted hip motion - Limited hip EXT, ADD, ER Empty-end feel Rule out systemic origin by performing log roll test, FABER, long-axis distraction, compressive hip loading, and scour test The presence of GI symptoms and palpable reproduction of painful sx's is usually considered extra-articular

question

Hip capsular pattern

answer

IR > FLX > ABD (and sometimes EXT)

question

Groin issues

answer

Isolated groin problems may be seen in sports or military populations Secondary groin complains are commonly due to back, pelvic, hip, knee, or SI problems

question

Intra-articular pathology can present as?

answer

groin pain due to innervation of hip capsule

question

Most common MSK cause of groin pain:

answer

Adductor strain; most commonly involving adductor longus

question

Extra-articular pathology can present as?

answer

pain radiates to lateral and posterior aspects of hip

question

Athletic Pubalgia:

answer

describes a sports or athletic hernia S/Sx: deep groin/lower abdominal pain, usually unilateral Relieved with rest, aggravated with activity

question

Labral Tears

answer

S/Sx: night pain, activity related pain, (+) trendelenburg sign, (+) impingement sign

question

Impingement Sign

answer

pain with hip flexion, adduction, and IR (FADIR)

question

Femoroacetabular Impingement

answer

Groin pain present w/or w/o hx of trauma Gradual and progressive onset Prolonged walking, sitting, or athletic activities stress the hip

question

Osteitis Pubis

answer

Inflammation and sclerosis of the pubic symphysis Can occur from leg length discrepancy TTP of pubic symphysis Pain with passive hip abduction, resisted hip add

question

Older adults typically experience groin pain associated with?

answer

arthritis lumbar stenosis insufficiency fx hip arthroplasty

question

Hip and groin pain secondary to lumbar stenosis → manifests as LBP that radiates to the LE

answer

Pain begin with amb and progressively worsens Pain relieved with forward flexion

question

Hip arthritis is characterized by..

answer

pain that radiates to the knee but NOT below decreased hip ROM eventual gait disturbances

question

Systemic presentation of groin pain:

answer

Pain from systemic source does not vary from MSK-induced groin pain Key to dx is to examine associated s/sx

question

Key associated S/Sx in systemic presentation of groin pain:

answer

age past medical hx gender

question

Inguinal lymph node examination:

answer

Enlarged and painless inguinal lymph nodes may be indicative of cancer Tender, movable inguinal lymph nodes may be a sign of food intolerance or allergies or an indication the body is fighting off infection

question

NMS Thigh Presentation:

answer

Lower lumbar vertebrae and sacrum can refer pain to gluteal/hip region Pain may radiate down posterior or posterolateral thigh

question

TFL or IT Band Syndrome

answer

Pain down lateral aspect of thigh due to inflammation or irritation

question

Anterior Thigh pain

answer

Disk related, resulting from L3-L4 disk herniation Common in older adults (+) Reverse SLR test and depressed knee reflex → L3-L4 herniation

question

(+) Reverse SLR test

answer

Pt positioned prone with LE extended at hip and knee caused by tension on femoral nn and its roots

question

Bursitis

answer

Hyper/hyporeflexia Decreased sensation to light touch or pinprick Decreased motor strength Positive "jump" sign w/pressure applied over greater troch

question

Lateral Femoral Cutaneous Nerve Neuralgia

answer

Anterior thigh pain May occur after spine surgery to repair nn damage Can be due to positioning during hip arthroplasty (obesity!), abnormal posture, chronic mm spasm, tight fitting braces/pants

question

Systemic presentation of thigh pain:

answer

Pain pattern for ant thigh pain caused by systemic causes is often the same as NMS causes Therapist must rely on clues from hx and presence of associated s/sx Obstruction, infection, inflammation, or compression of ureters may cause pattern of LBP, flank pain, and radiates anteriorly Retroperitoneal or intra abdominal tumor/abscess may also cause ant thigh pain

question

Psoas Abscess Causes

answer

Diverticulitis Crohn's disease Appendicitis Pelvic Inflammatory Disease Diabetes Mellitus Any other source of infection → renal, infective spondylitis, Osteomyelitis, sacroiliac joint infection

question

Knee and Lower Leg: Pain is most often caused by..

