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8/16/2019 Differential Diagnosis II

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JC Lau 2002

Differential Diagnosis II Mid-term

ANKLE SPRAIN PRESENTATION

CASE I – 20 year old male sustained an ankle injury. He has had multiple ankle injuries to bothankles over the last few years. He is very active and in addition to playin basketball and soccer!he also is a snowboarder. He injured his ankle snowboardin "Dorsiflexion, inversion injury #

$% &H' $(J)*+ $, ACUTE "2 -ays# (- &H'*' $, SIGNIICANT S!ELLING/

"ISTOR#Lookin for Instability

$% Me&'anism

• $f they fell forward on their board! they will do a -*,$%L'1$($(3'*,$( sprain

• -ue to boot holdin foot in -orsifle4ion yet still allowin foot to rotate inside.

(% Lots of s)elling

• $ndicative of L&, of injury

• 5ill throw off a lot of tests because fluid acts almost like a 6splint6

*% Otto)a G+idelines • $nability to bear weiht after injury * durin e4amination

• 7in point pain 8ony tenderness "specific areas of bony tenderness#

a. 9alleolib. (avicular c. Cuboidd. :th 9& head

E,AMINATION

,-ra ; < views you must take "if no findin! wait 2 weeks and reshoot films#$% A . P An/le

(% Lateral An/le

*% Mortise 0ie) • 5ill reveal a Talar Dome Fracture * Osteochondritis Dessicans of the ankle

• 9ortise view is taken ;7 with 20= internal rotation

1% ( Additional 2ie)sa. 9ortise $nversion &iltb. 9ortise 'version &ilt

• &ake two lines "one at the top of &alus! one at bottom of &ibia#

• &his anle is the Talar Tilt , should NOT be > 10°

Positi0e Talar Tilt findings

• $f anle is open! patient has &*( the Calcaneofibular ligament ! Anterior Talofibular

ligament

• 9ust also look for tearin of the Interosseous Membrane and Tibiofibular

ligament

If ,-ra is NEGATI2E3>. -rawer &est2. &alus *ock test


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Tests for Interosseso+s tear 1. S4+ee5e test E6ternal &om7ression test

• 7ain elicited with test due to further separation of $nterosseous tear@@

. E6ternal Rotation test ; B!T test to use""

• 7atient is seated with ankle in neutral position

• &hen 7,,$3'L+ '4ternally rotate the ankle

POSITI2E INDING3 Lookin for end;rane pain

!. S4+ee5e Dorsifle6ion test

• 7ain or limitation with 7,,$3' -orsifle4ion

• &hen sAueeBe

POSITI2E INDING3 &here will then be an Increase in #orsifle$ion andor #ecrease in %ain

Res+lts of Interosseso+s tear

• Calcification ",yndosmosis#

Diagnosis>. 8Sno)9oarder:s fra&t+re;

• &ateral %rocess of the Talus is fractured

• 9ay see on Lateral %ilm or – 7 "with internal or e4ternal rotation#

• 7ossibly even an bliAue %ilm

2. Me&'anism of Sno)9oarder:s ra&t+re -orsifle4ion and $nversion

'ATINT ()!T IN)*# +I! AN& AT A !'O*TIN- .NT T+AT /O) A* T+ #OCTO*O* /O) A* '*!NT TO 2A3 T+ AN& 4IT+IN 50 3IN)T! '*IO* TO AN/!I-NIICANT !4&&IN- 4+AT I! /O)* A''*OAC+6

E,AMINATION – in order

>. ttawa Duidelines2. Look for deformity


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• Cal&ane+s ad. $nterosseous &aloCalcaneal Liament

• $nside ,inus &arsi

• -ianosed with 9*$

• Can et entrapped

2. 8ifurcate Liament


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• $f this ets torn! often becomes unstable

An/le S7rains

$% General Notes• $nversion 7lantarfle4ion is 9,& C99(

a% IN2ERSION SPRAIN/ ,eAuence of &earin "from front to back#

• nterior &alofibular

• Calcaneofibular

• 7osterior &alofibular "this will only tear if ,'3'*'@#

9% E2ERSION SPRAIN/

• -eltoid Liament – rarely torn@

(% E0al+ationa% 7alpate for bony tenderness "for fracture#

9% nterior -rawer test&% &ilt &estd% ttawa *ules

• $nability to bear weiht after injury or at time of evaluation

• &enderness at specific bony areas "9alleoli! (avicular! Cuboid! Head of :th 9

• 3ust ta7e 29ray if AN/ of these are found""

