Clinical Examination of the Athletic

Back Pain Breakthrough

Lower Back Pain Homeopathic Remedies

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Brett A. Bralya,*, Douglas P. Beall, MDbc, Hal D. Martin, DOd aUniversity of Oklahoma College of Medicine, PO Box 26901, BSEB 100, Box 396, Oklahoma City, OK 73190, USA

bThe Physicians Group, 610 NW 14th Street, Oklahoma City, OK 73103, USA cUniversity of Oklahoma Health Sciences Center, 1100 N. Lindsay, Oklahoma City, OK 73104, USA Oklahoma Sports Science and Orthopedics, 6205 North Santa Fe Avenue, Suite 200, Oklahoma City, OK 73118, USA

The hip assumes an essential role in most sports-related activities. The hip is not only responsible for distributing weight between the appendicular and axial skeleton, but it is also the joint from which motion is initiated and executed. It is known that the forces through the hip joint can reach three to five times the body's weight during running and jumping [1,2]. Considering the amount of demand athletes place on their hips, orthopedic surgeons will evaluate them as patients having hip pain.

Ten percent to 24% of athletic injuries in children are hip related, and 5% to 6% of adult sports injuries originate in the hip and pelvis [3]. Ballet dancers are most likely to have a hip-related injury, and runners, hockey players, and soccer players are also prone to hip injuries [3]. Athletes participating in rugby and martial arts have also been reported as having increased incidence of degenerative hip disease [4-10]. Hip pain often stems from some type of sports-related injury [11-14]. In patients presenting with hip pathology, the hip is not recognized as the source of pain in 60% of all cases [15].

Hip pain has been documented in three categories: anterior-, lateral-, and posterior-based hip pain [16], with multiple etiologies. A short physical examination, complete with a history and evaluation of present illness, is fundamental and necessary in determining the source and cause of the presenting complaint. The results of these two assessment techniques will direct which radiological examination to consider. The history of present illness and physical assessment should be adequate if the physician suspects a specific diagnosis, and radiographic examination should be enough for a conclusive diagnosis to be made [1,4].

Diagnosing hip pain in athletes has been difficult for physicians in the past because of the parallel presenting symptoms shared with back pain, which may exist concomitantly or independently of hip problems [17]. Radiating pain below the knee, palpable pains in the hip and back, and weakness or sensory limitations

* Corresponding author. 14321 North Pennsylvania Avenue, Suite E, Oklahoma City, OK 73134.

E-mail address: [email protected] (B.A. Braly).

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blur the lines in appropriately differentiating between the hip and back [17-22]. Low back pathology involving the paravertebral muscles can lead to an abnormal soft tissue balance, causing an irregular tension absorbed by the hip joint, which leads to knee pain, groin pain, leg length discrepancies, and limited ranges of motion in the hip [23]. Muscle contractures of the hip flexors or extenders as well as leg length discrepancy have also been identified as factors that can cause hip and low back pain to present together [24-28]. Brown and colleagues [17] proposed that limited internal rotation associated with a limp and groin pain were the physical signs to make the distinction of hip-related pathology. The biggest problem facing physicians treating hip-related pathologies is the absence of a valid diagnosis [29].

The physical examination of the hip is evolving as the ability to understand normal and pathological conditions of the hip progresses. The physical examination of the hip is designed to detect a wide variety of pathologies, and has been developed by many generations of surgeons, therapists, and physicians [30-32]. The examination of the hip is optimally performed in a systematic and reproducible fashion in order to facilitate accurate diagnoses and treatment recommendation. The benefit of understanding the osseous, ligamentous, and musculotendonous contribution to the underlying pathology cannot be overestimated. Surgical and nonsurgical treatment outcomes will depend on a consistent method of evaluation to understand which treatments produce the optimal results for a particular type of patient. Conditions related to genitourinary, gastrointestinal, neurologic, and vascular systems, though unlikely in a sports-related injury, can compound the complexity of the assessment. This complexity also emphasizes the importance of a thorough examination.

