Flexion Abduction External Rotation Research Articles

Greater trochanteric pain syndrome: defining the clinical syndrome

BackgroundEffective treatment of hip pain improves population health and quality of life. Accurate differential diagnosis is fundamental to effective treatment. The diagnostic criteria for one common hip problem, greater trochanteric...

Screening of asymptomatic elite youth hockey players: clinical and MRI exam

BackgroundIce hockey players are reportedly at increased risk to suffer hip injuries. This may be due to repetitive hip positions during the ice hockey skate stride.ObjectiveTo determine if specific tests...

The Diagnostic Validity of Hip Provocation Maneuvers to Detect Intra-Articular Hip Pathology

To determine which hip provocation maneuvers best predict the presence of an intra-articular hip pathology. Prospective diagnostic study. Musculoskeletal clinic at a university-based multispecialty group practice. Fifty subjects referred for intra-articular hip injection under fluoroscopic guidance. Subjects were examined with 4 pain provocation maneuvers before and after anesthetic intra-articular hip injection administered under fluoroscopic guidance. Presence of intra-articular hip pain generator was confirmed by > or =80% improvement on visual analog scale after intra-articular hip injection. The most sensitive tests were flexion abduction external rotation (FABER) test and internal rotation over pressure (IROP) maneuver. For the FABER test, sensitivity was 0.82 (95% CI 0.57-0.96); sensitivity for the IROP maneuver was 0.91 (95% CI 0.68-0.99). The most specific test was the Stinchfield maneuver, with specificity at 0.32 (95% CI 0.14-0.55). FABER and IROP had the highest positive predictive value, with 0.46 (95% CI 0.28-0.65) and 0.47 (95% CI 0.29-0.64), respectively. IROP had the highest negative predictive value at 0.71 (95% CI 0.25-0.98). IROP and FABER may be worthwhile components of the clinical evaluation of hip pain to determine intra-articular hip pathology. These tests are nonspecific and therefore not necessarily negative in the absence of intra-articular hip pathology. These hip provocation maneuvers are a useful part of an evaluation that includes history, further examination findings, and other diagnostic studies.

Femoroacetabular Impingement Due to Synovial Chondromatosis of the Hip Joint

This article describes a rare case of primary synovial chondromatosis of the hip associated with classical femoroacetabular impingement. A 38-year-old man presented with left hip pain of 3 years' duration and range of motion (ROM) limitations. Flexion abduction external rotation and impingement tests were positive and preoperative Harris Hip Score was 68. Radiographs showed multiple loose bodies, a calcified labrum, and a bump at the head-neck junction. Computed tomography (CT) confirmed the findings. Acetabular overcoverage and the crossing over sign were present. The lateral center edge angle was 48 degrees, acetabular roof angle was +2 degrees, alpha angle was 80 degrees, triangular index was 2 mm more than the radius of the femoral head, and anterior offset was 4.5 mm. Magnetic resonance imaging (MRI) revealed an acetabular labral tear, impaction on the femoral head-neck junction, and mild synovial hypertrophy with no acetabular cartilage damage. Loose body removal along with a total synovectomy, excision of the calcified labrum, and osteochondroplasty of the head-neck junction were performed after safe surgical dislocation. At 6-month follow-up, the patient was doing well with a Harris Hip Score of 96, improved ROM, and negative flexion abduction external rotation and impingement tests. Early diagnosis of synovial chondromatosis and impingement can be made by MRI and CT. Clinically, flexion abduction external rotation and impingement tests are positive in 99% and 97% of cases, respectively. Although arthroscopy management has been described for both the entities separately, it has drawbacks. With an open procedure, debridement of the hip joint and excision of femoral and acetabular impingement deformities are possible at the same time.