Grading of Ligament In


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d% M+s&le Strengt'ening

• 7eroneals

• &ibialis nterior

• Hip bductors

• !trengthening of .*TO*! and #O*!I&2O*! :ill hel% %re;ent inF "to see how to test for flatfeet#

A 8=9year9old runner has been told that he has flatfeet +e is :ondering if you thin7 he does and :hat can be done about it

$% Non-)eig't 9earing 7osition! is t'ere an ar&'

lat oot

$% Tarsal Coalition

• Connection between Calcaneus and &alus and (avicular that

should not be there "connective tissue bride#

• 9ust take an 1;ray

• C& ,can or 9*$

(% Ti9ialis Posterior R+7t+re

• *heumatoid rthritis predisposes to this

NORMAL"&here is an arch#

>. (ormally

• 'ven if a person a flat footed! there should be an arch

(% E6&e7tion

• CH$L-*'(@

• &his is because when baby is in;utero! there is a period of time

that takes bones to 6-';*&&'6

• %eet are turned "baby fetal position# once baby bears

weiht! bones will rotate into normal position

• &his does not occur in some people Tarsal -oalition

If Ar&' is 7resent (& flat footed

:


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If Ar&' is NOT 7resent

>. $s 9edial rch presentsufficientG

• Can you et a finer underneath

2. 'valuate patient 7*('! e4amine relationship between forefootand hindfoota. 'valuate %orefoot 3arus3alus

b. 'vaulate Hindfoot 3arus3alus• 3alus eversion

MOST COMMON3>. "indfoot 2ar+s

• Have a lot to move when heel strike occurs to et to pronation

• $t is the 6rate6 that the patient has to pronate that causes the problem patient will have

a tendency to O)*/'O%&T*000

• Hindfoot 3arus will look supinated statistically! but will behave opposite durin motion

"3'*;pronates@@#

2. orefoot 2alg+s

• 5ith %orefoot 3alus! when patient bears weiht ? th and :th diits will not be touchin

• ,ub&alar joint must supinate to et ?th and :th diits down to the round@@ &hus

Hindfoot must be 3arus to allow for %orefoot 3alus to be able to bear weiht@@

Ort'odi&s$% "indfoot 2ar+s

• 9edial post would be placed on heel to prevent pronation@

(% orefoot 2alg+s

• Lateral %orefoot post to eliminate need for Hindfoot 3arus@

In Utero &a+ses of lat oot>. IN9)T*O en;ironment causes

• It has caused bony mal%osition that CANNOT be e$ercised or ad


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• ( need use orthodic )(L',, they are e4periencin symptoms@

S'oe Re&ommendations>. ,hoes 7arts

U77er )pper part of shoe

$% "eel Co+nter

• &he hiher the heel counter! the more cushion 8)& more

predisposition to $nversion sprain@@ 7erson who sprains ankle easy should have a small heel counter

(% 2am7 ; where laces o

*% Toe ?o6

Sole of S'oe

$% Insole

(% Midsolea. )sually made of/

• E2A "for cushion#

• Pol+ret'ene "for durability#

#ual #ensity is a combination of the two.

9ost shoes have this combo@@

b. ften add $* or D'L that is encapsulated

• ,ometimes with a plastic bar

• &his e4tends the life of the shoe@@

c. %L'1$8$L$&+ ,H)L- 8' & &H' 9'&&*,L, NOT T"EMIDOOT"middle of shoe#@@

• $f it bends at 9id;foot! it will predispose person to 7lantar;

fascitis@@@

*% O+tsole

2. Lasts the 9L- of the shoea% Straig't Last9% Semi;&+r0ed Last&% C+r0ed Last


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• %ront is slip;lasted

• 8ack is 8oard;lasted

S'oe Re&ommendations

Pronator

Motion -ontrol $hoe 8oard lasted

,traiht Last

• 8ecause you want a very firm Heel Counter.

