Approach to Hip Region Pain Physical Exam – Stanford Medicine 25

Approach to Hip Region Pain Physical Exam – Stanford Medicine 25

my name is dr. ball deep Singh and I’m an internist here at Stanford and today we’re going to talk about the physical exam and the differential diagnosis as it relates to pain in the hip region next we’re going to ask the patient where the pain is using the finger rule asking the patient to use their finger describe where the pain is focusing on three key areas the anterior the lateral area and the posterior area Steve is here to help us with our demonstration today and we’re going to show you that again by demonstrating here again having the patient focus is the pain here in the interior area in the front of the leg the lateral aspect or side of the leg or the posterior area or back of the leg it is really helpful to organize this pain into three locations anterior lateral and posterior anterior true anterior hip pain suggests pain within the hip joint this includes many diagnosis such as osteoarthritis neck fracture acute or septic arthritis femoral acetabular syndrome and avascular necrosis Morrall Chaparro stetic have presents with a superficial burning in the upper outer thigh and it sometimes initially confused with thigh pain lateral the differential for lateral hip pain includes greater trochanteric bursitis and external snapping hip by far greater trochanteric bursitis is the most common diagnosis with lateral pain posterior posterior pain includes radiculopathy radiating to the hip sacroiliac joint pathology and piriformis syndrome next I’ll demonstrate how to perform the examination for these diagnoses starting with the anterior hip we’re going to focus on a few key tests to help us differentiate if the pain is identified in the anterior region starting with the log-rolling test log-rolling test is quite helpful if we suspect a hip fracture whereby if the patient is becoming in the bed we can move the leg or roll the leg like a log back and forth trying to elicit pain at the hip area we can further confirm that with the compression test first by having the patient fully extend the leg and hitting down the leg the length of the leg tapping on the knee again also causing discomfort if there is a fracture at the hip anteriorly and finally laterally if that is all negative and we are convinced that there is no hip fracture then we would proceed with range of motion whereby we put the patient’s leg in full extension here where we’re going to at 45 degree angle externally and internally rotate the leg to about 45 degrees if we see severe limitation that is very suggestive of pathology within the joint itself such as seen in osteoarthritis finally we conclude by putting the patient in the extremes of range of motion if the patient elicits pain with this provocative test it is very suggestive of a labral injury finally if the patient complains more of thigh pain it may suggest the diagnosis of Morales appears dedica in which case the patient will have burning across the top of the thigh and an exam will have demonstrated decreased sensation next we move the patient to the lateral side in this position to assess for pain on the lateral aspect of their hip there are a couple things we’d like to focus on one is greater trochanteric bursitis where the patient will have pain over the greater trochanteric area so by palpating on this area directly if you’re able to elicit pain it is very suggestive of this diagnosis next we want to look at the diagnosis of snapping hip where the i-b tendon may be causing pain as it’s snaps back and forth over the greater trochanteric area to do that you’ll grab the entire leg and move it back and forth flexion and extension looking for a popping or pain elicit at this site thereby confirming the diagnosis of a snapping hip finally we end on posterior pain one of the chief causes of posterior hip pain is lumbar radiculopathy we would like to refer you to our Stanford 25 video on low back pain for that portion of the exam next we’d like to focus on the possibility of pain at the SI joint or sacroiliac joint to do that we do what’s called a Faber test Faber actually stands for flexion abduction and external rotation once the patient is in this position we place pressure over the knee and try to elicit pain in the posterior area finally we’d like to focus on another diagnosis which is para forma syndrome the piriformis muscle is the top of the buttock and can sometimes compress the sciatic nerve thereby causing posterior buttock pain or hip pain or also can simulate radiculopathy as we’ve seen in our low back videos to elicit this we will try to do two provocative tests to help us one is we can fully flex the leg all the way up to about 90 degrees at that the point if the piriformis is fully activated it may cause symptoms in the buttock area then if there’s any pain in this area we may want to bend the knee and put the knee across the body of the patient holding the hip and place to try to stretch that piriformis muscle and fully compress the sciatic nerve if that elicits pain it can be very suggestive of para formas syndrome this concludes our video on the approach to hip pain I would like to thank Steve for helping us with the demonstration today for further videos on other parts of the exam go to our Stanford 25 website the preceding program is copyrighted by the Board of Trustees of the Leland Stanford junior University please visit us at you


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