Back Clinic Screening Tests. Screening tests are typically the first assessment completed and are used to determine if further diagnostic testing might be needed. Because screening tests are the first step towards diagnosis, they are designed to be more likely to overestimate the true incidence of a disease. Designed to be different from diagnostic tests in that they might demonstrate more positive results than a diagnostic test.
This can lead to both true positives as well as false positives. Once a screening test is found to be positive, a diagnostic test is then completed to confirm the diagnosis. Next, we will discuss the assessment of diagnostic tests. Many screening tests are available for physicians and advanced chiropractic practitioners to utilize in their practice. For some tests, there is quite a bit of research demonstrating the benefit of such tests on early diagnosis and treatment. Dr. Alex Jimenez presents appropriate assessment and diagnostic tools used in the office to further clarify and appropriated diagnostic assessments.
Osgood-Schlatter disease is a common cause of knee pain in growing adolescents. It is characterized by the inflammation of the site below the knee where the tendon from the kneecap, or the patellar tendon, attaches to the shinbone, or tibia. Osgood-Schlatter disease occurs during growth spurts when muscles, bones, tendons, and other tissues shift�rapidly.
Physical activities can place additional stress on the bones, muscles, tendons and other complex structures of young athletes. Children and adolescents who participate in running and jumping sports have a higher chance of developing this condition. However, less active children and adolescents may also experience this well-known health issue.
In the majority of instances, Osgood-Schlatter disease will resolve on its own and the pain can be managed with over-the-counter drugs and/or medications. Stretches and exercises can also help improve strength, flexibility and mobility. Alternative treatment options, such as chiropractic care, can also help relieve pain and restore the patient’s�well-being.
Osgood-Schlatter Disease Explained
The bones of children and adolescents have a special area where the bone grows, known as the growth plate. Growth plates are made up of cartilage, which harden into solid bone, when a child or adolescent is fully grown.
Some growth plates function as attachment sites for tendons, the strong soft tissues which connect muscles to bones. A bump, known as the tubercle, covers the growth plate at the end of the tibia. The set of muscles in the front of the thigh, or the quadriceps, then attaches to the tibial tubercle.
When a child or adolescent participates in physical activities, the quadriceps muscles pull the patellar tendon which then pulls the tibial tubercle. In some children and adolescents, this traction on the tubercle can cause pain and inflammation in the growth plate. The prominence, or bulge, of the tubercle may become pronounced as a result of this problem.
Osgood-Schlatter Disease Symptoms
Painful symptoms associated with Osgood-Schlatter disease are often brought on by running, jumping, and other sports-related pursuits. In some cases, both the knees have symptoms, although one knee might be worse. Common symptoms of Osgood-Schlatter disease also include:
Knee pain and tenderness in the tibial tubercle
Swelling in the tibial tubercle
Tight muscles at the front or back of the thigh
Osgood-Schlatter disease is the inflammation of the bone, cartilage and/or tendon at the top of the shinbone, or tibia, where the tendon attaches to the kneecap, or patella. Osgood-Schlatter disease is considered to be an overuse injury rather than a disorder or condition. Osgood-Schlatter disease is one of the most common causes of knee pain in children and adolescents. Although it can be very painful, the health issue generally goes away on its own within 12 to 24 months.
Dr. Alex Jimenez D.C., C.C.S.T. Insight
Osgood-Schlatter Disease Diagnosis
Throughout the consultation, the healthcare professional will discuss the children or adolescent’s symptoms regarding their overall health and wellness. They will then conduct a comprehensive evaluation of the knee. This will consist of applying pressure to the tibial tubercle, which should be painful for a patient with Osgood-Schlatter disease. Additionally, the doctor may also ask the child or adolescent to walk, run, jump, or kneel to see whether symptoms are brought on by the movements. Furthermore, the healthcare professional may also order an x-ray of the patienet’s knee to help support their diagnosis or to rule out any other health issues.
Osgood-Schlatter Disease Treatment
Treatment for Osgood-Schlatter disease focuses on reducing pain and inflammation. This generally requires limiting physical activities until symptoms improve. Sometimes, rest may be necessary for many months, followed by treatment and rehabilitation program. However, participation may be safe to continue if the patient experiences no painful symptoms. The doctor may recommend additional treatment, including:
Stretchex�and exercises. Stretches and exercises for the front and back of the thigh, or the quadriceps and the hamstring muscles, can help alleviate pain and prevent the disease from returning.
