differential dx of lumbar spine, pelvis &...

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Differential Dx of Lumbar Spine, Pelvis & Hip

Michael Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS

Assistant Professor - Duke University PT Duke University Medical Center

Differential Diagnosis of Lumbar Spine, Pelvis, and Hip

Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS

Assistant Professor

Duke University Medical Center

Cross Country Education

Leading the Way in Continuing Education and Professional Development. www.CrossCountryEducation.com

To comply with professional boards/associations standards:

• I declare that I or my family (do, do not) have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship. •Requirements for successful completion are attendance for the full session along with a completed session evaluation form. •Cross Country Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.

Objectives

• 1. Using an algorithm, evidence based approach, be able to describe a systematic approach to evaluation of the lumbar spine.

• 2. Using an algorithm, evidence based approach,

be able to describe a systematic approach to evaluation of the pelvis.

• 3.Using an algorithm, evidence based approach,

be able to describe a systematic approach to evaluation of the hip joint.

Property of Michael Reiman, PT; please do not reproduce without permission

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Diagnostic Accuracy

4

True positive a False positive b

False negative c True negative d

Pathology

Present (+) Absent (-)

Test (+)

Test (-)

Sensitivity (Sn) = a/(a+c)

Specificity (Sp) = d/(b+d)

(+) LR = Sn/(1-Sp)

(-) LR = (1-Sn)/Sp

SpPin SnNout

Sensitivity

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• The proportion of people with the target disorder who have a positive test

• For a test to be useful in ruling out a disease, it must have a high sensitivity.

Specificity

6

• The proportion of people without the target disorder who have a negative test

• For a test to be useful at confirming a disease, it must have a high specificity.


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(+) Likelihood Ratio

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• sensitivity / (1 - specificity) or a/(a + c) / b/(b +d) • The LR of a positive test tells us how well a

positive test result does by comparing its performance when the disease is present compared with when it is absent

• The best test to use for ruling in a disease is the one with the largest likelihood ratio of a positive test.

(-) Likelihood Ratio

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• (1 - sensitivity) / specificity or c/(a + c) / d/(b + d) • The LR of a negative test tells us how well a

negative test result does by comparing its performance when the disease is absent compared with when it is present

• The better test to use to rule out disease is the one with the smaller likelihood ratio of a negative test.

How much do LRs change disease likelihood?

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LRs > 10 or < 0.1 Cause large changes

LRs 5 - 10 or 0.1 - 0.2 Cause moderate changes

LRs 2 - 5 or 0.2 - 0.5 Cause small changes

LRs < 2 or > 0.5 Cause tiny changes

LRs = 1.0 Cause no change at all

Sackett, D. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. (CD-ROM) Churchill Livingstone, 2000.


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Likelihood Ratios

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(+) LR Explanation (-) LR

1 – 2 Alters posttest probability of a diagnosis to a minimal degree .5 – 1

2 – 5 Alters posttest probability of a diagnosis to a small degree .2 - .5

5 – 10 Alters posttest probability of a diagnosis to a moderate degree .1 - .2

> 10 Alters posttest probability of a diagnosis significantly and almost conclusively

< .1

Concordant Sign/Response

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• An activity or movement that provokes the patient’s ‘familiar sign’ (the pain or other symptoms identified on a pain drawing and verified by the patient as being the complaint that has prompted one to seek diagnosis and treatment.)

Discordant Pain Response

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• A finding that may be painful or abnormal, but not related to the concordant sign as the

“discordant pain response”.

Cook C. Evidence based orthopedic manual therapy. Upper Saddle River:Prentice Hall; 2007.


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Clinical Reasoning

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• Each component of the clinical exam is a “test” with its own ability to shift probability

– History

– ROM

– Muscle performance

– Assessment of function

• Special tests

Clinical Reasoning in GP’s

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• A major cause of misdiagnoses is failure to properly integrate clinical data.

Groves et al. The clinical reasoning characteristics of diagnostic experts. Med Teach. 2003; 25(3):308-13.