• 9id;sole is 6built up6 thus is the H'3$',& shoe@@

• 7ronator cannot be dianosed just from L&'*L shoe wear@

Diagnosti& sign is bule on medial aspect of shoe from pronation@@

Normal B MildPronator

$tability $hoe ,emi;curved last Combination last

S+7inator

-ushion $hoe Curved last ,lip last

1 &I-+T!T of all shoes""

• ,lip last has no board

• Curved last has less 9id;sole@

LAST PRONATOR CASE ; F year old female with flat feet. 5hat should she doG

* Indi&ators for Ort'oti& Re&ommendation in a &'ild/>. verweiht kid2. )nilateral problem. Ner0e Damage – 7osterior &ibial (erve(% Mortons Ne+roma*% Tarsal T+nnel Sndrome

M+s&le A&tions3

>. -orsifle4ion ; L?:2. 7lantarfle4ion ; ,>2


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Stret&'

$% An/le S7rain

• nly if it was an 'version-orsifle4ion injury

• &his would stretch the &arsal &unnel

(% Pronation ; stretches medial ankle

Com7ression

>. &iht shoes

2. ,car &issue. ,urery at knee

• &hat cuts the ,aphenous (erve

Morton:s Ne+roma ; pp. . -orsifle4ion of toes and ankle

• &his will stretch the nerve and make symptoms worse

2. 7alpate for nodule "pea;siBed# and press on nodule@

• ,ee if symptoms et worse@


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$% Ort'odi&s

• &o correct pronationsupination

• -irect paddin to cushion (euroma

(% Lo&al in;2#

(% Ca+sesa. le6or Retina&+l+m compresses &unnel from/

• %rom scar tissue "tihtens *etinaculum#

• &ihtenedstretched from 7ronation "would cause a transient sins and symptoms

while walkin only#

b. "7er7ronation

• Collapses the arch and stretches the nerve

• lso tihtens the %le4or *etinaculum

c. Stret&' Com7ression of &arsal &unnel contents

d. Sstemi& Illness

e. S)elling

f. Ganglion &sts

• (o adjustment or soft tissue work will make this o away

• *eAuires e4cision usually

g. T+mor Gro)t'

h. S+9l+6ation ; These %ossibly cause stretch and com%ression of the ner;e

• Calcaneus

• &alus

*% Testinga. Dorsifle6ion and E0ersion

• ,tretches the nerve because the nerve is behind the 9edial 9alleolus

>0


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b. Com7ression of Tarsal T+nnel

• 8y %le4or *etinaculum

• Can compress only the Lateral or 9edial 7lantar (erve if you compress on nerve

after it bifurcates

c. Tinel:s Sign

• &ap or compression

d. Ne+rologi&al Testing

• *arely positive@

• ,ensory findins are more common than motor findins

1% Treatment3a. &rial of Ort'odi&s andor oot Ad


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a% Tarsal Coalition

• 5hen 2 bones that are supposed to separate - (&@

• %ailure to separate@

• --1 is when there is %O &- in %O%/2*I(T 3*&I%( 'O$ITIO%00

"(ormally! arch should re;appear in the (eutral foot@#

RESTRICTED ROM>. A&ti0e ROM Restri&ted ; see if movement pattern is restricted

a. &estin/

• 9uscle &endon problem pain

• (erve root problem painless

• 7eripheral nerve problem

2. Passi0e ROM Restri&tion ; (on;contractile tissues

• $f patient is 7,,$3' *estricted! most likely they will be C&$3'L+ *estricted as well.

• Can ha;e Acti;e restriction :ithout 'assi;e restriction, but not 'assi;e :ithout Acti;e""

Ca+ses of PROM Restri&tion3

a. Capsular &ihtness

b. 9uscle &endon &ihtness

c. bstruction ; most commonly 8('

• )sually fracture if traumatic! or an ccesory bone8one spur if (on;traumatic

d. $ntra;rticular

• Joint swellin

• 9echanical obstruction "joint mice#

Testing for PROM Restri&tion3>. Post-Isometri& Rela6ation testing ; e.. $&8 stretch that can o farther after an

$sometric contraction

a. $f it increases• Ca%sular tightness

• 3uscle Tendon Tightness

b. (+&H$(D $(,$-' J$(& 5$LL (& $(C*',' *9 5$&H &H$, 7*C'-)*'

• Joint swellin! joint mice! sublu4ation...etc

An/le E6am7les3>. Joint swellin ; ankle sprain

>2


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2. Joint mice ; steochondritis -essicans

st &oe2. 7ain worse when coupled with nkle -orsifle4ion

>


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• $f ( pain is elicited with -orsifle4ion of >st toe! -orsifle4 the nkle