answer

Injury, inflammation, tumor, altered peripheral circulation, DVT, or neurologic involvement

question

Vascular Claudication

answer

Pain Description - Bilateral, no burning Assoc. S/Sx - Decreased/absent pulse, Color/skin changes in feet, Normal DTRs Location - Calf, buttock, thigh, hip Aggravating Factors - Physical exertion Relieving Factors - Rest Cause - Atherosclerosis Age Affected - 40-60+

question

Neurogenic Claudication

answer

Pain Description - Uni/Bilateral, burning in back, thigh, legs Assoc. S/Sx - normal pulse, good skin color, (+) SLR, sciatica Location - low back, buttock, thigh, calves, feet Aggravating Factors - Spinal extension, ↑ walking downhill, ↓ walking uphill Relieving Factors - Sitting, laying down, flexion exercises Cause - Neoplasm/abscess, Disk protrusion, Osteophyte formation Age Affected - 40-60+

question

Peripheral Neuropathy

answer

Pain Description - Aching, numbness of feet, burning, prickling, tingling Assoc. S/Sx - Pulses may be affected, DTRs diminished or absent, (+) SLR or Sciatica Location - feet or hands in stocking glove Aggravating Factors - depends on cause Relieving Factors - pain meds Cause - varies Age Affected - varies

question

Restless Leg Syndrome

answer

Pain Description - Crawling, creeping sensation in legs Assoc. S/Sx - Sleep disturbance, paresthesias Location - feet, calves, legs Aggravating Factors - caffeine, pregnancy, iron deficiency Relieving Factors - eliminate caffeine, hydration, moderate exercise Cause - unknown Age Affected - variable

question

Systemic presentation in knee and lower leg:

answer

Burning and pain in legs and feet at night is common in older adults - Potential side effect of chemo drugs Leg cramps - Dehydration, arterial occlusion from peripheral vascular disease, medications, metabolic disturbances Heel Pain - Due to RA, bone tumors, metastatic disease, gout, sarcoidosis, Paget's disease, IBD, infectious disease, Sickle cell disease, Hyperparathyroidism

question

Cancer in knee and leg:

answer

- Unusual bleeding, easy bruising, unintentional weight loss, fatigue, fever - Night pain, localized swelling/warmth, locking, and palpable mass with any of the above symptoms

question

Birth Trauma

answer

Multiple births, prolonged labor and delivery (L/D), forceps/ vacuum delivery, and post epidural complication are more common birth-related causes of hip, groin, and LE pain

question

Stress Reaction or Fracture

answer

Can cause hip, thigh, groin, knee, shin, heel, or foot pain Def: microscopic disruption or break, in a bone that is not displaced Exercised-induced groin, tibial, or heel pain are the most common stress fractures

question

Insufficiency fractures =

answer

- breaks in abnormal bone under normal force - Most often in older adults

question

Fatigue or stress fractures =

answer

- breaks in normal bone that has been put under extreme force (due to activities such as marching, jumping, or distance running) - Affects the pubic ramus, calcaneus, femoral neck, anterior tibia most often in high-intensity athletes

question

Other risk factors for stress fracture:

answer

- changes in running surface - use of inadequately cushioned footwear - presence of female triad (disordered eating, osteoporosis, amenorrhea and menopause) - anything that can cause decreased bone density (chemo/ radiation, corticosteroids, renal failure, or metabolic disorders affecting bone)

question

Male long distance runners have a unique risk factor for tibial stress fxs due to..

answer

smaller cross-sectional diameter of long bones

question

Femoral stress fxs are common among distance runners and military due to repetitive loading:

answer

Pt can present with vague anterior thigh pain, radiating to the hip to knee with activity Usually has full and painful ROM

question

Heel pain from calcaneal fxs can occur after an increase in athletic activities or after a plantar fascia rupture:

answer

A medial-lateral squeeze test may help identify the need for further imaging

question

Two conditions in postmenopausal women and older adults with arthritis contributing to fracture and injury.

answer

osteopenia and osteoporosis

question

Pain with _____ is a RED FLAG sx for stress reaction or fracture in any individual.

answer

WBing

question

A heel strike test can be performed in pts complaining of bone pain:

answer

Can also ask the pt to hop on uninvolved side and do a full squat to clear the hip, knee, and ankle Reproduction of painful sxs with axial loading is positive and highly suggestive of bone fx or stress reaction ***Radiographs may not show the stress fx

question

On radiograph, intertrochanteric fractures may need an _____ view.