An 11-point physical evaluation is a tool presented here to help organize the structure ofthe physical examination ofathletes in a simple, reproducible manner, in order to differentiate between hip and back pathology and categorize the hip pain presented. The evaluation aids in the diagnosis of anterior, lateral, and posterior etiologies of the hip in regards to the osseous, ligamentous, and musculo-tendonous structures. An organized approach, with a systematic structure as used in evaluating other joints, will benefit both the patient and the physician.

The 11-point examination is described below in five parts: the standing, seated, supine, lateral, and prone examinations. The technique of the physical examination is discussed, along with the diagnostic tools that may further the investigation of suspected pathology.

A verbal history including mechanism, time of injury, location, and severity of pain should be obtained. The focus of this article is to describe the physical element of the examination. It should be noted that with any clinical examination the reproduction of pain or limited movement constitutes a positive test sign.

ELEVEN-STEP EXAMINATION

Standing Examination

The initial element in the structured evaluation (Table 1) should be the general body habitus, principally gait and alignment. Because of the hip's role in

Examination

Assessment/association

Body habitus

Examination

Assessment/association

Body habitus

1. Spinal alignment

Shoulder/iliac crest heights, lordosis, scoliosis, leg length

2. Gait a. Trendelenburg b. Antelgic c. Pelvic rotational wink d. Excessive external

Abductor strength, proprioception mechanism

Trauma, fracture, synovial inflammation

Intra-articular pathology, hip flexion contracture

Femoral retroversion, increased acetabular anteversion, torsional abnormalities, effusion

Increased femoral anteversion or acetabular retroversion, torsional abnormalities, effusion iliotibial band pathology, true/false leg length discrepancy rotation e. Excessive internal rotation f. Short leg limp supporting body weight, hip pathology can often be identified in gait abnormalities [1]. An antalgic gait (one that involves a self-protecting limp caused by pain, characterized by a shortened stance phase on the painful side so as to minimize the duration of weight bearing) is an indication of hip, pelvis, or low back pain [33,34]. The gait should be observed so that the full stride length can be assessed from the front and side [30]. Common key points of evaluation should include stride length, stance phase, foot rotation (internal/external progression angle), and the pelvic rotation in the X and Y axes [1,30,32]. It is recommended that the patient walk down the hall if the room is not big enough to give the physician a chance to observe six to eight full strides.

A Trendelenburg gait is indicative of hip abductor weakness, and is often referred to as an abductor lurch. The pelvic wink displays excessive rotation in the axial plane (greater than the normal 40°) toward the affected hip to obtain terminal hip extension. This gait pattern is associated with internal hip pathology or with hip flexion contractures, especially when combined with increased lumbar lordosis or a forward-stooping posture. Special attention should be given to a limp, noting that a limp with an external foot progression could indicate effusion or traumatic condition. Consideration should also be given to any snapping or clicking the patient or physician hears, noting location as internal or external to the hip joint or derived from within the joint itself. This audible sign could be indicative of psoas contracture (coxa sultans interna), tightness of the iliotibial band (coxa sultans externa) or intra-articular pathology. Coxa sultans interna/ externa can be distinguished by the patient actively demonstrating the pop by recreating the sound as he rotates the hip.

The second aspect in observing general body habitus is alignment. Compare the patient's shoulder heights with the heights of the iliac crests to further any leg length discrepancy issues. Other palpable bony structures for pelvic alignment assessment include the anterior superior iliac spine and posterior superior iliac spine. A tilted pelvis can indicate a leg length discrepancy, which can be further investigated by measuring leg lengths manually from the anterior superior iliac spine (ASIS) to the ipsilateral medial malleolous in order to differentiate between

Table 2

Seated examination

Examination

Assessment/association

Neurocirculatory evaluation

Pulse, sensation, motor strength, deep tendon reflexes

Straight leg raise

Radicular neuropathy

Ranges of motion

Internal and external rotation

true and functional leg length discrepancies [32]. A true leg length issue is present when the bony structures are of different proportions. Functional leg length issues arise when muscle spasms, scoliosis, or deformities of the pelvis cause the truly identical leg lengths to function as if they were disproportionate.