• 5ill et a sharp! lihtenin;like pain across foot@

*% "eel S7+r

• &ension from 7lantar %ascia will cause Heel ,pur to develop

• $s (& the cause of 7lantar %ascitis (* the cause of pain@@

•7ain is due to the tension of the 7lantar %ascia@@

d. Treatment3$% Podiatrist

• rthotics >st

• Cortisone $njections – if pain persists "breaks down tissue can lead to 7lantar

%ascia rippin#

(% C'iro7ra&ti& &are

• Low dye tapin

• Dradual stretchin

• rthotics

• *&9*&

Case (

=@ year old male %atient com%lains of +& 'AIN The %ain remains local to his heel and is feltonl u%on :eightbearing +e has :or7ed in a factory for 8= years that has hard concrete floorsand as a manager he has s%ent uite a bit of time :al7ing the floors

Possi9le Diagnosis$% at Pad Sndrome ; 9ost likely dianosis

a. $s there a firm heel counter in her shoeG

LOOSE 7oorl fitting

"eel Co+nter

• llows Calcaneal fat pad to spread at heel strike

• 7ermits increased transmission of impact to heelIRM )ell fitting

"eel Co+nter

• 9aintains the compactness of fat pad

• 8uffers the force of impact

9% General Information

• %at pad deenerates with ain and therefore is more common in elderly0

• 9ust differentiate between 7lantar %ascitis

&% E0al+ation>. &enderness is decreased with/

a% S4+ee5e test

• ,AueeBe heel and poke on center of heel see if pain oes away

• -onPt sAueeBe and then poke to see if pain is increased

9% In&reased 7adding at 'eel

2. 7ain is at 9$--L' of Heel

• $f pain is at 9edial Heel! it is indicative of 7lantar %ascitis "because 7lantar

%ascia oriinates off of the medial heel#


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• 7at 7ad ,yndrome feels better with

&$DH& %$&&$(D ,H',

• ,AueeBin fat pad around heel will

decrease tenderness

• 3ery unlikely that pain is just localiBed

at the Heel@@@

• ,AueeBin fat pad makes no difference

d% Treatment

$% T+li C+7s• 9imics %at 7ad cushion

(% irm "eel Co+nter

(% Stress ra&t+re

• Hihly more likely in female due to 'stroen levels linked to 8one -ensity

• 'motional or physical stress can throw off menstrual cycles as well as low body fat

• &hus! must ask patient what her menstrual status is@@

Diagnosti& Tests3$% Lateral ,-ra of Cal&ane+s

(% ?one S&an

• $s the definitive tool if there was a neative 1;ray

*% ?one ?r+ise

• %at pad didnIt act to cushion well enouh

• 5ill show a positive ,AueeBe test as well

1% Plantar as&itis

• (ot likely due to localiBed pain

% Psoriati& Art'ritis

• Look for skin lesions

• 8ehind ear! e4tensors surfaces

• Look for localiBed spots

Tests for Sero-negati0e Art'ritides3

• HL;82F

• (

• C;*eactive proteins

• "LL are non;specific#

F% Reiter:s Sndrome

% An/losing S7ondlitis

Case *

8= year old male com%lains of %ain at the bottom of his &T +& +e has not %erformed any

unusual acti;ities and is not in;ol;ed in any s%orts or e$ercise routine +e also has noticed some!I %ain that tends to flair u% occasionally

Possi9le Diagnosis$% Reiter:s Sndrome

(% An/losing S7ondlitis

*% Psoriati& Art'ritis LL involve the ,$J to some deree in some people LL involve H''L to some deree in some

>:


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LL involve ,7$(' to some deree in some

• 7ossible that adjustment could aravate the condition

• 5ould want to tell patient to take some anti;inflammatories to prevent e4cessive

inflammation and aravation of joints

1% Anatomi&al S'ort Leg

• 7ossible that short le would cause more weiht to be forced on lon le side

Case 1

10 year old male %atient com%lains of *I-+T +& 'AIN +e noticed this after landing from ; :#

• Lookin for a rade : due to compression@

• 4ill see some sli%%age or fractures"

Tests/a. 7oint tendernessb. ,AueeBe testc. Lateral and ;7 1;ray

• 5hiter bone 3one necrosis

• 7ossibility of kid havin &vascular %ecrosis

• *adiolucent line Fracture

• %utrient canal looks like a line that is perpendicular line to the Drowth plate