answer

oblique

question

Clinical S/Sx of Stress Fracture:

answer

Pain described as aching or deep in hip and/or groin area; may radiate to knee Muscle weakness (reduced MMT grade) Compensatory gluteus medius gait Pain localizing to a specific area of bone (+) Faber's test Pain reproduced by translational/rotational stress (exquisite pain in response to active resistance to hip ADD/ hip ADD + ER) Thigh pain reproduced by the fulcrum test (femoral stress fx) Possible local swelling Night pain (femoral neck stress fx)

question

Sciatica =

answer

pain in a sciatic distribution without overt signs of radiculopathy; Usually related to mechanical pressure or inflammation of the lumbosacral nn roots Sciatic nn is innervated by L4-S2 (sometimes S3)

question

Radiculopathy =

answer

objective signs of nn irritation or dysfunction, usually from involvement of the spine Sx include numbness, weakness, or reflex changes

question

Sciatic neuropathy =

answer

damage to the peripheral nn, due to a lesion outside the spine that affects the sciatic nn e.g. ischemia, inflammation, infection, direct trauma to the nerve, compression by neoplasm or piriformis muscle

question

In the patient with sciatica: unremitting, severe pain and increasing neurologic deficit are...

answer

RED FLAG findings

question

T/F Neurodynamic testing (SLR) differentiates between discogenic disease and neoplasm.

answer

False

question

Erythrocyte sedimentation rate (ESR) =

answer

- rate at which RBCs settle out of unclotted blood plasma within 1 hr High ESR indicates infection or inflammation

question

NMS risk factors for sciatica:

answer

Previous low back injury or trauma; direct fall on buttock; gunshot wound THA Pregnancy Work related postures or movements Fibromyalgia Leg-length discrepancy Congenital hip dysplasia; hip dislocation DDD, spinal stenosis Piriformis syndrome

question

Systemic/Medical risk factors for sciatica:

answer

Tobacco use Hx of DM Atherosclerosis Previous hx of CA Presence of intra abdominal or peritoneal inflammatory disease (Crohn's, PID, Diverticulitis) Endometriosis of sciatic nn Radiation therapy Recent spinal surgery

question

Clinical S/Sx of Sciatic/Sciatica Radiculopathy:

answer

Pain along the sciatic nn anywhere from the spine to the foot Numbness or groin in the groin, rectum, leg, calf, foot or toes Diminished or absent DTRs Weakness in the L4-S2 myotomes (distal more prominent than proximal) Diminished or absent DTRs Ache in the calf

question

Clinical S/Sx of Sciatic Neuropathy:

answer

Sxs of sciatic as described above Dysesthetic pain described as constant burning or sharp, jabbing pain Foot drop Flail lower leg (severe motor neuropathy)

question

Cancer Recurrence

answer

Metastases are more common than primary cancer Breast cancer affects shoulder, thoracic vertebrae, and hip first Recurrence of colon cancer is possible with referred pain to hip/groin

question

Hodgkin's Disease

answer

Arises in lymph glands, most common on single side of neck or groin Lymph nodes in groin can become enlarged due to STD Presence of painless, hard lymph nodes is always a red flag

question

Spinal Cord Tumors

answer

Tumors present as dull, aching discomfort or sharp pain the thoracolumbar area Symptoms may be unilateral or bilateral Disk herniation can mimic tumor Tumor is suspected with painless neurologic deficit, night pain, or increased pain when supine Cremasteric reflex can help identify neurologic impairment in males Teenagers with disk herniation symptoms should be examined for a tumor Spinal metastases to femur or lower pelvis may appear as hip pain

question

Osteoid osteoma is a small, benign but painful tumor:

answer

Common 20% lesion occurring in proximal femur and 10% in pelvis During 2nd decade of life Chronic dull hip, thigh, or knee pain worse at night Antalgic gait Point tenderness over lesion

question

Clinical S/Sx for buttock, hip, groin, or lower extremity pain associated with cancer:

answer

Bone pain, especially with weight bearing Antalgic gait Local tenderness Night pain Pain relieved disproportionately by aspirin Fever, weight loss, bleeding, skin lesions Vaginal/penile discharge Painless, progressive enlargement of inguinal and/or popliteal lymph nodes

question

Ischial Bursitis

answer

equal leg length (-) Trendelenburg test normal sensation, reflexes, joint play LIMITED SLR with NO further HIP FLX after bending knee

question

Irritation of T10-L1 sensory nerve roots may cause..

answer

(genitofemoral and ilioinguinal nerves) may cause labial or testicular and buttock pain

question

Screening for urologic causes of buttock, hip, groin, or thigh pain

answer

Ureteral pain begins posteriorly in the costovertebral angle and can radiate anteriorly to upper thigh and groin Pain is referred to site where organ was located during fetal development Lower thoracic and upper lumbar vertebrae and SI joint can refer pain to groin and anterior thigh Murphy's percussion test can be used to rule out kidney involvement

question

Positive Murphy's percussion test indicates...