Lateral inspection of the lumbar spine is effective for detecting postural or kinetic abnormalities such as excessive lordosis or paravertebral muscle spasm. Increased lumbar lordosis is a common finding in patients who have hip flexor contractures involving the psoas muscle. The spine is initially evaluated with forward bending, recording the range of motion. This assessment will allow inspection of the spine from behind for the purpose of detecting types of scoliosis.

In addition to body habitus, the second point of examination in the standing position involves Trendelenburg's sign. The Trendelenburg's test should be performed on both legs, and the nonaffected leg should be examined first. This test helps to establish a baseline for the patient's neuroproprioceptive function. As with the indications of the Trendelenburg's gait abnormality, this assessment evaluates the proper mechanics of the hip abductor musculature and neural loop of proprioception. When the right foot is lifted, the left abductor muscles are being tested. If the musculature is weak, the pelvis will tilt toward the unsupported side. The shift of the pelvis should not be more than 2 cm at the midaxis in either the ipsilateral or contralateral direction. A shift of greater than 2 cm constitutes a positive Trendelenburg's sign.

Seated Examination

The sitting examination (Table 2) is composed primarily of the basic evaluation points of extremity assessment, the neurocirculatory evaluation, and the rotational ranges of motion. Even in the healthy individual, standard basic assessment should be followed.

Table 3

Assessment of motor function

Score

Motor function

0

No muscle function

1

Some visible movement

2

Full range of motion, not against gravity

3

Movement against gravity, but not resistance

4

Movement against resistance, less than normal

5

Normal strength

Table 4

Deep tendon reflexes

Score

Description

0

No reflex

1+

Hypoactive (less than normal)

2+

Normal

3+

Hyperactive (more than normal)

4+

Hyperactive with clonus (like a muscle spasm)

The neurocirculatory evaluation consists of the motor function, perceived sensation, and circulation appraisal. The motor portion includes assessing muscles supplied by the obturator, superior gluteal, sciatic, and femoral nerves. The function is assessed and graded on a 0 to 4/4 scale (Table 3). The sensory assessment includes evaluation of the sensory nerves originating from the L2 through S1 levels, and the sensory function should be compared (left to right) to assess uniformity. Neurologic function can be further evaluated by the deep tendon reflexes (Table 4). Reflexes at the patella (knee-jerk) test the L2-L4 spinal nerves and femoral nerve. Reflexes at the Achilles (ankle-jerk) test the L5-S1 sacral nerves. A straight leg raise is helpful in detecting radicular neurological symptoms, such as the stretching of a centrally entrapped nerve root [35].

The vascular examination includes evaluating the pulses of the dorsalis pedis and posterior tibial arteries. These should be recorded as present or absent on a 0 to 4/4 scale (Table 5). Sensation is assessed by lightly touching both sides of the patient's thigh and lower leg and asking the patient to compare these subjective findings with the other leg. A common neuralgia occurs on the anterior thigh, deriving from the anterior femoral cutaneous nerve compressed within the femoral nerve, as it passes near the psoas muscle through the pelvic brim [31,36-38]. The skin and lymphatics are also quickly inspected for swelling, scarring, or side-to-side asymmetry.