Non-steroidal anti-inflammatory drugs. Medications like ibuprofen and naproxen can also help reduce pain and inflammation.
Most symptoms will completely vanish when a child completes the adolescent growth spurt, around age 14 for girls and age 16 for boys. Because of this, surgery is often not recommended, although the prominence of the�tubercle will remain.�The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topic Discussion: Relieving Knee Pain without Surgery
Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.
Sinding-Larsen-Johansson, or SLJ, syndrome is a debilitating knee condition that most commonly affects teens during periods of rapid growth. The kneecap, or patella, is attached to the shinbone, or tibia, from the patellar tendon. The tendon connects to an expansion plate at the bottom of the kneecap throughout growth.
Repetitive stress on the patellar tendon can make the growth plate within the knee become inflamed and irritated. SLJ mainly develops in children and adolescents between the ages of 10 and 15 because that is when most people experience growth spurts. SLJ is most common in young athletes due to excess or repetitive strain in the knee.
Causes of SLJ Syndrome
The large muscle group at the front of the upper leg is known as the quadriceps. When straightening the leg, the quadriceps pull to deliver the leg forward. This puts pressure on the growth plate at the bottom of the kneecap. During rapid growth, the bones and muscles don’t always grow at precisely the same rate.
Since the bones grow, tendons and muscles can get tight and stretched. This increases the strain around the patellar tendon and also on the growth plate it’s attached to. Repetitive or extra stress and pressure in this area can cause the growth plate to become irritated and painful. Matters that can contribute to growing SLJ syndrome are comprised of:
Sports that involve a lot of running and jumping, such as field and track or other sports such as football, gymnastics, basketball, lacrosse, and field hockey, can place stress on the knees.
Increased or incorrect physical activity can add strain on the knees. Improper form while training, shoes that don’t support the toes or an unusual way of jogging can increase chances of SLJ syndrome.
Tight or stiff quadriceps muscles can also lead to SLJ syndrome. Muscles that are more powerful and more elastic will work better, reducing the strain on the patellar and kneecap tendon.
Activities that place more pressure on the knees or demanding tasks for the knees, such as lifting heavy items, walking up and down stairs, and squatting can cause SLJ syndrome. If there’s already pain on the knee, then these movements may make it worse.
Symptoms of SLJ Syndrome
Symptoms demonstrating the presence of�Sinding-Larsen-Johansson, or SLJ, syndrome include: pain at the front of the knee or near the bottom of the kneecap, as this is the main symptom of SLJ; swelling and tenderness around the kneecap; pain that increases with physical activities like jogging, climbing stairs, or leaping; pain that becomes more acute when kneeling or squatting; and a swollen or bony bump at the bottom of the kneecap.
Sinding-Larsen-Johansson, or SLJ, syndrome is medically referred to as a juvenile osteochondrosis which affects the patella tendon in the kneecap which attaches to the inferior pole of the patella in the shinbone. Commonly characterized by knee pain and inflammation, SLJ is considered an overuse knee injury rather than a traumatic injury. Sinding-Larsen-Johansson syndrome is similar to Osgood-Schlatter syndrome.
Dr. Alex Jimenez D.C., C.C.S.T. Insight
Diagnosis of SLJ
Should you see a healthcare professional for knee problems, they will generally ask questions about how much pain the patient is experiencing and if they do any sports or other physical activities and exercises. Whether or not the patient has also had a recent growth spurt, the doctor will examine the patient’s knee for swelling and tenderness.
In very rare instances, the healthcare professional may also ask patients to acquire an X-ray or other imaging diagnostics, such as magnetic resonance imaging, or MRI, to rule out other health issues like fracture or disease.
Prevention of SLJ
The most significant way that patients can prevent getting SLJ is to stop doing physical activities which cause pain in the knee. The patient should limit themselves before the pain goes off.
It is crucial to warm up well and stretch before exercising, playing sports or engaging in any other physical activities. A jog around the track for a couple of minutes and some dynamic stretching is enough to warm up the body.
If the quadriceps muscles are tight, then you might want to do some specialized exercise and physical activity routines. Talk to your healthcare professional, such as a chiropractor or physical therapist, to discuss what’s best for you. Doing a few stretches and warm up exercises after sports or physical activities can help prevent SLJ syndrome from developing.
Treatment of SLJ
The first and most important way to treat SLJ is to stop any action that causes irritation in the knee. It’s essential for a patient to not resume any physical activities without first being cleared by a healthcare professional.