Case

8@ year old male runner com%lains of %osterior heel %ain around the %osterior structures The

%ain is 5orse 5hile running , ho:e;er, :hen he rests or sits for a %eriod of 50 minutes or longer,he notices a shar% increase in %ain and a %erce%tion of stiffness :hen he stands u% and initiallyu%on :al7ing The %ain and stiffness tends to D 5or# itself out E after he :al7s for a minute or so

Possi9le Diagnoses/$% A&'illes Tendonitis ; p. :O;K>

a. General Information

• 1° or 8° !train of Tendon

• rea most affected is 2 cm pro4imal to the Calcaneal insertion

>K


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• rea is surrounded by a 7eri;tendon

• 9ost common with runners and jumpers

-an lose u6 to 789 of &chilles tendon fibers and $TI F+%-TIO% O:000 &he daner with the chilles is that person can operate with 2:E of fibers and feel

fine $t will only take a sliht jar to cause full rupture of this thin band

Thus this is :hy :e can ha;e %artial ru%ture :ithout bad sym%toms and then

e$%erience a sudden ru6ture000

T)o T7es of A&'illes Tendonitis3$% S+9stan&e Tendonitis

• $n the substance of the tendon "not at the insertion point#

(% Insertion Tendonitis

• Located & the insertion site

• 5ill lead to local inflammation! causin *etrocalcaneal 8ursitis later

b. Ca+ses1. ,hock absorption

. Hyperpronation!. Cavus foot4. M+s&les tendon atta&'ing to Cal&ane+s are *ccentrically 5ea#0

• Leads to CH*($C chilles tendon injuries

• 7atient is very painful when he ets up from sittin. ,tiff@@

• Chronic &endonitis with overlap of *etrocalcaneal 8ursiitis

• steoarthritis if older person

c. E0al+ation1. Pal7ation

• $f tender at insertion or a couple of inches above insertion

. S)elling

• 7alpable defects may be found with impendin rupture "often visible#

!. Diagnosti& Ultraso+nd or MRI

• %or suspected partial ruptures

4. C'e&/ for tig'tness of Tri&e7s S+rae gro+7 "'rescribe stretching :hat is tight"a. -o with knee %L'1'-

• &estin ,oleus primarily "takin Dastroc out of it#

• (ot much improvement with knee %L'1'-! mainly Sole+s is tig't@@

b. -o with knee '1&'(-'-/

• &estin LL of the &riceps ,urae roup

• (ot much improvement with knee %L'1'-! mainly Gastro& is tig't@@

8. T'om7son test• %or acute ruptures

d DBD, from Retro&al&aneal ?+rsitis – BOT+ OCC)* IN T+ !A3 !'OT"

>. !earing S'oes/

A&'illes Tendonitis Retro&al&aneal ?+rsitis

• 9akes it feel better

• Dives support

• 9akes it 5*,'@

• 9ore friction on the inflamed 8ursa@

>F


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Treatment$% Conser0ati0e Care

a. *estb. $cec. 9odify activityd. ,tretch portion of &riceps ,urae that is tiht "from testin#e. Plaster &asting into 7L(&*%L'1$(

• llows connective tissue to heal "by reducin stress on tendon#

• H$DH *&' of Mre;tearN if patient is active

f% E&&entri&all s'ortenBstrengt'en A&'illes Tendon

• ,horten with Heel Lift "relieves tension off of tendon#

• 'lastic &apin

• 'ccentrically train &riceps ,urae

E&&entri&all train Tri&e7s S+rae

• &rain on a small 2 1 ? "to adjust depth#

• -o 2 feet first with body weiht

• 9ove on to usin a MstepN

• Lower with ravity >st. $f that does not elicit discomfort

by the . Do up fast into 7lantarfle4ion2. Lower slowly0 "st set non;painful

• 2nd set non;painful

•


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• 9ay proceed to the development of a osseous deformity called "agl+nds Deformit

