Many papers written on the hip begin with the statement “clinicians find it difficult to differentiate between symptoms caused by the spine or hip.” Brown et al. conducted a study to determine which signs and symptoms from evaluation were best able to predict whether the origin was hip or spine (1). The best predictors of the primary pain generator being the hip were: groin pain, limited internal rotation, and gait with a limp.
Knowing these three variables is helpful, as one of the first forks met during a hip evaluation is whether the pain generator is actually the hip or some other cause upstream. This brings us to the purpose of today’s post – how do we differentiate a hip problem from a back problem? Now this seems easy and in many cases it is, however I have come across older patients with pain that seems to be caused by the hip on the first day and then the back at the next. Lumbar stenosis and hip degeneration is going to be more common in this group so running into a patient that has both will not be surprising. It is one of the reasons that pain remaining in the hip after a laminectomy usually leads to a total hip arthroplasty.
Where to begin?
The patient walking in the door with hip pain is a diagnostic challenge. When I started the process of reading and researching for my first dive into the ‘hip’ subject, I began by jotting down thoughts. I stopped about 25 minutes into the endeavor because the 3 page brainstorm confused me more about where to start (see Figure 1) and led me to question the best starting point.
Would it be more useful to rule out the pathologies that could refer to the hip? While screening is important and normally performed first in the physical exam, this would involve more examination of the sacroiliac joint and the low back.
How about a general overview of the pathoanatomy? Too broad for the first post.
Would a review of the basics diagnostic history taking be most appropriate? This would be important, specifically if the focus is on those symptoms associated with more difficult presentations.
What do recognized hip experts in the field of orthopedics do?
The last question led me to a different course of action. I decided to immerse my thought process into a case study or editorial about expert practice concerning hip examination. Luckily I found an article examining the practice pattern of hip experts. Martin et al. (4) systematically evaluated a group of hip specialists during the examination of 11 patients.
As a new year begins, I feel the urge to change up the normal routine and refine my approach to professional and clinical development. As an early riser, I get up at 3 am (I imagine this habit is why my mother taught me how to make my own breakfast as soon as I could reach the table). Historically mornings are my most productive time of the day. No one is up. I can get to emails later when I get to the clinic. There are no phone calls or urgent matters that I must attend. I do whatever I want. Lately that has consisted of reading about injury surveillance, general statistics, and critical reasoning and problem solving. Really it’s just a scattershot of whatever crosses the desk or the inbox. My goal is to be the best physical therapist possible. Instead of randomly grabbing an article, I believe an outline with clear objectives of topics to be mastered is necessary. I notice that I always revert to areas I know well instead of challenging those I do not.
Reflecting on the past year, I can confidently say that 90% to 95% of my reading was on topics that I knew very well before picking up the paper. This is really not good or bad, but it is definitely the habit I have developed, but I do not support the main goal to become an expert physical therapist because critical aspects are missed.read more
Why the definition of injury matters?
I assume when writing that people will automatically understand the terms I use. If I write, “injury was recorded”, my assumption is that you, the reader, completely understand what that means. Obviously that is not accurate. Your definition is colored by your profession, current employment, previous experiences, and probably the last article you read on the subject. It is a term that can mean different things. We know that it means some type of physical damage to the body, however when it comes to recording the injury ‘event’, many other factors come into play. Is pain an injury? Does medical personnel have to be seen prior to the determination or an injury? I do not define the word sufficiently, you will use your own definition and most likely make incorrect assumptions on the paper. Further, a definition based on time loss or mechanism will exclude or include results that completely change the findings. Walter et al.(22) termed it the “tip of the iceberg phenomenon” because a definition predicated on medical personnel will be biased to acute, serious injuries and completely underestimate overuse and less severe injuries. This is a big problem if we believe that one injury increases the likelihood of another.(20) Based on a definition we may get an incomplete picture of the problem we face when trying to protect athletes from injury.