Clinical Reasoning of Pain

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• Results showed a dynamic, multidimensional nature to the therapists' clinical reasoning, which was found to be grounded in a number of established models of pain – (i) biomedical, (ii) psychosocial, (iii) pain

mechanisms, (iv) chronicity and (v) irritability/severity

Smart K, Doody C. The clinical reasoning of pain by experienced musculoskeletal physiotherapists. Man Ther. 2007; 12(1):40-9.


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Pain Generator? Bogduk et al,

1995

• 39% Discogenic

• 15% Facet

• 13% SIJ

• 33% Undefined

Laslett & April 2003

• 65% Discogenic

• 15% Facet

• 7% SIJ

• 13% Undefined

Depalma et al. 2011

• 42% Discogenic • 31% Facet • 18% SIJ

Schwarzer et al. Spine. 1995

• Disc: 39% • Facet joint:

15% • SIJ: 13%

Sembrano & Polly. Spine 2008

• 65% spine only • 17.5% Spine and Hip/SIJ • 8% Hip/SI and no spine at all • 10% ??? • Overall, 12.5% had hip pathology and

14.5% and SIJ

Ugh!

• There are numerous pain generators of L spine; many are clinically difficult to isolate secondary to convergence

Bogduk N, et al. A universal model of the lumbar back muscles in the upright position. Spine. 1992;17(8):897-913.

Treatment Based Classification


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• 25.2% did not meet the criteria for any subgroup

• 49.6% met the criteria for only one subgroup

• 25.2% met the criteria for more than one subgroup

• Most common combination of subgroups was manipulation + specific exercise (68.4%)

• Reliability of the algorithm decision was moderate (kappa=0.52)

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TBC

Stanton TR, Fritz JM, Hancock MJ, et al. Evaluation of a treatment-based classification algorithm for low back pain: a cross-sectional study. Phys Ther. 2011;91(4):496-509.

Rule OUT Lumbar Spine

Imaging

• Absence of degeneration on MRI was the only test found to reduce the likelihood of the disc as the source of pain: –LR = 0.21

Hancock MJ, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007; 16:1539–1550.


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Imaging

• No correlation with pathology on imaging and symptoms

• L – Spine Weber U, Maksymowych WP. Am. J. Med. Sci. 2011.; Carragee EJ, et al. Spine (Phila Pa 1976). 2000.; Carragee E, et al. Spine J. 2006.; Jensen MC, et al. N. Engl. J. Med. 1994.; Borenstein DG, et al. J. Bone Joint Surg. Am. 2001.; Maus T. Phys. Med. Rehabil. Clin. N. Am. 2010.; Modic MT, et al. Radiology. 2005

• Hip Silvis ML, et al. Am. J. Sports Med. 2011.; Jung KA, Restrepo C, et al. J. Bone Joint Surg. Br. 2011; Gerhardt MB, et al. Am. J. Sports Med. 2012;

Hartofilakidis G, et al. J. Bone Joint Surg. Br. 2011

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Modic et al. Radiology. 2005

• MR imaging does not appear to have a measurable value in terms of planning conservative care

• Patient knowledge of imaging findings does not alter outcome, may be counterproductive and is associated with a lesser sense of well-being

Patient Hx. Considerations

Sciatica due to disc herniation

• Pain below knee (Sn 90%) (Vroomen et al. J Neurol. 1999)

Stenosis

• No pain when seated: (Sp 93%) (Katz et al. Arthritis Rheum. 1995)

• Symptoms improved seated: (Sp 83%)(Katz et al.1995)

• Best posture: sitting (Sn 89%) (Fritz et al. J Spinal Disord.

1997)

• Worst posture: stand or walk (Sn 89%) (Fritz et al. J

Spinal Disord. 1997)


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Patient Hx. Considerations

Facet Joint

• Pain reduced with recumbancy (Sn 89%) (Revel et

al. 1992; Revel et al. 1998)

• Rest of Revel’s criterion lack sufficient evidence

Hancock MJ, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007; 16:1539–1550.

Radiculopathy/Discogenic signs and symptoms

Reflexes, Myotomes, Sensation • Babinski (UMN): SN 80%, SP 90%, QUADAS 7 (Berger JR, Fannin M. The “bedsheet”

Babinski. South Med J. 2002; 95(10):1178-1179.)