"e4tra bone formation from irritation of the 8ursa# – p. >: of notes

c. E0al+ation>. Tenderness on 7al7ation *)(- the tendon! not on the tendon

9ust e4amine shoes to see/

• $f they have adeAuate paddin• $f they rub on the heels e4cessively

• $f they are in a constant position of sliht plantarfle4ion where heel rubs on shoe

d. Treatment>. 7ad the area

• &o dissipate forces

• 5ith Mthick mole skinN behind the Calcaneus

2. &apin

• ,ame as chilles &endonitis tapin

O


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TI?IAL ?ONE TUMORS

Malignant

T+mor Lo&ation

steosarcoma • -iaphysis

• 7ro4imal 9etaphysis

'winIs ,arcoma -iaphysis

• $f you think &ibial pain is due to tumor! most commonly the tumor is 9alinant@

?enign

T+mor

>. steoid steoma2. Diant Cell &umor


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• $ncreased pressure in compartment may be acute from blood buildup or chronic due

to e4ercise

ACUTE8uildup of 8L-%L)$-

• (ot common

C"RONIC

'1'*C$,'/• 8lood oin into muscle causin swellin

• %ascia canPt adapt to the swellin "canPt e4pand#

• &his causes compression increases pressure@@

• $ncreased pressure will eventually damage the

muscle000

&% Signs B Sm7toms3>. %ine walkin or liht run2. Continuous runnin increases pressure

• Causes pain

• 7ain radually ets better upon cessation of runnin "takes 20 –


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d% E0al+ation1 "oman:s test ; 'A!!I.&/ #orsifle$ the an7le Not a ;aluable test"

a% S7e&ifi& to a 'os7ital setting

• 5here patients were bed ridden

• $f they tested positive! they knew it couldnPt be muscular because they were

bed;ridden

9% O+tside of 'os7ital• $t would not --1 from a muscle strain

• 9ay be able to differentiate if you do a resisted m+s&le test alon with

HomanPs

8 Do77ler-Ultraso+nd *eAuired to -ianose

e% Treatment>. I2 !arfarin B Co+madin

• %or < ; K months

• 7roloned use will increase chance of bleedin out@

• Contraindicated to adjust due to risk of ,ubarachnoid bleedin post adjustment

"documented@#

2. Later o to ral medications

(% Tennis Lega% Me&'anism of In


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Anterior S'in S7lints"Lateral#

$% M+s&les In0ol0ed

• &ibialis nterior and '4tensors of toes and ankle

(% Ca+ses3

• *unninwalkin on hard surface

• 7oor shock absorption from shoes "shoes worn down#

• $f you strike down hard on foot

*% Treatment Goals

• Have to work e&&entri&all to C(&*L MLowerinN of

foot to round

Posterior S'in S7lints"9edial#

$% M+s&les In0ol0ed

• &ibialis 7osterior and %le4ors of toes and ankle

(% Ca+ses3

• )sually due to Hyperpronation@

• $f you accelerate throuh mid;stance & S)$CL+@@

ACUTE CARE

$% I&e(% S+77ort with 'lastic tape

• pplied in a spiral pattern! upward pattern toward area of tenderness

• &o apply compression towards the 7eriosteal tension

• Can also use *lastic $toc#ing :ith .elcro stra%s

*% Ort'oti&s

• 'specially helpful for 7osterior ,hin splints

1% S'o&/ a9sor9ent s'oes

• nterior ,hin ,plints reAuire this

% In&rease Dietar Cal&i+m

DBD, S'in S7lints from Com7artment Sndrome>. Onset of Pain - 8iest difference between ,hin ,plints and Compartment ,yndrome is

onset of paina. Compartment ,yndrome

• Hits you >0 – >: minutes into the run

• Compartment ,yndrome will only have pain durin activity

b. ,hin splints

• Hurts riht away! feels better later in run

• ,hin splints will have pain in between activity

SNAPPINGBPOPPING "IP PRESENTATIONSCase $

A 8= year old female dancer com%lains of sna%%ing and %o%%ing :ith some discomfort in the*I-+T -*OIN area It seems to be :orse :ith circumduction maneu;ers

>. Sna77ing "i7 Sndrome p. >FFa% General information

• ,nap without pain &endon snap

• ,nap with pain &endon snappin over a 8ursa@

SNAPPING B CLICKING IN "IP3

2?