SLJ can be challenging to treat since it may not completely resolve before the bones have completely matured and the growth plates are completely shut. During physical activities, knee pain may come and go in the meantime. Other treatments to help ease SLJ syndrome include:
Use the RICE formula.
Rest. Limit physical activities as much as possible and keep weight off the knee. Walking must be kept to a minimum.
Ice. Apply ice or a cold compress to the affected area for 15 to 20 minutes every few hours. Repeat this for 2 to 3 days or until the painful symptoms have decreased.
Compress. Give the knee additional support with a strap, a band, or a ribbon. This will also�help manage symptoms.
Elevate. Keep the knee higher than the heart to reduce swelling.
Take anti-inflammatory or painkilling drugs. Painkillers like acetaminophen and ibuprofen can help relieve pain and decrease swelling.
Begin a stretching and strengthening program. After the pain and tenderness on your knee have been gone, speak with your physician or sports injury professional about a physical rehabilitation program to strengthen the muscles of your leg and increase their flexibility and range of movement.
It’s easy to become impatient when sidelined by an injury, but the proper treatment can help build the strength needed for future physical activities.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topic Discussion: Relieving Knee Pain without Surgery
Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.
Patellar tendinitis is a common health issue characterized by the inflammation of the tendon which joins the kneecap, or patella, to the shinbone, or tibia. The knee pain associated with this problem may range from mild to severe depending on the circumstances of the knee injury.
Patellar tendinitis, or jumper’s knee, is a well-known sports injury among athletes who play in basketball and volleyball. Among recreational volleyball players, an estimated 14.4 percent of them have jumper’s knee, where the incidence is even higher for professional athletes. An estimated 40 to 50 percent of elite volleyball players have patellar tendinitis.
Causes of Patellar Tendinitis
Patellar tendinitis is caused by repetitive strain on the knee, most often from overuse in physical activities. Stress can create tears along the tendons which can cause inflammation in the complex structures of the knee.
Other contributing factors of patellar tendinitis include:
Tight or stiff leg muscles
Uneven leg muscle strength
Misaligned toes, ankles, and legs
Obesity
Sneakers without enough padding
Tough playing surfaces
Chronic health issues that weaken the tendon
Athletes have a higher chance of developing patellar tendinitis because running, jumping, and squatting put more force over the tendon. Running can place a force of as many as five times the body weight on the knees.
Intense physical activity for an extended amount of time has been previously associated with jumper’s knee. A 2014 research study noted that jump frequency was also a significant risk factor for amateur players.
Symptoms of Patellar Tendinitis
The initial symptoms of patellar tendinitis include pain,�discomfort, and tenderness at the base of the kneecap or patella. Other symptoms of patellar tendinitis may include a burning sensation. For many patients, getting up from a squat or kneeling down can also be particularly debilitating.
The pain associated with patellar tendinitis may be irregular at first, manifesting immediately after participating in physical activities. Damage or injury to the tendon can also make the pain worse. Jumper’s knee can affect regular daily activities, such as climbing stairs or sitting in a vehicle.
�
Patellar tendinitis, also known as “jumper’s knee”, is a particularly common cause of pain and discomfort in the patellar region of many athletes. While it frequently occurs as a result of repetitive or continuous jumping, research studies have demonstrated that patellar tendinitis may be associated with stiff ankle movements and ankle sprains, among other sports injuries.
Dr. Alex Jimenez D.C., C.C.S.T. Insight
Patellar Tendinitis Diagnosis
At the start of a�consultation, the healthcare professional will first ask the patient about their specific health issue. The doctor will then physically evaluate the patient’s knee, probe for where they are feeling pain, and test the assortment of knee motion by bending and extending the patient’s leg.
Furthermore, the healthcare professional may additionally order imaging diagnostics to find out if there’s any damage or injury to the tendon or even the bone. These tests can help rule out a broken bone, or fracture. The doctor may use an X-ray to look for a displaced or fractured kneecap, and an MRI or an ultrasound to reveal any harm to the soft tissue.
Patellar Tendinitis Treatment
Treatment for patellar tendinitis depends on the damage or injury to the knee. Conservative steps to reduce pain, such as rest or exercises are generally the first line of treatment. The healthcare professional will usually recommend a span of controlled rest, where they will prevent the patient from engaging in physical activities that put�pressure on the knee.
Drugs and/or Medications
The healthcare professional may prescribe over-the-counter drugs and/or medications for short-term pain relief and inflammation reduction.
