Musculoskeletal Scenario 13!!

Scenario 13 – the hip
Arthur Black is an otherwise fit and healthy 67 year old who has had longstanding problems with his left hip. He was diagnosed with OA hip by his GP and has recently had a total hip replacement. He returned home 6 days post operation and has been referred to the domiciliary physiotherapist for assessment and treatment. Arthur is a retired engineer who usually cycles and runs alternate days; he is keen to return to his usual activities. He is managing his pain with NSAIDs. He has a medical history of insulin dependent diabetes and previous episodes of low back pain.

Identify the Pathology:
You already know he has been diagnosed with OA hip. Osteoarthritis is the most common form of arthritis in which low-grade inflammation results in pain in the joints. This is caused by abnormal wearing of the cartilage that covers and acts as a cushion inside joints and there is also destruction or a decrease of synovial fluid that lubricates those joints. As the bone surfaces become less well protected by cartilage, the patient experiences pain upon weight bearing, including walking and standing. Ligaments also become more slackened. It can arise from trauma or can be hereditary. It causes mainly pain and loss of movement.
OA can’t be cured but can be improved through rest, weight control and exercise. In this particular patient NSAIDS have been used which are local injections of glucocorticoid (a steroid hormone) which help with pain.
He also has diabetes which requires the injection of insulin.
He has had a total hip replacement recently and so has been unable to exercise, likely to have stiff joints and need active assisted movement.
Has previous history of low back pain.


Relevant anatomy of the hip:
Joints:
Hip joint between the head of the femur covered in articular cartilage and the hip bone.
Bony Points:
Greater trochanter
Lesser trochanter
Gluteal tuberosity
Anterior superior iliac spine of the pelvis
Rim of acetabulum on pelvis

Common symptoms and where is the pain?
Acute pain around joint of hip, especially when performing larger movements. Often occurs when walking or exercising. Pain is sharp.
Stiffness of the hip joint which increases throughout the day.
Reduced ROM in flexion, extension and medial/lateral rotation of the hip.
Possible swelling of the joint later on in the day.
Pain and difficulty when abducting/adducting the hip.

Post-operation
· Slight pain, but no chronic pain as before.
· Joint is inflamed and swollen but will decrease in size as days go on.

What would you expect to hear in a subjective assessment?
Joint becomes more painful as the day goes on. Pain is constant but worsens throughout the day.
Pain feels sharp and there is a burning sensation in the surrounding muscles and tendons during movement.
Feel unsafe walking, often feel fatigued and feel joints seize up.
Patient is on NSAIDS steroids.
Patient is retired but still does regular exercise i.e. biking and running.
Lower back pain could be causing patient problems, it is a yellow flag for chronicity of the OA condition.

Post-operation
Patient wants to return to daily activities i.e. biking and running.
Less pain and feels joints are stiff after resting after the operation.

Objective assessment
Observe the area around the hip. Look for:
Swelling
Skin colour
Posture of patient
Any deformities
Any loss of muscle bulk

Active movements. For each of these look at range of movement (measure using goniometer, amount of pain experienced and compare right leg to left.
Laid on bed – Hip flexion/extension
Laid on bed – Hip adduction/abduction
Laid on bed – Medial rotation
Laid on bed – Lateral rotation

Passive movements (same as above), and compare ROM and pain to active movements.

Resisted Tests:
Hip flexion
Hip extension
Hip abduction
Hip adduction
Medial rotation
Lateral rotation
Check for muscle strength, compare right and left legs.
You would do all of the above tests both before and after the operation to compare the results.

Special tests to uncover any problems with the hip replacement or muscle tone:
Faber’s test
Ober’s sign
Rectus Fermoris contracture test
Thomas test
Trendelenburg’s sign

What would the results be if the model had the condition?
With low back pain the result could be chronic OA.
Reduced ROM on all the tests pre-operation compared to post-op.
Improvements with stiffness post-op.
Possible weakness in hip abductors so positive Trendelenburg’s test.