answer

kidney infection or inflammation

question

Screening for Male Reproductive Causes of Groin Pain

answer

Groin pain can be due to prostate cancer, testicular cancer, benign prostatic hyperplasia (BPH), or prostatitis Groin pain is usually accompanied with low back, buttock, or pelvic pain

question

Screening For Infectious and Inflammatory Causes of Lower Quadrant Pain

answer

Unknown joint pain with skin rash or recent infection needs to be referred Conditions affecting entire peritoneal cavity may cause hip or groin pain in young adults

question

Psoas Abscess

answer

Infection or inflammation can lead to irritation of psoas muscle Pelvic inflammatory disease (PID) is a common cause of pelvic, groin, or hip pain and can cause psoas abscess Most viscera in abdominal and pelvic cavities come into contact with iliopsoas muscle Hip pain with abscess may involve medial thigh Muscular spasm may occur Direct back, pelvic, or hip pain from palpations is likely musculoskeletal Pinch-an-inch test is used for rebound tenderness

question

Pain elicited by stretching the psoas through hip extension is called?

answer

positive psoas sign

question

Hemorrhage within the psoas can cause painful compression of ______ nerve.

answer

femoral

question

Clinical Presentation of Infectious and Inflammatory Causes of Lower Quadrant Pain

answer

Fever is not dramatic Unusual perspiration may occur Loss of appetite is common Laboratory results can reveal ESR

question

S/Sx of Psoas Abscess

answer

Pain confined to psoas fascia but can extent to buttock, hip, groin, upper thigh, or knee Pain in anterior hip area of medial thigh, accompanied or alternating abdominal pain Psoas spasm causing function hip FLX contracture Leg pulled into IR Positive psoas sign Fever up and down/sweats Loss of appetite or other GI symptoms Palpable mass in inguinal area Positive iliopsoas or obturator test

question

Screening for GI Causes of Lower Quadrant Pain

answer

Clinical expression of immune-mediated joint disease results from immunologic response to an antigen that crosses the gut mucosa with an autoimmune response against itself Determine if back or abdominal pain has ever been present

question

Symptoms unrelieved by PT intervention are always...

answer

RED FLAG

question

Symptoms form iliopsoas trigger point are aggravated by weight-bearing activities and relieved with hip _____.

answer

flexion

question

Crohn's Disease

answer

New onset of low back, sacral, buttock, or hip pain can be sign of GI disease 25% of those with inflammatory enteric disease have concomitant back or joint pain that are symptoms of spondys A skin rash that comes and goes can accompany enterically induced arthritis

question

Reactive Arthritis

answer

Joint symptoms occur 1-4 weeks after an infection Joints are aseptic Occur at joints away from primary infection Client is unable to bear weight through the joint Acute presentation can occur in patients that have fever or immunosuppressed

question

Peripheral Vascular Disease (PVD)

answer

Arteries are occluded by atherosclerosis Can cause unilateral or bilateral low back, hip, buttock, groin, or leg pain Claudication and trophic changes of LE can occur Intermittent claudication of vascular origin has burning, cramping, or sharp pain PVD is a rare cause of lower quadrant pain in anyone under age of 65

question

Screening for Vascular Causes of Lower Quadrant Pain

answer

Vascular pain is throbbing in nature and exacerbated by activity Lag time of 5-10 minutes occurs between start of activity and oxygen demand

question

DVT as a cause of lower leg pain may present as loss of knee or ankle motion, swelling of knee, calf, or ankle, with calf tenderness or erythema:

answer

Increased local skin temp, local edema, and decreased distal pulses in LE

question

Sx of impending AA rupture or actual rupture:

answer

Rapid onset of severe groin px (usually accompanied by abdominal or back px) Radiation of px to the abdomen or to posterior thighs Px not relieved by change in position Pain described as "tearing" or "ripping" Cold, pulseless lower extremities

question

Abdominal Aortic Aneurysms (AAA)

answer

May be asymptomatic until the wall of aorta grows large enough to rupture Most common sx is awareness of pulsating mass in the abdomen, with or without px, followed by abdominal or back px May be any age bc it is congenital, but usually >50, more likely >65

question

Bruits =

answer

abnormal blowing or swishing sounds heard on auscultation of the arteries; Bruits with both SBP and DBP suggest turbulent blood flow of partial arterial occlusion