These can consist of:
Ibuprofen (Advil)
Naproxen sodium (Aleve)
cetaminophen (Tylenol)
If the patient’s symptoms are severe, the healthcare professional may recommend the use of corticosteroid injection in the area around the patellar tendon. This treatment is effective in reducing acute pain.
Another method of utilizing corticosteroid for patellar tendinitis is by spreading the medication over the affected knee and use a low electrical charge to push it through the skin, in a process known as iontophoresis.
Chiropractic Care and Physical Therapy
The goal of chiropractic care and physical therapy for patellar tendinitis is to reduce pain and inflammation, among other symptoms, as well as to strengthen the leg and thigh muscles with stretches and exercises.
If the patient’s symptoms are severe, even while resting, the doctor may recommend that you wear a brace and then use crutches to avoid additional damage or injury to the tendon. If the patient has no painful symptoms, then they can start participating in a physical therapy activities.
A rehabilitation program generally consists of:
A warm-up interval
Massage, heat or ice to the�knee
Stretching exercises
Strengthening exercises
A doctor of chiropractic, or chiropractor, may use ultrasound and electrical stimulation to relieve the patient’s knee pain. A�knee brace or taping of the knee might also help reduce pain by supporting the kneecap when engaging in physical activities. The healthcare professional may develop a workout program that may include a series of stretches and exercises.
Surgery
When other treatments are not effective in relieving painful symptoms associated with patellar tendinitis, the doctor may advise surgery to repair the patellar tendon. Traditional surgery involves opening the knee to scrape on the kneecap and tendon. More recently,�arthroscopic surgery is used for this particular process. This surgical intervention involves making four small incisions in the knee and it has a shorter recovery time.
The recovery period for surgery varies per procedure. Some surgical intervention advise for immobilization with a cast. Others suggest�an immediate rehabilitation program. Regardless of the level of damage and/or injury, it’s essential for patients to seek medical attention for their patellar tendinitis. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topic Discussion: Relieving Knee Pain without Surgery
Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.
The rectus femoris muscle attaches to the pelvis and just below the knee as it is one of four muscles found at the front part of the thigh. It functions by extending the knee and flexing the hip. The rectus femoris muscle is made up of�fibers which adapt to quick action. Rectus femoris muscle strain is caused by forceful movements, such as kicking a ball or when beginning to sprint, and it is particularly vulnerable to stress and pressure.
Painful symptoms generally manifest at the top of the thigh after the rectus femoris muscle suffers a strain or tear. In severe cases, the health issue may even become noticeable if the tissue is completely ruptured. Fortunately, complete tears are rare. Healthcare professionals will commonly use an MRI scan to diagnose the extent of the sports injury. Proper diagnosis and treatment�are�essential. A rectus femoris muscle strain should not be rushed, as individuals who return-to-sport too soon may suffer re-injury.
Treatment for Rectus Femoris Strain
According to many healthcare professionals, when it comes to sports injuries to the rectus femoris muscle, it’s crucial to immediately apply the RICE principle (Rest, Ice, Compression, and Elevation) to the affected thigh. This treatment aims to decrease bleeding and inflammation to the muscle. Also, it will help reduce painful symptoms after the injury. Based on how much pain has been experienced, simple painkillers might be utilized, although it’s best to attempt to prevent the use of these.
Once movement is restored enough to allow the individual to walk using their regular range of motion, and once the swelling has gone down, then you will have recovered from the acute phase of the injury. It would then be an excellent time to engage in physical activity, without inflicting damage or stress to the quadriceps muscles. This can be performed on an exercise bicycle or through swimming, where the weight is kept�off the limb. Stretches and gentle resistance exercises are crucial, as this will help to align the scar tissue that has formed during the healing process.
Recovery must be monitored so that improvements can be noted and the treatment shifted to help the rehabilitation process. It is hard to measure the length of time to complete recovery. It can take from six to eight weeks or even longer, although some people will commonly recover within one to four weeks.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
The hip is commonly described as a “ball-and-socket” type joint. In a healthy hip, the ball at the top end of the thighbone, or femur, should fit firmly into the socket, which is part of the large pelvis bone. In babies and children with developmental dysplasia, or dislocation, of the hip, abbreviated as DDH, the hip joint may not have formed normally. As a result, the ball of the femur might easily dislocate and become loose from the socket.