Iliopsoas Bursitis

A 60-yr-old man with osteoarthritis, lumbar degenerative disc disease, and left total hip arthroplasty presented with right groin and buttock pain for several months. There was no history of rheumatoid arthritis or known precipitating event or injury. Aching pain was increased with weight-bearing activities. Unsuccessful previous treatment included nonsteroidal antiinflammatory drugs, chiropractic adjustments, and physical therapy. Physical examination demonstrated an endomorphic male patient with a reduced lumbar range of motion, and the results of the neurological examination were normal. Flexion Abduction External Rotation test on the right reproduced low-back and buttock pain. The x-rays of both hips in weight bearing demonstrated severe osteoarthritis of the right hip and a stable left hip total arthroplasty. An initial diagnostic consideration was right sacroiliac joint inflammation, and treatment included weight reduction, an exercise program, and a corticosteroid injection of the right sacroiliac joint. This procedure and a subsequent fluoroscopically guided corticosteroid injection of the right hip joint were ineffective. Magnetic resonance imaging of the right hip and pelvis demonstrated a large periarticular thin-rimmed cystic lesion centered anterior to the right femoral head within the iliopsoas muscle and extending inferiorly along its tendon, consistent with iliopsoas bursitis (Fig. 1). The iliopsoas tendon was intact, and there was no evidence of avascular necrosis of the femoral head.FIGURE 1: Axial T2-weighted, fat-saturated image demonstrates the right iliopsoas tendon with surrounding fluid-distended bursa (white arrow). ote the normal contralateral tendon and lack of bursal fluid (black arrow) in this patient who is status postleft total hip arthroplasty.Aspiration of the cyst was performed using ultrasonography guidance, withdrawing 25 ml of serous fluid (Fig. 2) followed by injection of methylprednisolone and bupivicaine. Within 48 hrs, his pain level had dropped from a score of 5 to 2 on a visual analog scale. At 3 wks after the procedure, he had partial return of his symptoms, and a repeat aspiration/corticosteroid injection was performed with resolution of his groin pain.FIGURE 2: Iliopsoas bursitis aspiration and injection. agittal image demonstrates the needle within the fluid collection (arrow). Note the iliopsoas tendon (*) and the acetabulum (+).Pain in the region of the groin and anterior hip in a patient with advanced osteoarthritis involving both the hip and spine may pose diagnostic and therapeutic challenges. Differential diagnosis includes lumbosacral radiculopathy, hip joint pathology, inguinal hernia, appendicitis, gynecological pathology, femoral artery aneurysm, and other causes. Risk factors for iliopsoas bursitis include rheumatoid arthritis. Pain is increased with weight-bearing activities, putting on socks and shoes, or arising from a chair. Blood tests are not usually indicated but may help in assessing for a rheumatological disorder. The results of hip radiographs are normal in cases of iliopsoas bursitis. Diagnostic ultrasonography may demonstrate bursitis or tendinitis but can be operator dependent. Magnetic resonance imaging is the current imaging standard for evaluation of painful conditions of the hip and pelvis. The most commonly reported magnetic resonance imaging appearance of iliopsoas bursitis is a thin-rimmed, homogeneous cystic fluid collection. Treatment may include antiinflammatory medications and stretching of the hip flexor muscles followed by a strengthening program. Aspiration and corticosteroid injection of the bursa should be performed for persistent pain symptoms. Communication with the hip joint may occur in up to 15% of cases, and repeat injection may be required. Surgery is rarely indicated.

The Diagnostic Accuracy of a Clinical Examination in Determining Intra-articular Hip Pain for Potential Hip Arthroscopy Candidates

One purpose of this study was to determine whether signs and symptoms could identify when a majority of the hip pain was originating from intra-articular sources in potential arthroscopic surgery candidates. The second purpose was to quantify pain reduction after an anesthetic intra-articular injection in those with potential labral pathology. Subjects with hip pain being evaluated by an orthopaedic surgeon specializing in hip arthroscopy were prospectively enrolled in the study. Clinical examination results were recorded. Sensitivity, specificity, and likelihood ratios were calculated to determine their accuracy in identifying those who would have greater than 50% pain relief from those with 50% pain relief or less. We enrolled 105 subjects in this study. An anesthetic intra-articular injection was performed in 49 potential candidates for arthroscopic surgery (47%). The mean age in these 49 subjects was 42 years (SD, 15 years; range, 18 to 68 years), with 25 men (51%) and 24 women (49%). According to magnetic resonance imaging (MRI) arthrogram, 18 individuals had a definite labral tear, 29 had a possible tear, and 2 had no labral tears. In those with definite tears or possible tears, 39% (n = 7) and 45% (n = 13), respectively, did not achieve a greater than 50% reduction of pain. Groin pain, clicking, pinching pain with sitting, lateral thigh pain, flexion abduction external rotation test, flexion-internal rotation-adduction test, and trochanteric tenderness were not useful in identifying those with greater than 50% pain relief from those with 50% relief or less. The symptoms and signs investigated in this study did not accurately or consistently identify subjects with primary intra-articular pain sources. Furthermore, candidates for hip arthroscopy with a labral tear identified on MRI arthrogram had varied responses to anesthetic intra-articular injection. Therefore all labral tears identified on MRI arthrogram may not be a major contributor to patients' pain complaints, and medical personnel should look for other causes of pain. Level III, diagnostic study of nonconsecutive patients (without consistently applied gold standard).

The Early Diagnosis of Sacroiliac Joint Infections in Children

We retrospectively reviewed the medical records and imaging studies of 15 children with infections of the sacroiliac joint to determine the usefulness of specific examinations and studies to aid in the early diagnosis of this condition. The clinical presentation, physical examination findings, pertinent laboratory data, and imaging studies were reviewed. Thirteen patients (87%) were febrile at the time of presentation. One patient presented in septic shock requiring intubation and critical care management. Tenderness to palpation over the sacroiliac joint was present in all 9 patients who had this examination performed, and the flexion abduction external rotation test was positive in 10 of 12 patients (83%) who had this test done. Laboratory indicators of infection were elevated in most patients, and 6 patients (46%) had positive blood cultures, most commonly growing Staphylococcus aureus. Initial conventional radiographs were negative in all but 1 patient. Radionuclide 99-m-technetium bone scans were positive in 7 of 10 patients (70%), and magnetic resonance imaging studies were ultimately positive in 13 of 14 patients (93%). However, within the first 6 days after the onset of symptoms, only 5 of 8 bone scans (63%) and 5 of 9 magnetic resonance imaging studies (57%) were consistent with infection. We conclude that while diagnostic imaging studies are ultimately helpful in confirming the diagnosis of sacroiliac joint infections in children, studies made within 6 days of the onset of symptoms may not always confirm the diagnosis. The early diagnosis of this condition is best made on the basis of clinical and laboratory findings. Therapeutic Study, level IV (Case series [no, or historical control group]).