The second part of the seated examination involves examining internal and external rotational ranges of motion of the hip. The internal and external rotation measurements of the hip are recorded in the sitting position, because it provides sufficient stability and a fixed angle of 90° at the hip joint [16]. Differences may exist in the degree of internal and external rotation in extension and flexion, and assessment of these measurements is subject to substantial variability. The normal range of motion is 20° to 35° for internal rotation and

Table 5

Grading of pulses

Table 5

Grading of pulses

Traditional

Basic

4+

Normal

2+

Normal

3+

Slightly reduced

1+

Diminished

2+

Markedly reduced

0

Absent

1+

Barely palpable

0

Absent

30° to 45° for external rotation. Adequate internal rotation is important for normal hip function, and there should be at least 10° of internal rotation at terminal hip extension. The loss of internal rotation is an important physical finding, because it is one of the first signs of internal hip pathology [29]. The loss of internal rotation at the hip joint can be related to diagnoses such as arthritis, effusion, internal derangements, slipped capital femoral epiphysis, and muscular contracture [29,32]. Pathology related to osteocartilaginous impingement (femoroacetabular impingement) or to rotational constraint from increased or decreased femoral acetabular anteversion can result in significant side-to-side measurement differences [17]. An increased internal rotation combined with a decreased external rotation may indicate excessive femoral anteversion [32]. Further ranges of motion are assessed in the supine examination, below.

Supine Examination

An important examination position to address the multifactorial presentation of complex hip pathology is the supine position (Table 6). The battery of tests, conducted with the patient in the supine position, helps to further distinguish internal from extra-articular sources of hip symptoms. There are four initial examination s of the athletic hip in the supine position.

The first examination completes the hip ranges of motion initiated in the seated position, focusing now upon flexion, adduction, and abduction. With the patient supine, abduct the affected leg by holding the ankle, and note the degree between the body's center line and the shaft of the femur. A normal abduction is 45°. To adduct, the leg must cross over the nonaffected leg. Note the degree again between the center line and femoral shaft. Normal adduction is 20° to 30°. During this evaluation, place one hand on the ASIS to assess any

Table ó

Supine examination

Examination

Assessment/association

Ranges of motion

Abduction, adduction, flexion

Thomas test

Hip flexor contracture (psoas), femoral neuropathy, intra-articular

pathology, abdominal etiology

McCarthy's

1. Internal

Anterior femoroacetabular impingement, torn labrum

2. External

Superior femoroacetabular impingement, torn labrum

Patrick FABER

Distinguish between back and hip pathology, specifically

sacroiliac joint pathology

Palpation

1. Abdomen

Fascial hernia or associated gastrointestanal/genitourinary

pathology

2. Pubic symphosis

Osteitis pubis, calcification, fracture, trauma

3. Adductor tubercle

Adductor tendonitis

Trauma assessment

1. Log roll

Effusion, synovitis

2. Heel strike

Femoral fracture, trauma

compensatory motion in the pelvis. Limited adduction/abduction could result from a contracture of the respective musculature. Flexion is recorded by having the patient flex both thighs into the chest, flattening the lumbar spine and keeping the knee flexed to oppose any hamstring tightness. Normal flexion is 120°. Difficulties in flexion result in limited active daily living [1].

The Thomas test is performed to assess any hip flexor contracture that may be present. With the patient holding the nonaffected leg in the flexed position, lower the affected leg to the table. If the thigh cannot reach the table, this represents a positive Thomas test, and is a sign of the hip flexor contraction. Note the angle between the femoral shaft and the table [32]. If a clicking is audible during this test, it may be an indication of a labral tear [16], or coxa sultans externus. Clicking is most indicative of a tear and a louder, more audible pop, is snapping of the psoas tendon.

The McCarthy test is performed in an attempt to re-establish the discomfort felt by the patient in order to discover the underlying etiology. The cause of pain reconstructed from this test is likely a tear of the acetabular labrum. This test is relevant in that most tears occur in the anterior acetabulum, compounded in athletes who have acetabular dysplasia [39-44]. By rolling the hip in a wide arc of internal and external rotation through flexion to extension, the goal is to find a site of bony impingement that may have caused a tear [45]. A positive McCarthy sign is noted by recreation of the patients pain in a specific position.