Although DDH is often present from birth, it could also develop during a child’s first year of life. Recent research studies have demonstrated that infants whose thighs are swaddled closely with the hips and knees straight are at a higher risk for developing DDH. Because swaddling has become�increasingly popular, it is essential for parents to understand how to swaddle their babies safely, and they should realize that when done improperly, swaddling may cause health issues such as DDH.
Diagnosis for�Developmental Dysplasia of the Hip
In addition to visual cues, when�diagnosing for DDH, the healthcare professional will perform a careful evaluation, such as listening and feeling for “clunks” which indicates that the hip is placed in different positions. The doctor will also utilize other methods and techniques to determine if the hip is dislocated. Newborns recognized to be at higher risk for DDH are often tested using ultrasound. For babies and children, x-rays of the hip might be taken to provide further detailed images of the hip joint.
Treatment for�Developmental Dysplasia of the Hip
If DDH is discovered at birth, it can usually be treated with the use of a harness or brace. If the hip isn’t dislocated at birth, the condition might not be diagnosed until the child starts walking. At that point, treatment for DDH is much more complex, with less predictable results. If diagnosed and treated accordingly, children ought to have no restriction in function and develop the standard hip joint. DDH may result in atherosclerosis and other problems. It may produce a difference in agility or leg length.
In spite of proper treatment, hip deformity and osteoarthritis may develop later in life. This is particularly true when treatment starts after the age of 2 years. Therefore, diagnosis and treatment are essential in newborns and children with DDH. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
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Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Hip pain is a well-known health issue which can be caused by a wide array of problems, however, the site of the patient’s hip pain can provide valuable information regarding the underlying cause of this common health issue. Pain on the inside of the hip or groin can be due to problems within the hip joint itself while pain on the outside of the hip, upper thigh and outer buttocks may be due to problems with the ligaments, tendons and muscles, among other soft tissues, surrounding the hip joint. Furthermore, hip pain can be due to other injuries and conditions, including back pain.
Abstract
Hip pain is a common and disabling condition that affects patients of all ages. The differential diagnosis of hip pain is broad, presenting a diagnostic challenge. Patients often express that their hip pain is localized to one of three anatomic regions: the anterior hip and groin, the posterior hip and buttock, or the lateral hip. Anterior hip and groin pain is commonly associated with intra-articular pathology, such as osteoarthritis and hip labral tears. Posterior hip pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, and less commonly ischiofemoral impingement and vascular claudication. Lateral hip pain occurs with greater trochanteric pain syndrome. Clinical examination tests, although helpful, are not highly sensitive or specific for most diagnoses; however, a rational approach to the hip examination can be used. Radiography should be performed if acute fracture, dislocations, or stress fractures are suspected. Initial plain radiography of the hip should include an anteroposterior view of the pelvis and frog-leg lateral view of the symptomatic hip. Magnetic resonance imaging should be performed if the history and plain radiograph results are not diagnostic. Magnetic resonance imaging is valuable for the detection of occult traumatic fractures, stress fractures, and osteonecrosis of the femoral head. Magnetic resonance arthrography is the diagnostic test of choice for labral tears.
Introduction
Hip pain is a common presentation in primary care and can affect patients of all ages. In one study, 14.3% of adults 60 years and older reported significant hip pain on most days over the previous six weeks.1 Hip pain often presents a diagnostic and therapeutic challenge. The differential diagnosis of hip pain (eTable A) is broad, including both intra-articular and extra-articular pathology, and varies by age. A history and physical examination are essential to accurately diagnose the cause of hip pain.
Anatomy
The hip joint is a ball-and-socket synovial joint designed to allow multiaxial motion while transferring loads between the upper and lower body. The acetabular rim is lined by fibrocartilage (labrum), which adds depth and stability to the femoroacetabular joint. The articular surfaces are covered by hyaline cartilage that dissipates shear and compressive forces during load bearing and hip motion. The hip’s major innervating nerves originate in the lumbosacral region, which can make it difficult to distinguish between primary hip pain and radicular lumbar pain.
The hip joint’s wide range of motion is second only to that of the glenohumeral joint and is enabled by the large number of muscle groups that surround the hip. The flexor muscles include the iliopsoas, rectus femoris, pectineus, and sartorius muscles. The gluteus maximus and hamstring muscle groups allow for hip extension. Smaller muscles, such as gluteus medius and minimus, piriformis, obturator externus and internus, and quadratus femoris muscles, insert around the greater trochanter, allowing for abduction, adduction, and internal and external rotation.