• Achilles DTR: SN 87%, SP 89%, QUADAS 7 (Kerr RSC, Cadoux-Hudson TA, Adams CBT. The

value of accurate clinical assessment in the surgical management of the lumbar disc protrusion. J Neurol Neurosurg Psychiatr.

1988;51:169-173.)

• Extensor Digitorum Brevis: SN 14%, SP 91%, QUADAS 8 Stankovic R, Johnell O,

Maly P, Willner S. Use of lumbar extension, slump test, physical and neurological examination in the evaluation of patients with suspected herniated nucleus pulposus: a prospective clinical study. Man Ther. 1999;4(1):25-32.

• Myotomal Testing (L3-S1): SN 0-28%, SP 100%, QUADAS 7 (Kerr et al. 1988)

• Sensation (light touch, sharp/dull): SN 50%, SP 100%, QUADAS 8 Peeters GG, Aufdemkampe G, Oostendorp RA. Sensibility testing in patients with a lumbosacral radicular syndrome. J Manipulative Physiol Ther. 1998;21:115-128.

• Combined Testing (sensory, weakness, reflexes) SN 12%, SP100%, QUADAS 6* Lauder T, Dilingham T, Andary M, Kumar S, Pezzin L, Stephens R. Predicting electrodiagnostic

outcome in patients with upper limb symptoms: are the history and physical examination helpful? Arch Phys Med Rehabil. 2000;81:436-441.

Radiculopathy/Discogenic signs and symptoms

Range-of-Motion • Centralization/Peripheralization 5-20 reps

– SN 92%, SP 64% QUADAS 12 (Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine. 1997;22(10):1115-1122.)

– SN 40%, SP 94% QUADAS 13 (Laslett M, Oberg B, Aprill CN, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine J. 2005;5(4):370-380.

• Extension Loss – SN 27%, SP 87%, QUADAS 10 (Laslett M, Aprill CN, McDonald B,

Centralization as a predictor of provocation discography: a study of clinical predictors of lumbar provocation discography. Eur Spine J. 2006;1-12.)


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Radiculopathy/Discogenic signs and symptoms Special Tests

• Straight leg raise test – SN 97%, SP 57%, QUADAS 10 (Vroomen P, de Krom M, Wilmink J,

Kester A, Knottnerus J. Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. J Neurol Neurosurg Psyciatry. 2002;72:630-634.)

• Slump test – SN 83%, spec 55%, QUADAS 11 (Stankovic R, Johnell O, Maly P,

Willner S. Use of lumbar extension, slump test, physical and neurological examination in the evaluation of patients with suspected herniated nucleus pulposus: a prospective clinical study. Man Ther. 1999;4(1):25-32.)

• Well-Leg Raise – SN 24%, SP 100%, QUADAS 7 (Kosteljanetz M, Bang F, Schmidt-

Olsen S. The clinical significance of straight leg raising (Lasegue’s sign) in the diagnosis of prolapsed lumbar disc. Spine. 1998;13:393-395.)

Mobility

• PA’s (useful to identify impaired segment)

– SN 43%, SP 95%, QUADAS 12 (Fritz JM, Piva S, Childs J.

Accuracy of the clinical examination to predict radiographic instability of the lumbar spine. Eur Spine J. 2005;14(8):743-50.)

Rule OUT Pelvic Girdle


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Pelvic Girdle Diagnosis

• Signs and symptoms

• Special Testing

– Static anatomical position

testing

– Motion palpation testing

– Pain provocation testing

Static Anatomical Position Testing

• Palpation of Sacral Sulcus, Pubic symphysis, ASIS, and iliac crests to detect differences from side to side

• Multiple studies have concluded caution should be used if performing these tests during assessment

Motion Palpation Testing

• “Motion of the SIJ is limited to minute amounts of rotation and of translation suggesting that clinical methods utilizing palpation for diagnosing SIJ pathology may have limited clinical utility.”

