Study Guide Questions: 9.

The questions for this week will focus on a case study that will require
students to formulate a series of questions in the history and complete
the table below with details to assist you with your diagnosis for this
patient, similar to Table 11-16 from Magee D, Orthopedic Physical
Assessment, 6th Edition (2014), page 759- 759 provided as an exemplar

Using the precis of hip assessment as shown below create your own differential
diagnosis and management plan for a 45 year old male patient brought in for
assessment. He walks with a limp and complains of anterior hip and buttock pain
after his weekly soccer game that is becoming incresingly worse throughout the
season.

Differential Diagnosis of Hip OA Osteoarthritis verses FAI Femoral Acetabular

Impingement
Differential Diagnosis Femoral Acetabular Impingement and Osteoarthritis
FAI
History Questions Where is the Pain, can you feel it
into the groin?
Is there pain on squatting?
Is there pain when you run or
changing direction?
Is there pain when sitting for
longer periods of time?
Do you have any pain in the groin
area?
Observations How do they walk, are they
limping?
Active Movements Reduced flexion, internal rotation
OA
Do you have stiffness in
the morning (30mins)?
Any pain during the
night?
Any pain when you lay on
your side?
Is it difficult to go up and
down stair?
Does anything worsen
your pain?
Have you had any
accidents previously?
Does your family have
any history of arthritis?
Have you had your blood
checked recently?
Antalgic gait. Short stride.
Reduction in all directions
Passive Pain in Flexion Pain in internal and
Movements external rotation

Resisted Isometric Weakened/can pain occur Restricted

Movements
Special Tests Scours, Patrick fabere test Patrick Fabere test,
Yeomans, Sign of
buttock, scours, craigs
test
Sensation L1, L2, S3, S4 L1, L2
Reflexes na na
Joint Play Painful movement through joint Reduced motions
Movements play

Diagnostic Different signs (CAM and Pincer) Reduction in join space,

Imaging osteophytes

Management Plan:

Life style factors if they are active or need to diet ect.

Reduce weight bearing exercises (pool exercises going through ROM)
Mobilization, manipulation, TrP work though ST, PNF stretches.
Case Study 3

Robert is a 30-year-old solicitor.

Presenting Complaint

Robert complains of right hip pain.

History of Presenting Complaint

There has no previous history of hip pain, and his medical history is unremarkable. He
reports a gradual onset of pain that started approximately two months ago and is now
felt more often, whereas before he would feel it only when lying down on his right side.
Robert, unfortunately, cannot recall any incident that may have caused his hip pain.
He rates it at a level of 5/10, describing it as being very sore and tender.

He also mentions that he occasionally gets pain in his right shoulder, which is not
related to movement or physical activity. This shoulder pain has been present for
about six months.

Physical Examination

Robert walks into your office with no visible limitations.

Active right hip ROM: 30 degrees of abduction with pain, 20 degrees of external
rotation with pain. All other ranges of motion of the right hip are normal.

Lumbar ROM: Flexion is reduced by 50% due to hamstring tightness. All other
movements are unremarkable.

Muscle strength: 4/5 on the abductors and external rotators; other muscles are
normal.

Patrick Fabere test is negative

Right Sign of Buttock test reproduces the pain in the right hip

Right Ober’s test reproduces the pain in the right hip.

Palpation: Robert exhibits increased tenderness on the right greater trochanter with
slight tenderness on the middle portion of the buttock on the right side.

Shoulder examination: Unremarkable. Pain cannot be reproduced during your

consultation.

1. List the statements (clues) in the case history that aligns with the diagnosis of
hip pain. Use the script concordance.

- Iliotibial Band Tightness +1

 - Glut max muscle strain +1
- OA -2
- SIJ issue 0
- Trochanteric bursitis +2

2. The above case history is incomplete. What further questions or what

information would you need to acquire?

- Previous Treatment and how effective was that treatment?

- Does it radiate to another part of the body?
- Is there anything I need to know about your previous medical history?
- Have you had any MVA
- Does anything relieve or aggravate the pain?
- Can you point to where you have pain?
- Does the pain come and go?

3. Based on the given information from the case history and physical examination,
do you think Robert has a hip problem, facet syndrome or muscle strain? Give
reasons for your answer.

- Hip pain because he has had the problem for longer than 2 months, pain
when laying on the side. Positive pain of the buttock.

4. For the above case history alone, give 3 possibilities (differential diagnoses) for
his hip pain. Explain each answer.

- Glute muscle strain

- Trochanteric bursitis
- SIJ disorder

5. Your colleague thinks that Robert as an ischiogluteal bursitis (weaver’s bottom).

Do you agree with your colleague?

No as there is only slight tenderness around the buttock, most pain around
trochanter. Although weavers aggravated by long amounts of sitting they can’t
sleep on the hip and patient experiences this

6. Using the information from the above case history and physical examination,
what is the more likely diagnosis for

i. His hip pain – Trochanteric bursitis

ii. His shoulder pain – requires more questions
Case Study 4

Joey is a 45-year-old computer programmer

Presenting Complaint:

Joey presents to your office with right low back pain which occasionally radiates into
the right buttock.

History of Presenting Complaint and Onset: The pain had been present for three
weeks. It started one day after he played a game of golf. He has no history of back
pain, and he denies any medical history of significance. X-rays are unremarkable.

Aggravating Activities

Running, prolonged fast walking of more than a mile. When the symptoms are at its
worst, he is unable to stand or walk without pain. Joey also finds it difficult to stand
from a seated position. When the pain is present, he is unable to sleep, waking him
as he rolls over in bed.

Physical Examination

Observation: Standing on the right foot reproduced his pain in the right low back
area. He also has a right flat foot.

Trunk extension was full range but reproduced his pain. All other movements were
pain-free and full range.

Neurological: Unremarkable.

SLR: Full range but mildly painful in the right low back at 70 degrees.

Nachlas and Ely’s: Unremarkable

Lumbar Compression/distraction: Unremarkable.

Standing on the right leg only reproduced the pain in the right low back however, if
the sacro-iliac joints were supported (as in supported Adams or the belt test) the pain
disappeared.

NB If the question incorporates ‘Based on the information in the case history and/or
physical examination’ assume that all other tests are unremarkable.

1. List the statements (clues) in the case history that aligns with the diagnosis
sacro-iliac pain. Use the script concordance.

- SIJ disfunction
- Muscle sprain/strain
 - Facet issue
- Bursitis

2. The above case history is incomplete. What further questions or what

information would you need to acquire?

3. Based on the given information from the case history and physical
examination, do you think Joey has a sacro-iliac problem, hip problem, facet
syndrome or muscle strain? Give reasons for your answer.
SIJ issue due to
4. For the above case history alone, give 3 possibilities (differential diagnoses)
for his back and buttock pain? Explain each answer.
Facet – KEMPS, Prone springing, Slump
SIJ - SIJ compression test. Galstens test, Supported adams, hibbs test
Trochanteric bursitis – Obers test, scour test
5. What other tests would you like to perform?
6. Joey presents with the x-ray below: Would this change your diagnosis?

- Change treatment, blocking and mobilization.