In persons who are skeletally immature, there are several growth centers of the pelvis and femur where injuries can occur. Potential sites of apophyseal injury in the hip region include the ischium, anterior superior iliac spine, anterior inferior iliac spine, iliac crest, lesser trochanter, and greater trochanter. The apophysis of the superior iliac spine matures last and is susceptible to injury up to 25 years of age.2
The hip joint is one of the larger joints found in the human body and it serves in locomotion as the thigh moves forward and backward. The hip joint also rotates when sitting and with changes of direction while walking. A variety of complex structures surround the hip joint. When an injury or condition affects these, it can ultimately lead to hip pain.
Dr. Alex Jimenez D.C., C.C.S.T.
Evaluation of Hip Pain
History
Age alone can narrow the differential diagnosis of hip pain. In prepubescent and adolescent patients, congenital malformations of the femoroacetabular joint, avulsion fractures, and apophyseal or epiphyseal injuries should be considered. In those who are skeletally mature, hip pain is often a result of musculotendinous strain, ligamentous sprain, contusion, or bursitis. In older adults, degenerative osteoarthritis and fractures should be considered first.
Patients with hip pain should be asked about antecedent trauma or inciting activity, factors that increase or decrease the pain, mechanism of injury, and time of onset. Questions related to hip function, such as the ease of getting in and out of a car, putting on shoes, running, walking, and going up and down stairs, can be helpful.3 Location of the pain is informative because hip pain often localizes to one of three basic anatomic regions: the anterior hip and groin, posterior hip and buttock, and lateral hip (eFigure A).
Physical Examination
The hip examination should evaluate the hip, back, abdomen, and vascular and neurologic systems. It should start with a gait analysis and stance assessment (Figure 1), followed by evaluation of the patient in seated, supine, lateral, and prone positions (Figures 2 through 6, and eFigure B). Physical examination tests for the evaluation of hip pain are summarized in Table 1.
Imaging
Radiography. Radiography of the hip should be performed if there is any suspicion of acute fracture, dislocation, or stress fracture. Initial plain radiography of the hip should include an anteroposterior view of the pelvis and a frog-leg lateral view of the symptomatic hip.4
Magnetic Resonance Imaging and Arthrography. Conventional magnetic resonance imaging (MRI) of the hip can detect many soft tissue abnormalities, and is the preferred imaging modality if plain radiography does not identify specific pathology in a patient with persistent pain.5 Conventional MRI has a sensitivity of 30% and an accuracy of 36% for diagnosing hip labral tears, whereas magnetic resonance arthrography provides added sensitivity of 90% and accuracy of 91% for the detection of labral tears.6,7
Ultrasonography. Ultrasonography is a useful technique for evaluating individual tendons, confirming suspected bursitis, and identifying joint effusions and functional causes of hip pain.8 Ultrasonography is especially useful for safely and accurately performing imaging-guided injections and aspirations around the hip.9 It is ideal for an experienced ultrasonographer to perform the diagnostic study; however, emerging evidence suggests that less experienced clinicians with appropriate training can make diagnoses with reliability similar to that of an experienced musculoskeletal ultrasonographer.10,11
These are numerous causes for hip pain. Although some hip pain may only be temporary, other forms of hip pain can become chronic if left untreated for an extended period of time. Several common causes of hip pain include, arthritis, fracture, sprain, avascular necrosis, Gaucher’s disease, sciatica, muscle strain, iliotibial band syndrome or IT band syndrome and hematoma, among others described below.
Dr. Alex Jimenez D.C., C.C.S.T.
Differential Diagnosis of Anterior Hip Pain
Anterior hip or groin pain suggests involvement of the hip joint itself. Patients often localize pain by cupping the anterolateral hip with the thumb and forefinger in the shape of a �C.� This is known as the C sign (Figure 1A).