• Multiple studies have concluded caution should be used if performing these tests during assessment

Goode et al. Three-Dimensional Movements of the Sacroiliac Joint: A Systematic Review of the Literature and Assessment of Clinical Utility. JMMT. 2008; 16:25–38.


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Goode et al. Three-Dimensional Movements of the Sacroiliac Joint: A Systematic Review of the Literature and Assessment of Clinical Utility. JMMT. 2008; 16:25–38.

Anatomic Landmark and Motion Testing

• Gillet’s (+LR 1.2)

• Long sit test (+LR 1.13)

• Standing Flexion Test (+ LR 0.81)

• Standing ASIS Asymmetry > 3mm (+LR 0.94)

• Standing PSIS Asymmetry >3mm (+LR 1.11)

• Seated PSIS Asymmetry >3mm (+LR 0.88)

Levangie P. Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain. Phys Ther. 1999; 79:1043-1057.

Accessory Motion

Medial to PSIS


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Sensitivity .91, Specificity .78, +LR 4.16, -LR .12

Laslett, et al. assessed the diagnostic utility of the McKenzie method of mechanical assessment combined with the following sacroiliac tests: Distraction, thigh thrust, Gaenslen, sacral thrust, and compression McKenzie assessment consisted of flexion in standing, extension in standing, right and left sidegliding, flexion in lying, and extension in lying. The movements were repeated in sets of 10, and centralization and peripheralization were recorded. If it was determined that repeated movements resulted in centralization, the patient was considered to present with pain of discogenic origin. If discogenic origin of pain was ruled out the cluster of tests exhibited:

Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother. 2003; 49:89-97.

SI Joint – Thigh Thrust Test

• The patient is supine and the hip and knee are flexed to 900. The examiner provides compression along the long axis of the femur using a hand under the patient’s sacrum as a wedge to create shearing force at the SIJ.

SN 88; LR- 0.17

• 30 seconds • Thrust at end

Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. 2005;10(3):207-218.

Gaenslen’s Test

SN .71, SP .26,

+LR 1.0, -LR 1.12

Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 1996; 21:2594-2602.

• Overpressure into hip flexion and hip extension

• 3-5 torsions


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Distraction

SN .60, SP .81, +LR 3.20, -LR .49

Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validation of individual provocation test and composites of tests. Man Ther. 2005; 10:207-218.

• 30 seconds • Bounce force at end

Compression

SN .69, SP .69

+LR 2.20, -LR .46

Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validation of individual

provocation test and composites of tests. Man Ther. 2005; 10:207-218.

**For Ankylosing Spondylitis**

SN .30, SP .90, +LR 3.0, -LR .78 Russell A, Maksymowych W, LeClerq C. Clinical examination of the sacroiliac joints: a prospective study. Arthritis Rheum. 1981; 24:1575-1577.

• 30 seconds • Bounce force at end

Sacral Thrust

SN .63, SP .75

+LR 2.50, -LR .50

Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validation of individual provocation test and composites of tests. Man Ther. 2005; 10:207-218.

**For Ankylosing Spondylitis**

SN .53, SP .29, +LR .75, -LR 1.62 Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 1996; 21:2594-2602.

• 3-5 hard thrusts at S3


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Pelvic Girdle Pain/Pelvic Instability

• The patient is supine with legs 20 cm apart and asked to raise one leg while rating the difficulty of the lift. The process is repeated on the opposite leg. A belt is placed securely around the pelvis and each leg lift is repeated and the patient is asked whether the lift was more difficult, as difficult, or easier than the lifts without the belt

SN 87; SP 94; LR+ 14.5

Active Straight Leg Raise

Mens J et al. Validity of the active straight leg test for measuring disease severity in patient with posterior pelvic pain after pregnancy. Spine. 2002; 27: 196-200

Stork Test – Movement Test

• Pattern of intrapelvic load during transfer

• Patient lifts one leg and

• maintains single leg stance

• (+) = PSIS moves cephalic with respect to S2 during load transfer

• (-) = PSIS stays neutral or moves caudal

• Hypomobility?