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Anteriorl

$% Psoas Tendon! snaps over/a. Lesser &rochanter b. $liopectineal eminence

(% Sm7'sis P+9isa. -ue to instability from/

• 7ost partum

• &rauma

Laterall$% Ilioti9ial ?and

a. ,naps over Dreater &rochanter

Posteriorl$% ?i&e7s emoris Tendon

• ,naps over the $schial &uberosity

Ca+ses of "i7 Sna77ing or Cli&/ing>. ,uction effect2. ,ublu4ation


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JC Lau 2002

(% Lo&ation of 7ain

• &o $- tendon that is snappin over the 8ursa

f% Treatment>. ,trenthen muscle of tendon if & L12. djust areas

• &o prevent abnormal stressbiomechanics

Ot'er "i7 ?+rsitis

S+9tro&'anteri&?+rsitis

,ubluteus 9edius bursa,ubluteus 9a4imus bursa

Ilio7e&tineal JIlio7soas?+rsitis

Ilio7soas ?+rsa$% Ca+ses3

• &iht Hip %le4ors coupled with repetitive activity

(% Signs B Sm7toms3

• nterior tenderness at hip! > – 2 cm below middle >< of

$nuinal Liament#

Is&'ial ?+rsitis

$% Ca+ses• -irect blow

• cute or Chronic &rauma

a. %rom proloned sittin on hard surfacesb. Horseback ridin

(% Sm7toms

• '4tension of knee! which rotates the $schial &uberosity away

from the sittin surface

• Local tenderness over $schial &uberosity

Case *

A 1= year old hurdler had an in


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JC Lau 2002

b. ccurs most often at Myofascial @unction of &dductor Magnus

• -ue to sudden contraction of the dductors from a stretched position of H$7

8-)C&$( or %L'1$(

(% Signs B Sm7tomsa. *eports a sudden pullin sensation in the roin that was in&a7a&itating

b. -ifficulty in bearin weihtc. 3ery painfuld. ,evere injury may affect the ,ymphysis 7ubis

*% E0al+ationa. Dis&rete tenderness at

• dductor 9uscle roup

• 7ubic attachment

b. Resisted Add+&tion

• ,harply increases the pain or discomfort

1% Treatmenta. ig+re S+77orti0e Ta7ing

• 9ore anle so it pulls Minwards@N

b. Gentle stret&'ing

c. Slo) ret+rn to a&ti0it

• 8ecause it will take a lon time to heal

• 9inimal stretchin to avoid over;tearin

• ,tretchin is reAuired however to prevent healin in a MshortenedN position

Case 1

A 8= year old bicyclist com%lains that he has sna%%ing in the B)TTOC! area e;erytime hee$tends his &-

$% Sna77ing "i7 Sndrome

Posteriorl $% ?i&e7s emoris Tendon• ,naps over the $schial &uberosity

Ca+ses of "i7 Sna77ing or Cli&/ing>. ,uction effect2. ,ublu4ation


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JC Lau 2002

Ca+ses of "i7 Disorders3

Tra+ma>. %racture2. ,prain. veruse

2. $nfection. Stress fra&t+re "at %emoral neck# p >>a% General Information

• %ound more with join and aerobics

• ,he is at the riht ae and runs enouh to et it

9% T7es of "i7 Stress ra&t+res/>. S+7erior Trans0erse T7e "&ension#

• Considered unstable

• 9ay need pinnin

2. Inferior T7e "Compression#

&% Ca+ses3>. veruse2. steoporosis or 7oor bone status

• mennorheic patients

• Hih level athlete

• Low body fat

d% Signs and Sm7toms/>. Droin pain and $nuinal pain

• FE report this@

• %rom a stress fracture at the %emoral neck

• 9ay not be visible on 1;ray

2. -iscomfort at the e4tremes of Hip rotation

• Heel percussion is not a ood test in this case

e% E0al+ation$% "istor/

a. -iet ; intake of Calciumb. 9enses

(% ,-ra

• ,tress fracture at %emoral neck may not be visible on 4;ray unless there is Callus

formation

• &akes < ; ? weeks to develop

*% ?one S&an

• -efinitive -4@@

2


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JC Lau 2002

f% Treatment$% ?ed ; rest

• %or severe cases

(% Non-)eig't 9earing )it' &r+t&'es

• %or less severe cases

*% Pool )al/ing• %or *ehabilitation

2. Add+&tor Strain

• nother possible dianosis

• -1 with *esistive 9uscle test for dductors

Case (

A ?= year old female %atient com%lains of %ain in her +I' that is getting strong enough that shenotices lim%ing !he #I# NOT fall on the +I' !he says the %ain is dee% and bothers hersometimes at night