Osteoarthritis
Osteoarthritis is the most likely diagnosis in older adults with limited motion and gradual onset of symptoms. Patients have a constant, deep, aching pain and stiffness that are worse with prolonged standing and weight bearing. Examination reveals decreased range of motion, and extremes of hip motion often cause pain. Plain radiographs demonstrate the presence of asymmetrical joint-space narrowing, osteophytosis, and subchondral sclerosis and cyst formation.12
Femoroacetabular Impingement
Patients with femoroacetabular impingement are often young and physically active. They describe insidious onset of pain that is worse with sitting, rising from a seat, getting in or out of a car, or leaning forward.13 The pain is located primarily in the groin with occasional radiation to the lateral hip and anterior thigh.14 The FABER test (flexion, abduction, external rotation; Figure 3) has a sensitivity of 96% to 99%. The FADIR test (flexion, adduction, internal rotation; Figure 4), log roll test (Figure 5), and straight leg raise against resistance test (Figure 6) are also effective, with sensitivities of 88%, 56%, and 30%, respectively.14,15 In addition to the anteroposterior and lateral radiograph views, a Dunn view should be obtained to help detect subtle lesions.16
Hip Labral Tear
Hip labral tears cause dull or sharp groin pain, and one-half of patients with a labral tear have pain that radiates to the lateral hip, anterior thigh, and buttock. The pain usually has an insidious onset, but occasionally begins acutely after a traumatic event. About one-half of patients with this injury also have mechanical symptoms, such as catching or painful clicking with activity.17 The FADIR and FABER tests are effective for detecting intra-articular pathology (the sensitivity is 96% to 75% for the FADIR test and is 88% for the FABER test), although neither test has high specificity.14,15,18 Magnetic resonance arthrography is considered the diagnostic test of choice for labral tears.6,19 However, if a labral tear is not suspected, other less invasive imaging modalities, such as plain radiography and conventional MRI, should be used first to rule out other causes of hip and groin pain.
Iliopsoas Bursitis (Internal Snapping Hip)
Patients with this condition have anterior hip pain when extending the hip from a flexed position, often associated with intermittent catching, snapping, or popping of the hip.20 Dynamic real-time ultrasonography is particularly useful in evaluating the various forms of snapping hip.8
Occult or Stress Fracture
Occult or stress fracture of the hip should be considered if trauma or repetitive weight-bearing exercise is involved, even if plain radiograph results are negative.21 Clinically, these injuries cause anterior hip or groin pain that is worse with activity.21 Pain may be present with extremes of motion, active straight leg raise, the log roll test, or hopping.22 MRI is useful for the detection of occult traumatic fractures and stress fractures not seen on plain radiographs.23
Transient Synovitis and Septic Arthritis
Acute onset of atraumatic anterior hip pain that results in impaired weight bearing should raise suspicion for transient synovitis and septic arthritis. Risk factors for septic arthritis in adults include age older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint surgery, and hip or knee prostheses.24 Fever, complete blood count, erythrocyte sedimentation rate, and C-reactive protein level should be used to evaluate the risk of septic arthritis.25,26 MRI is useful for differentiating septic arthritis from transient synovitis.27,28 However, hip aspiration using guided imaging such as fluoroscopy, computed tomography, or ultrasonography is recommended if a septic joint is suspected.29
Osteonecrosis
Legg-Calv�-Perthes disease is an idiopathic osteonecrosis of the femoral head in children two to 12 years of age, with a male-to-female ratio of 4:1.4 In adults, risk factors for osteonecrosis include systemic lupus erythematosus, sickle cell disease, human immunodeficiency virus infection, smoking, alcoholism, and corticosteroid use.30,31 Pain is the presenting symptom and is usually insidious. Range of motion is initially preserved but can become limited and painful as the disease progresses.32 MRI is valuable in the diagnosis and prognostication of osteonecrosis of the femoral head.30,33
Differential Diagnosis of Posterior Hip and Buttock Pain
Piriformis Syndrome and Ischiofemoral Impingement
Piriformis syndrome causes buttock pain that is aggravated by sitting or walking, with or without ipsilateral radiation down the posterior thigh from sciatic nerve compression.34,35 Pain with the log roll test is the most sensitive test, but tenderness with palpation of the sciatic notch can help with the diagnosis.35
Ischiofemoral impingement is a less well-understood condition that can lead to nonspecific buttock pain with radiation to the posterior thigh.36,37 This condition is thought to be a result of impingement of the quadratus femoris muscle between the lesser trochanter and the ischium.