Stork Test and ASLR

• Together, these tests measure the presence of a pelvic ring instability AND poor neuromuscular control during loading


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SI Provocative Tests (European Guidelines – Dx. & Tx. PGP)

• Recommendation

– The following tests are recommended for clinical examination of PGP:

• SIJ Pain – Posterior pelvic pain provocation test (P4/thigh

thrust)

– Patrick’s/FABER test

– Palpation of the long dorsal SIJ ligament

– Gaenslen´s test

SI Provocation Tests (European Guidelines – Dx. & Tx. PGP)

• Symphysis

– Palpation of the symphysis and the modified Trendelenburg function test of the pelvic girdle

• Functional pelvic test

– Active straight leg raise test (ASLR)

Modified Trendelenburg Test • Pubic Symphysis Movement • Rotates 3 degrees and translates

2 mm One legged Stance: • 2.6 mm vertically • 1.3 mm sagittally Walking: • Pubic symphysis pistons • 2.2 mm vertically • 1.3 mm sagittally

Walheim et al. Mobility of the pubic symphysis : in vivo measurements with an electromechanic method and a roentgen stereophotogrammetric method. Clin Orthop. 1984; (191): 129-35.

(Presswood et al. Strength Cond J. 2008)


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Passive Physiological Movement

Top leg flexed and knee in clinician anterior hip

• What is innominate motion? • What is sacral motion? • Look for concordant pain

Top leg extended and supported

Palpation

• Useful for Extraarticular disorders Berthelot et al. Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliacjoint pain. Joint Bone Spine. 2006 Jan; 73(1): 17-23

• Useful to implicate the long dorsal ligament Vleeming et al. Possible role of the long dorsal sacroiliac ligament in women with peripartum pelvic pain. Acta Obstet Scan. 2002;81(5):430-6

Rule OUT Hip


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Fracture

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Patellar Pubic Percussion (PPP) Test

• A stethoscope is placed on the pubic bone while the examiner either taps or places a tuning fork on the patella

SN 95; SP 86

LR+ 6.11; LR- .07

R/O femoral neck fracture

Reiman MP, et al. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. Br J Sports Med. 2012

Test, authors SN/SP LR+/LR- QUADAS Criterion

Adams &

Yarnold

94/95

20.4/0.06

8

Radiography

Bache & Cross 91/82 5.1/0.11 8 Radiography

Tiru et al 96/86 6.7/0.75 10 Radiography, bone

scintigraphy, MRI or CT

Meta-analysis revealed a pooled sensitivity of 95% and a specificity of 86%

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Stress Fx. (Fulcrum) Test

Clinician places one forearm under patient’s thigh to be tested. Clinician’s other hand a downward pressure is applied to the proximal knee. Assessment: Test is considered (+) if the patient reports pain with the maneuver. Special Note: Confirmation of a stress fracture requires a bone scan, therefore a positive finding warrants physician referral.

R/O femoral stress fracture

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Stress Fx. (Fulcrum) Test

Johnson et al

(1994)

7 college-aged athletes with

proximal 1/3 femoral shaft stress

fracture

93/75

3.7/0.09

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Scintogram or

Radiography

Kang et al

(2005)

6 female Lacrosse players with

femoral shaft stress fracture; age

range of 19-23 years

88/13

1.0/0.92 7 Radiography,

bone scan

and/or MRI

Test, authors Sample size SN/SP LR+/LR

-

QUADAS Criterion

standard

56


Posterior Pelvic Palpation

McCormick

et al (2003)

98/94 16.3/0.02 7 CT scan

Test, authors SN/SP LR+/LR- QUADAS Criterion

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Intra-Articular Pathology

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Scour Test – R/O:R/I ?

• Traditionally considered test of hip Intra-articular pathology • 2 arcs without, then 2 with longitudinal compression

loading • No diagnostic values

– Variations of testing, naming, etc.

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FABER’s Test (Patrick’s Test; Figure-Four Test)

Hip joint is passively externally rotated and abducted by placing pressure over the ipsilateral knee, while stabilizing the contralateral innominate. Assessment: is of quantity and quality of motion, as well as for pain. ROM measurement can be taken in reference to the horizontal plane of the table.

