Hip bursae There are multiple bursae that surround the greater trochanter of the lateral hip and function to reduce friction between the bony greater trochanter and the overlying large hip stabilizer muscles of the gluteus maximus, gluteus medius, and gluteus minimus. Clinically, these bursae are collectively referred to as the greater Anatomical range of motion Normal hip joint passive range of motion (PROM) is 120º of flexion, 15º of extension, 60º of internal rotation, 90º of external rotation, 45º of abduction, and 30º of adduction, according to the seminal research by James Cyriax, MD (Cyriax, 1982). However clinically there can be considerable variation of these ranges. Considering the available PROM on the unaffected hip can be an optimal way to assess expected outcomes. Patients with OA of the hip joint can demonstrate restricted PROM due to adaptive shortening of the joint capsule and ligamentous structures. The adaptive shortening frequently occurs when an individual who has pain in certain ranges of hip motion avoids
trochanteric bursae. In addition to the greater trochanteric bursae, the iliopsoas and ischial bursae can become inflamed postoperatively where compression of these bursae can occur when limited muscle flexibility occurs, compressing the bursae.
these motions and thus does not extend the collagen of the joint capsule or ligaments. Frequently a loss of internal rotation of the hip is first noticed with this adaptive shortening (Cibulka et al., 2009). The closed-pack position of the hip joint is full hip extension with slight abduction, which helps position the femoral head closely into the acetabular socket due to maximal ligamentous tension. With the hip orientated in 30º of flexion, 30º of abduction, and slight external rotation, it is considered to be in an open-packed position, where there is the least ligamentous tension.
THE PHYSICAL THERAPIST’S ROLE IN DIFFERENTIAL DIAGNOSIS
The scope of practice of physical therapists is rapidly changing in the United States, with more states legalizing direct access to PT services (Ojha, Snyder, & Davenport, 2014). With this movement to physical therapists becoming first-line healthcare providers comes the responsibility of the physical therapist in being able to determine the appropriateness of a patient’s suitability for PT services (George et al., 2015). Therefore, when a patient presents with pain in the hip region, it is important that a thorough history and physical examination is completed to determine the potential source of the patient’s symptoms. Because an individual with hip pain may present directly to a physical therapist, it is important for PTs to be able to recognize various potential causes of hip pain in order to determine when to treat and when to refer. This information will be particularly relevant for physical therapists working with patients preoperatively as well as postoperatively. The physical therapist must be able to select appropriate tests and measures with suitable reliability, validity, and sensitivity in order to make sound clinical decisions when evaluating patients with hip pain. Symptoms experienced in the region of the hip can arise from a number of anatomical sources, not exclusively the hip joint. When examining a patient presenting with hip pain, it is important to consider whether the symptoms might be nonmusculoskeletal in nature. The physical therapist must be able to recognize clusters of symptoms or red flags that suggest a nonmechanical source of symptoms, which would warrant referral back to the physician. Common intra-articular hip conditions Patients presenting with hip OA frequently report a gradual onset of symptoms. There can be a deep ache in the groin or anterior thigh, and occasionally the symptoms will extend to or be felt in and around the knee joint. The pain is typically worse with weight- bearing activities. In addition to the symptoms of pain, patients frequently report stiffness, in particular after sitting (Wilson & Furukawa, 2014). Morning stiffness can also be of significance if it lasts for 60 minutes or longer (Cibulka et al., 2009). Examination of the hip will frequently expose range of motion losses. Where loss of motion occurs in all three planes of motion (sagittal, frontal, and transverse), this increases the likelihood of hip OA (Birrell et al., 2001). Early and mid-stage hip OA may respond to PT interventions, but frequently end-stage hip OA does not respond with conservative means and warrants further work up for a THA. More THAs are performed as a result of OA than any other diagnosis (Shan, Shan, Graham, & Saxena, 2014). The radiograph in Figure 5 depicts the changes seen in hip OA with reduced joint space and irregularities of the joint surfaces.
When the history does point to a mechanical problem of the musculoskeletal system suitable for PT intervention, then it must be determined if the source of the symptoms is coming from the hip joint (intra- or extra-articular) or from the lumbar or sacroiliac regions (de Schepper et al., 2013). It is not uncommon for pain to be referred to the hip from the lumbar spine or from the pelvis (Wilson & Furukawa, 2014). The use of range of motion testing and passive accessory intervertebral glides can help identify whether the lumbar spine is the source of the symptoms experienced in the hip. In the case of the pelvis and the sacroiliac joints, the use of the cluster of provocation tests proposed by Laslett currently provides the strongest evidence for the source of the symptoms coming from the pelvic joints (Laslett, Aprill, McDonald, & Young, 2005). The four tests that comprise this cluster are the compression test, thigh thrust test, the distraction test, and the sacral thrust test. When the source of the symptoms is from the hip joint, knowledge of frequently presenting hip pathologies allows the therapist to determine whether the patient should be referred to another medical provider for additional investigation. This can be the case with advanced degeneration of the hip joint such as in OA and in particular if the patient fails to respond to a short course of PT interventions. Although there are multiple pathologies of the hip that could be potential sources of a patient’s symptoms, a few of the most frequently seen clinically are hip joint OA, acetabular labral tears, femoroacetabular impingement, and greater trochanteric pain syndrome (previously referred to as trochanteric bursitis).
Figure 5: Radiograph Showing Hip Osteoarthritis
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