Unlike sciatica from disc herniation, piriformis syndrome and ischiofemoral impingement are exacerbated by active external hip rotation. MRI is useful for diagnosing these conditions.38
Other
Other causes of posterior hip pain include sacroiliac joint dysfunction,39 lumbar radiculopathy,40 and vascular claudication.41 The presence of a limp, groin pain, and limited internal rotation of the hip is more predictive of hip disorders than disorders originating from the low back.42
Differential Diagnosis of Lateral Hip Pain
Greater Trochanteric Pain Syndrome
Lateral hip pain affects 10% to 25% of the general population.43 Greater trochanteric pain syndrome refers to pain over the greater trochanter. Several disorders of the lateral hip can lead to this type of pain, including iliotibial band thickening, bursitis, and tears of the gluteus medius and minimus muscle attachment.43�45 Patients may have mild morning stiffness and may be unable to sleep on the affected side. Gluteus minimus and medius injuries present with pain in the posterior lateral aspect of the hip as a result of partial or full-thickness tearing at the gluteal insertion. Most patients have an atraumatic, insidious onset of symptoms from repetitive use.43,45,46
In conclusion, hip pain is a common complaint which may occur due to a wide variety of health issues. Moreover, the precise location of the patient’s hip pain can provide valuable information to healthcare professionals regarding the underlying cause of the problem. The purpose of the article above was to demonstrate and discuss the evaluation of the patient with hip pain. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Data Sources: We searched articles on hip pathology in American Family Physician, along with their references. We also searched the Agency for Healthcare Research and Quality Evidence Reports, Clinical Evidence, Institute for Clinical Systems Improvement, the U.S. Preventive Services Task Force guidelines, the National Guideline Clearinghouse, and UpToDate. We performed a PubMed search using the keywords greater trochanteric pain syndrome, hip pain physical examination, imaging femoral hip stress fractures, imaging hip labral tear, imaging osteomyelitis, ischiofemoral impingement syndrome, meralgia paresthetica review, MRI arthrogram hip labrum, septic arthritis systematic review, and ultrasound hip pain. Search dates: March and April 2011, and August 15, 2013.
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
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9.�Blankenbaker DG, De Smet AA. Hip injuries in athletes.�Radiol Clin North Am. 2010;48(6):1155�1178.
10.�Balint PV, Sturrock RD. Intraobserver repeatability and interobserver reproducibility in musculoskeletal ultrasound imaging measurements.�Clin Exp Rheumatol. 2001;19(1):89�92.
11.�Ramwadhdoebe S, Sakkers RJ, Uiterwaal CS, et al. Evaluation of a training program for general ultrasound screening for developmental dysplasia of the hip in preventive child health care.�Pediatr Radiol. 2010;40(10):1634�1639.
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Achondroplasia is a genetic disorder that leads to dwarfism. In those with the condition, the legs and arms are short, while the chest is generally of regular length. Those affected have an average adult height of 131 centimetres (4 ft 4 in) for males and 123 centimetres (4 feet ) for females. Other features include a prominent forehead and an enlarged head. Intelligence is typically considered normal in people with achondroplasia. The condition affects approximately 1 in 27,500 individuals.
Diagnosis for Achondroplasia
Achondroplasia is the result of a mutation in the fibroblast growth factor receptor 3 (FGFR3) gene. This occurs during early development as a new mutation. It is also inherited from the parents in an autosomal dominant way. Those with two affected genes do not survive. Testing if uncertain of diagnosis based on symptoms is often strongly encouraged.
Achondroplasia can be detected before birth�through the use of prenatal ultrasound. Moreover, a DNA test can also be performed to identify homozygosity, where two copies of the gene are inherited causing the deadly condition resulting in stillbirths. Clinical features include megalocephaly, short limbs, prominent forehead, thoracolumbar kyphosis and mid-face hypoplasia. Complications such as dental malocclusion, hydrocephalus and replicated otitis media may also develop. The risk of death in infancy may be increased as a result of the probability of compression of the spinal cord with or without upper airway obstruction.
Achondroplasia and Sciatica
Individuals with achondroplasia commonly experience back pain, which may often progress to sciatica symptoms, such as pain and discomfort, tingling and burning sensations in the lower extremities, and numbness, among other consequences. Both children and adults with achondroplasia have hip flexion contractures which have been found to be a contributing factor for sciatica and muscle fatigue reported by individuals with achondroplasia. Individuals with achondroplasia also typically demonstrate a mixed pattern of joint mobility, including joint contracture and joint hypermobility at characteristic joints.�
Achondroplasia Management
There is no known cure for achondroplasia even though the cause of the mutation has been found. Management for the condition might include support groups and growth hormone treatment. Efforts to treat or prevent complications like obesity, hydrocephalus, obstructive sleep apnea, middle ear infections, or spinal stenosis may be required for the management�of achondroplasia. Life expectancy of those affected is approximately 10 years less than ordinary.�The scope of our information is limited to chiropractic, spinal injuries, and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Alternative treatment options, such as chiropractic care, can help ease back pain through spinal adjustments and manual manipulations, ultimately improving pain relief.
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