$% Osteoart'riti& "i7

a% Signs Sm7toms• 7ain is worse on weihtbearin

• 7atient demonstrates an 8ductor lurch or Auick step off pattern "Auickly step off of

painful side#

• s *9 is lost! a shufflin ait is seen

9% General Information

• *9 is lost in a seAuence with rotation first affected "$nternal first#! followed by

%L'1$( and 8-)C&$( later

Pre-ris/ fra&tors for OABDD3>. Conenital hip dysplasia2. Conenital hip dislocation


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JC Lau 2002

(% Lateral "eel Lift

• $f there is a decrease in 9edial Joint space

*% Posterior Ti9ial Ad0 ; >:E of elderly patients• 9ay be asymptomatic

• 7ossibly due to a slow virus

*% T+mor

• 7ain wakin at niht

• History of cancer

• Cache4ia

Case *

'arents of a 10 year old boy ha;e noticed that their son is starting to lim% he has notcom%lained of hi% %ain, ho:e;er, he has told them that his 7nee hurts

$% Legg;Cal0e-Pert'es ; p >Fa% General Information

• vascular necrosis that is $diopathic@

• vascualr necrosis of %emoral head with associated subchondral fracture "$diopathic#

• )sually vascular necrosis is due to &rauma or ,lipped Capital 'piphysis! but in this

case! it is idiopathic in nature

9% Signs and Sm7toms

• 5hen kid has knee pain! always check the hip

>. Chronic limp

• 5ith minimal pain

• 9ade worse with activity

2. 7ain refers to knee

• ids with knee pain 9),& have hips evaluated@@

• 9ay be fle4ionadduction contracture

&% E0al+ation$% ,;ra

• Later staes seen

• 5hen vascular necrosis occurs! bone death occurs

• 8one will row aain! but it is weaker 6Mushroom sha6e6

• -eforms

(% M%R%I

• 8est seen with this method

d% Treatment>. 8racin

2. ,urery voidin trauma to hip is the main treatment oal

&ry to take stress off hip to prevent acceleration of disease

(% Transient Sno0itis of "i7


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JC Lau 2002

• ,ee ne4t case

Case 1

A 18 year old boy :ho is =H 10 com%lains of a sudden onset of hi% %ain that is bad enough thathe is not able bear :eight on the in;ol;ed side

>. Sli77ed Ca7ital E7i7'sis p. >?a% General information

• 7roressive or sudden 7,&'*$*$(%'*$* slippae of the %emoral 'piphysis

• ccurs between aes of ; >2

• 20 ; 2:E occurs bilateral

( T7es3>. S+dden ; traumatic induced

• :0E

2. Progressi0e "without any trauma#

• :0E

• 5ill be able to walk on it for awhile

( ?od t7es )ill 9e e0ident3$% &all! rapidly rowin adolescent

(% ro'li& Sndrome

• &oo many female hormones

• Dynecomastia

9% E0al+ation$% PASSI2E LE,ION of "IP

• &ends to '4ternally rotate

(% Radiogra7'i& e0iden&e ; ;7 and %ro le views reAuireda. ; 7 view

• $nferior slippae is seen on to 7

b. %ro le Lateral for Hip

• 5ill show 7osterior slippae

• 9ost of the displacement is seen 7ostierorly! thus %ro le is best@

&% Treatment/$% S+rgi&al &ons+lt

• 9inimal slippae is often 67inned6

(% DO NOT ADUST

• $f you try to adjust it back in! you 5$LL C),' vascular necrosis@

• 9ust pin it back

2. Transient Sno0itits of t'e "i7 ; p. >FOa% General information

• Caused by trauma/

>. %all2. -irect blow

• $nfective

• )sually &*(,$'(&• However! proloned course may indicate impendin Le;Calve;7erthes

9% Signs Sm7toms

• ,evere pain in Hip and Droin

• $nability to bear weiht

&% E0al+ation$% ?one S&an


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JC Lau 2002

(% CT S&an

• 8one scan and C& may help dianose! but main way is lookin for sins of

infection*% LOOK OR SIGNS O INECTION

• 8i distinction between this and other hip disorders is that you are lookin for

sins of infection@

• )nable to bear :eight, recent infection, fe;eretc

d% Treatment

• 9ust be aspirated

• &reated with $3 ntibiotics