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Authors Subjects SN/SP LR+/LR- QUADAS Criterion standard

Maslowski

et al (2010)

50 subjects with signs/symptoms

suggestive of hip pathology;

mean age: 60.2 years, 30 females

81/25 1.1/0.72 7 ≥ 80% improvement on

visual analog scale after

intra-articular hip injection

Martin et al

(2008)

105 subjects with hip pain; mean

age 42±15 years, 24 females

60/18 0.73/2.2 9 MRA; anesthetic intra-

articular injection

Troelsen et

al (2009)

18 subjects with previous

periacetabular osteotomy (17 had

labral tear); median age 43 years

(32-56 years), 16 females

42/75 1.7/0.77 9

MRA

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Hip Osteoarthritis

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Hip ROM

• Restriction in any single hip motion (flexion, ER, or IR):

Sensitivity = 86% Specificity = 54%

• (+) LR = 1.9 for mild to moderate radiographic arthritis.

• Limited IR ROM was found to be most predictive finding of mild to moderate OA, with

(+) LR = 3.6

Birrell F, et al. Predicting radiographic hip osteoarthritis from range of movement. Rheumatology (Oxford). 2001;40:5-6=512.

“Gold Standard” • Individuals with hip pain and hip IR

ROM ≤ 150 who experienced pain with IR, had morning stiffness ≤ 60 minutes, and were 50 y.o. or older could be identified as having hip OA

Sensitivity = 86%; specificity = 75% • If hip IR ROM was < 150 and hip

flexion ≤ 1150

Sensitivity = 86%; specificity = 75% Altman R, et al. The American College of Rheumatology criteria for classification and reporting of osteoarthritis of the hip. Arthritis Rheum. 1991;34:505-514.

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Hip Impingement/Labral Tear

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Subjective history

• 96% (Keeney et al. Clin Orthop Relat Res. 2004) and 100% (McCarthy and Busconi, 1998) of individuals with arthroscopically identified labral tear reported groin pain

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“C” – Sign

66


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Martin RL, et al. Acetabular labral tears of the hip: examination and diagnostic challenges. J Orthop Sports Phys Ther. 2006;36(7):503-515.

Authors Findings

Keeney et al. 2004 •Groin pain most common location (96%), anterior hip (35%), lateral hip (38%), buttock (17%) •Presence of locking or catching may not be sensitive (58% reported hip locking or catching)

McCarthy & Busconi, 1995 •Groin pain may indicate not only labral tear, but presence of intra-articular pathologies in general (100% with labral tear reported it, 98% with intra-articular pathology reported it) •Inguinal clicking & giving way correlated (r = 0.79) with labral tear

Narvani et al. 2003 •Presence or absence of clicking in hip my provide useful diagnostic information •Clicking in hip had 100% sensitivity, 85% specificity and (+) LR of 6.67 for labral tear

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Flexion Adduction Internal Rotation Test (FADDIR) • The patient is supine. The

examiner moves the patient’s leg into the combined motions of flexion, adduction, and internal rotation

SN 96 to 100

Ito K, Leunig M, Ganz R. Histopathologic features of the acetabular labrum in femoroacetabular impingement. Clin Orthop Relat Res. 2004(429):262-271. Sink EL, Gralla J, Ryba A, Dayton M. Clinical presentation of femoroacetabular impingement in adolescents. J Pediatr Orthop. 2008;28(8):806-811.

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FADDIR Test

• Multiple studies

– Most are case cohorts

– High SN, poor SP

– Highest LR+ = 2.4

– Lowest LR- = 0.2

Troelsen A, Mechlenburg I, Gelineck J, Bolvig L, Jacobsen S, Soballe K. What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics? Acta Orthop. 2009;80(3):314-8.

Keeney JA, Peelle MW, Jackson J, Rubin D, Maloney WJ, Clohisy JC. Magnetic resonance arthrography versus arthroscopy in the evaluation of articular hip pathology. Clin Orthop Relat Res. 2004 Dec(429):163-9.