question

Avascular Osteonecrosis

answer

AKA osteonecrosis or septic necrosis, often associated with trauma (hip dislocation/fx) as well as nontraumatic, chronic use and abuse of alcohol is a risk factor Also associated with systemic lupus erythematosus, pancreatitis, kidney disease, blood disorders (sickle cell disease, coagulopathies, leukemia), DM, Cushing's disease, gout. Immunodeficiency conditions (long-term corticosteroids, HIV meds, AIDS, organ transplant recipients, cancer, RA, other autoimmune disorders)

question

Clinical S/SX of AVN:

answer

May be asymptomatic at first Hip px (mild at first, progressively worse over time) Groin or anteromedial thigh px possible Px worse on WB Antalgic gait with gluteus minimus limp Limited hip ROM in capsular pattern (IR, FLX, ABD) Tenderness to palpation over the hip joint Hip joint stiffness or dislocation

question

Osteoporosis

answer

May result in hip fx, especially postmenopausal women who are not taking hormone replacement. Usually Left side Px usually subsides and x-ray normal within several months of delivery Transient osteoporosis of the hip can occur during third-trimester pregnancy, aggravated with WB

question

S/Sx of Osteoporosis

answer

Spontaneous acute and progressive hip px, sometimes referred to lateral thigh Minimal night discomfort Hip ROM spared though there may be px at end of IR Px subsides 6-8 wks., with resolution of bone edema Non-pregnant: spontaneous regression and recovery within 6-9 months with no permanent problems. X-ray often normal at presentation but later show progressive osteoporosis of femoral head

question

Extrapulmonary Tuberculosis

answer

Tubercular disease of the hip or spine, may occur with AIDS With hip involvement, pt. appears with chronic limp and describes px in hip persistent at rest. Approx. 60% do not have constitutional sxs., tuberculin skin test is usually positive, radiographs similar to those with septic arthritis

question

Sickle Cell Anemia and Hemophilia

answer

Hemophilia may involve GI bleeding accompanied by low abdominal, hip, or groin px. caused by bleeding into the wall of the large intestine or the iliopsoas muscle. This retroperitoneal hemorrhage produces a muscle spasm of the iliopsoas muscles leading to bleeding-spasm cycle that increases hip px and hip flexion spasm/contracture. Other sx: melena, hematemesis, and fever

question

Hip Hemarthrosis S/Sx

answer

Px in groin and thigh Fullness in the hip joint, both anterior in the groin and over the greater trochanter Limited motion in hip FLX, ABD, and ER (allows most ROM for the blood in the joint capsule)

question

Liver Disease Manifestations in leg:

answer

Tarsal tunnel syndrome characterized by px around the ankle that extends to the plantar surface of the toes, may result in tibial nn compression from any space=occupying lesion. Causes of compression: trauma (nonunion or displaced fx), varicosities, lipomas, ganglion cysts, or tumors. Burning px and numbness on the plantar surface of the foot. Ascites (+) Tinel's

question

Tinel's sign

answer

- reproduction of px or tingling with tapping or compression of the tibial nerve - may be positive, but does not differentiate between a musculoskeletal cause vs. systemic origin

question

Ascites =

answer

- abnormal accumulation of serous (edematous) fluid in the peritoneal cavity; contains large quantity of protein and electrolytes as a result of portal backup and loss of proteins. Associated with liver disease and alcoholism Distended abdomen, abdominal hernias, lumbar lordosis in clients with ascites may present groin or low back px.

question

If abdominal distention present, therapist should ask about...

answer

liver impairment, chronic alcohol use, presence of carpal or tarsal tunnel syndrome

question

Screening tests for liver impairment:

answer

Liver flap, palmar erythema, scan for angiomas (upper body and abdomen), assessment of nail beds for change of color

question

Guidelines for Immediate Medical Attention

answer

Painless, progressive enlargement of lymph nodes, or lymph nodes that are suspicious for any reason and that persist or that involve more than one area (groin and popliteal areas) Hip or groin px. alternating or occurring simultaneously with abdominal px at the same level (Aneurysm, colorectal cancer) Hip or leg px on WB with + tests for stress reaction or fx

question

Guidelines for Physician Referral

answer

Hip, thigh, or buttock px in a client with THA that is brought on by activity but resolves with continued activity (Loose prosthesis), or who has persistent px that is unrelieved by rest (Implant infection) Sciatica accompanied by extreme motor weakness, numbness in the groin or rectum, or difficulty controlling bowel or bladder function One or more of Cyriax's Signs of the buttock (Box 16-2) New onset of joint px in a client with a known history of Crohn's disease

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