The Patrick FABER (Flexion ABduction External Rotation) test is the classical physical examination test for the characterization of hip pain in the abducted position. The test is performed by laying the ankle of the affected leg across the thigh of the nonaffected leg proximal to the knee joint, creating a figure 4 position. This position displaces the anterior superior rim of the femoral neck to the twelve o'clock position of the acetabular rim. Pressure is applied to the knee of the affected leg, causing stress in the ipsilateral sacroiliac (SI) joint. Pain in the posterior hip should cause consideration of SI joint pathology. Pain in the groin can be caused by pathology of the iliopsoas muscle, resulting in an iliopsoas sign [32]. Pain in the lateral aspect of the hip can also be associated with lateral femoroacetabular impingement (FAI).

Because of the demands placed on the hip in sports-related activities, it is necessary to assess the hip for trauma. This assessment is made through the log roll test and the heel strike test. Rolling the leg in the Z axis on the table will reproduce pain in femoral fractures. Striking the heel of the foot will reproduce pain if the fracture has occurred in the femoral neck. Positive signs in either of these two tests should warrant radiographic investigation.

Finalizing the supine examination, bony and soft tissue structures around the pelvis should be palpated for tenderness. The abdominal examination should include inspection and palpation for fascial hernias. Fascial hernias may be difficult to detect by palpation, and the isometric contraction of the rectus abdominus and obliques can facilitate their detection. The region of the ilio-inguinal ligament should be inspected and the presence or absence of a Tinel's sign (tingling sensation in the distribution of the femoral nerve) at the level of the ilioinguinal ligament indicating femoral nerve pathology should be noted [32]. Palpation of the adductor tubercle as the patient adducts the extended leg may help identify adductor tendonitis, because point tenderness will be present in this location. Pain with palpation of the pubic symphosis is a cause for further examination of the area. Additional palpation should be continued in the lateral position.

Lateral Position

The lateral hip examination (Table 7) is performed with the patient in the lateral recumbent position lying on the unaffected hip with his shoulders perpendicular to the table. The physical examination tests in the lateral position are useful in the determination of lateral-based hip pain, and can further confirm the presence of intra-articular pathology.

Palpation for tenderness is continued, with special attention given to the SI joint, gluteus maximus origin, piriformis, sciatic nere, iliotibial band (ITB), greater trochanteric bursae, tensor fascial lata and ischial tuberosity [1,16,31, 32,46,47]. Tenderness in one of these regions warrants further examination.

Ober's test is used to assess the tightness of the IT B and fascia lata. Three positions are examined in this test: extension, neutral, and flexion. These refer to the positions of the affected leg in respect to the nonaffected leg. In extension, the affected leg is abducted with the knee flexed. When the force abducting the leg is removed, the affected leg should adduct due to gravity. If the leg remains abducted, this is a positive Ober's sign. The neutral position is performed similar to extension with the knee flexed, and is a test of the gluteus medius tension. In flexion, the ipsilateral shoulder should be rotated posteriorly (making both shoulders come into contact with the table) and the knee extended to assess the gluteus maximus origin in cases with gluteus maximus contractures. The ITB tension may be released by flexing the knee, and this technique can

Table 7

Lateral examination

Examination

Assessment/association

Palpation

1. Greater trochanter

Greater trochanteric bursitis, iliotibial band contracture

2. Sacroiliac joint

Distinguish between hip and back pathology,

gluteus maximus assessment

3. Ischium

Biceps femoris contracture, avulsion fracture,

bursitis

FAI assessment

1. Flexion, abduction, internal

Anterior FAI, torn labrum

rotation

2. Lateral rim impingement

Lateral FAI, torn labrum

Ober's

1. Extension

Tensor fascia lata contracture

2. Neutral

Gluteus medius contracture/tear

3. Flexion

Gluteus maximus contracture, contribution to

iliotibial band

Table 8

Prone examination

Examination

Assessment/association

Ely Test

Hip flexor contracture, rectus contracture

be helpful in isolating and assessing the gluteus medius, specifically for musculotendinous tears. If the affected leg in any position cannot adduct to the table, this constitutes a positive Ober's sign.