69


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Flexion-Internal Rotation Test

Movement: Combined motions of flexion to 900 and IR are performed as shown. Assessment: As with impingement test, pain in groin is indicative of labral degeneration, fraying, or tearing.

70

Flexion-IR Test

71

Number of studies/sample size

SN SP LR + LR-

3 studies/ 42 total subjects

96 17 1.12 0.27


Internal Rotation-Flexion-Axial Compression Test

Movement: Combined motions of flexion, IR, and axial compression are performed as shown. Assessment: Reproduction of concordant pain, locking, clicking, catching

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Internal Rotation-Flexion-Axial Compression Test

Narvani et al

(2003)

18 athletic

subjects with

complaints of

groin pain;

mean age of

30.5±8.5

years, 5

females

75/43 1.3/0.58 8 MRA

Test, authors Subjects Sensitivity/

specificity

LR+/LR- QUADAS score Criterion standard

73


Thomas Test

Patient holds leg not being tested in a flexed position. Clinician: Extends leg being tested.

Special note: Examiner can use proximal hand to monitor lumbar spine position. Lumbar spine should maintain contact with table.

Assessment: • If less than 0 degrees of hip extension is achieved - indicates a

tight iliopsoas. Simultaneous extension of the knee during this maneuver indicates tightness of the rectus femoris.

• Knee flexion: If less than 80 degrees is available, the rectus femoris is tight. (Kendall et al. 2005)

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Thomas Test

McCarthy &

Busconi

(1995)

59 subjects with

refractory hip pain (35

had labral tear); mean

age: 37 years, 32

females

89/92 11.1/0.12 10 Arthroscopy


specificity

LR+/LR- QUADAS

score

Criterion standard

75



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Avascular Necrosis

76

Avascular Necrosis

Joe et al (2002)

(extension < 15

degrees)

176 HIV infected subjects;

no demographic

information reported

19/92

2.38/0.88

Joe et al (external

rotation < 60 degrees)

38/73

0.48/0.85

Joe et al (pain with

internal rotation)

13/86 0.93/1.01


specificity

LR+/LR- QUADAS

score

Criterion

standard

10

MRI

77


Gluteal Tendinopathy

78


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Trendelenburg’s Sign • The patient stands in front of

the examiner. • The examiner instructs the

patient to stand on one leg. • The examiner evaluates the

degree of drop of the contralateral pelvis once the leg is lifted.

• Confirmation of abnormal pelvic drop is required during gait.

• A positive test is identified by an asymmetric drop of one hip compared to the other during single stance.

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(Presswood et al. Strength Cond J. 2008)

Trendelenburg’s Sign

Bird et al (2001) 24 subjects with clinical features consistent

with greater trochanteric pain syndrome;

median age 58 years, range 36-75 years, all

subjects were female

73/77 3.15/0.35 10 MRI

Woodley et al

(2008)

40 patients with unilateral lateral hip pain;

mean age: 54.4±9.5 years, 37 females and 3

males

23/94 3.6/0.82 12 MRI

Lequesne et al

(2008)

17 patients with refractory greater trochanteric

pain syndrome; mean age: 68.1±10.8 years, 16

females and 1 male

97/96 24.3/0.03 10 MRI/Surgery


specificity

LR+/LR- QUADAS

score

Criterion

standard

80


Modified Trendelenburg Test

1 The patient starts in the standing position, while gently holding onto examiner. 2 The patient lifts the non-tested lower extremity off the ground and stands on the tested lower extremity for 30 seconds. 3 No lateral deviation of trunk to ipsilateral side is allowed. 4 The patient is asked whether any concordant pain occurred. 5 Pain similar to spontaneous pain is recorded as immediate, early, or late if it occurred after 0–5 seconds, 6–15 seconds, or 16–30 seconds, respectively.

81


28

Trendelenburg

82


SN SP LR + LR-


61 92 6.83 0.25


Resisted Hip Abduction

• The patient is placed in a sidelying position. • The examiner instructs the patient to abduct the leg to

45 degrees. • The examiner applies force, resisting hip abduction

against the leg. • A positive test is replication of symptoms during the

testing.