The last examination in the lateral position assesses the degree of FAI present. This series of examinations includes the FADDIR (flexion adduction internal rotation) test. When examining the hip with the patient in the lateral recumbent position, the examiner stands behind the patient with the examiner's arm beneath the patient's lower leg. The examiner holds the knee with the supporting hand while the opposite hand monitors the hip. The hand monitoring the hip should grasp the joint with the index finger anteriorly and the thumb posteriorly. Position the leg in FADDIR to assess impingement from the femoral neck, which may have caused an acetabular labral tear. Reproduction of the patient's pain with this maneuver is suggestive for anterior FAI. A lateral rim impingement can also be assessed by taking the leg from flexion to extension in continuous abduction, trying to reproduce the pain in order to identify impingement. The emphasis in lateral examination should be toward the primary area of complaint, and additional examinations should be performed as necessary.

Prone Examination

The prone position is optimal for identifying the precise location of pain related to the SI joint region (Table 8). The SI joints and surrounding region should be palpated in three areas: the infra SI region adjacent to the origin of the gluteus maximus, the supra SI location adjacent to the spinous process of L4-L5, and the SI joint location itself.

Table 9

Eleven-step examination of the adult athletic hip

Standing

1. Body habitus

2. Trendelenburg's test

Seated

3. Neurocirculatory evaluation

4. Ranges of motion

Supine

4. Ranges of motion (continued)

5. Thomas test

6. McCarthy test

7. Trauma assessment

8. Palpation

Lateral

8. Palpation (continued)

9. FAI assessment

10. Ober's test

Prone

11. Ely's test

Examination

Assessment/association

Scours

Foveal distraction

Extension, abduction, external rotation Craig's test

Intra-articular pathology, internal pop/click Torn labrum

Hyperlaxity, high instability index Femoral anteversion

Examination

Assessment/association

Scours

Foveal distraction

Extension, abduction, external rotation Craig's test

Intra-articular pathology, internal pop/click Torn labrum

Hyperlaxity, high instability index Femoral anteversion

The physical examination test recommended for assessing any contracture of the rectus femoris muscle is Ely's test. This assessment is performed by flexing the knee and drawing the lower leg into the thigh. A negative test demonstrates full flexion of the knee to the thigh with no movement in the pelvis. A positive Ely's sign demonstrates that with flexion at the knee, the pelvis will tilt, raising the buttocks from the table.

The 11-point athletic hip examination can be effective in screening and evaluating patients who have hip pain, and can be helpful to direct further diagnostic studies (Table 9). A marcaine injection test may be necessary to distinguish between hip and back pathology. This and other auxiliary clinical tests may be helpful in further evaluation of the hip (Table 10). The majority of examinations that compose the 11-point athletic hip examination were developed over many years, before the pathomechanics were fully understood. Individuals using these tests and the tests that have been more recently developed could benefit from validation to determine their accuracy in the detection of the various types of hip pathology. A thorough systematic physical examination coupled with history is the best method to determine subsequent radiologic or diagnostic testing recommendations. As with any examination, practice and repetition are essential to gain an appreciation of what constitutes a normal as well as an abnormal exam. When used consistently and with practice, the 11-point athletic hip examination will help the examiner to formulate an accurate list of diagnostic possibilities and to determine what other diagnostic examinations or techniques may benefit the patient.

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Back Pain Revealed

Back Pain Revealed

Tired Having Back Pains All The Time, But You Choose To Ignore It? Every year millions of people see their lives and favorite activities limited by back pain. They forego activities they once loved because of it and in some cases may not even be able to perform their job as well as they once could due to back pain.

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