83


Bird et al

(2001)

24 subjects with clinical features

consistent with greater trochanteric

pain syndrome; median age 58 years,

range 36-75 years, all female

73/46 1.35/0.59 10 MRI

Lequesne

et al

(2008)

17 patients with refractory greater

trochanteric pain syndrome; mean

age: 68.1±10.8 years, 16 females

71/97 23.7/0.30 10 MRI/

Surgery

Subjects Sensitivity/

specificity

LR+/LR- QUADAS

score

Criterion

standard

84



29


85


SN SP LR + LR-


71 84 6.83 0.25


Resisted External Derotation Test • The patient lies supine, with hip

and knee flexed at 90 degrees, hip in external rotation.

• The examiner slightly diminishes the external rotation just enough to relieve the pain (if any was present).

• The patient then actively returns the lower extremity to neutral rotation (place the lower extremity along the axis of the bed) against resistance.

• The test was considered positive if spontaneous pain was reproduced. • If the result was negative, the test was repeated with the patient lying

prone, hip extended and knee flexed at 90 degrees.

86

Lequesne et al. Arthritis & Rheumatism 2008

Resisted External Derotation Test

Lequesne et

al (2008)

17 patients with refractory

greater trochanteric pain

syndrome; mean age:

68.1±10.8 years, 16 females

88/97.3 32.6/0.12 10 MRI


specificity

LR+/LR- QUADAS

score

Criterion

standard

87



30

Sports Related Chronic Groin Pain

88

Single Adductor Test

• The patient is supine, hip flexed to 30 degrees, and the other leg at 0 degrees on the table.

• Patient resists the clinicians attempt to abduct the leg to be tested, effectively contracting their adductor muscle on that side.

• Assessment was made for the presence or absence of pain in the pubic bone/adductor region.

• The other side was then tested. 89

Squeeze Test

• The clenched fist of the examiner is placed between the patient’s legs at the level of the knees with approximately 45 degrees of bilateral hip flexion and 90 degrees of knee flexion (heels flat on bed surface, in supine hooklying position).

• The patient is then asked to contract maximally both adductor muscles simultaneously to ‘‘squeeze the fist’’ effectively.

90


31

Bilateral Adductor Test

• The patient is supine with bilateral legs raised off the table (approximately 30 degrees of hip flexion) with slight hip abduction and leg internal rotation.

• The examiner then attempts to perform bilateral hip abduction, requiring resisting this movement, thereby effectively contracting both adductor muscles simultaneously. 91

Test, authors Sample size Sensitivity/

specificity

LR+/LR- QUADAS

score

Criterion

standard

Single Adductor Test

Verrall et al

(2005)

89 Australian Rules football

players; 47 with chronic groin

pain; all were male

30/91 3.3/0.66 7

MRI (bone

marrow

edema)

Squeeze Test

Verrall et al

(2005)

43/91 4.8/0.63

Bilateral Adductor Test

Verrall et al

(2005)

54/93 7.7/0.49

92


Test of General Ligament Laxity

93


32

Dial Test

Assessment: Evaluate side-to-side ROM differences and clicking. A negative Dial test constitutes external rotation of the lower limb less than 45°, as measured vertically, with a firm endpoint. Patients with passive ER greater than 45° are considered to have a positive Dial test.

Movement: With the hip in a neutral flexion/extension and abduction/adduction position, the clinician grasps the patient’s LE at the femur and tibia and is passively rolled into full IR.

The LE is released and allowed to ER.

94

Log Roll Test

With the hip in a neutral flexion/extension and abduction/adduction position, the patient’s LE is passively rolled into full IR and ER. Assessment: Evaluate side-to-side ROM differences and clicking. A click reproduced during the test is suggestive of labral tear, while increased ER ROM may indicate iliofemoral ligament laxity.

95

Function


33

Conclusion

• Lumbar spine – Pelvis – Hip

• Entire exam

– Subjective, observation, triage, myotomes/dermatomes

• R/O vs R/I

• Function Assessment

– Why is the patient seeing you?

• Assess – Re-assess

97

Thank You! [email protected]


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differential dx of lumbar spine, pelvis &...

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