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Early Capsular Pattern of the Hip

 
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Early Capsular Pattern of the Hip - May 18, 2005 7:35:00 AM   
Jordan

 

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I have been researching Hip capsular patterns for OA and I am coming up with some interesting findings. There is some new research (2003) out of Sweden suggesting that Cyriax and Kaltenborns capsular patterns may be unreliable for hip OA. Has any one had experience with loss of extension / internal rotation as an early cappsular hip pattern?
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Re: Early Capsular Pattern of the Hip - May 18, 2005 8:37:00 AM   
dosrinc

 

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From my experience, loss of hip IR is the earliest sign of true capsular patterns of the hip, usually in concert with groin pain with overpressure at end range. I have found restrictions in any other direction to be less reliable.
Rick

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Re: Early Capsular Pattern of the Hip - May 18, 2005 10:56:00 AM   
Jordan

 

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Rick, this sounds reasonable considering the lack of reliable evidence out there. Thought process: IR requires posterior capsule acompanyment. Extension produces a wraping effect of the Y ligament possibly forcing a posterior glide of the femoral head. This may increase the requirement of the posterior capsule when applied with distraction. What do you think?

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Re: Early Capsular Pattern of the Hip - May 18, 2005 11:14:00 AM   
JLS_PT_OCS

 

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Check out these links calling into question the concept of capsular patterns as a useful method for examining hip/determining OA.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12701461

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9808397

Enjoy...
J

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Re: Early Capsular Pattern of the Hip - May 18, 2005 11:39:00 AM   
Jordan

 

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Thanks J

these are what I was refering to

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Re: Early Capsular Pattern of the Hip - August 21, 2005 7:33:00 PM   
kenstack

 

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Given that PROM values are a poor indicator of OA status in the hip I think the clinician is more likely to determine the presence of OA in the hip through WB testing in the absence of radiologic information. The palpable or even audible crepitus from touching joint surfaces can tip you off to OA. This could be assessed with some functional stepping movements. I'm don't believe that crepitus phenomenon will occur with avascular necrosis but I'm not sure - maybe someone knows. I will continue to check for flexion and IR limitations at a minimum when OA is suspected in the hip.

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Re: Early Capsular Pattern of the Hip - August 21, 2005 8:20:00 PM   
jma

 

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This is very interesting news. Definitely something to think about. Wonder if this is being told to students in PT programs.

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Re: Early Capsular Pattern of the Hip - August 22, 2005 11:28:00 AM   
JLS_PT_OCS

 

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Ken-
That sounds like a reasonable approach to me.

I don't think this news really changes those of us doing impairment-level treatment that much, as the deficits are still there regardless of the "diagnosis".
But good stuff to be aware of...

J

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Re: Early Capsular Pattern of the Hip - August 26, 2005 2:18:00 PM   
srcase

 

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I just evaluated a 20-year-old male soccer player with groin pain who has almost no hip IR on the symptomatic side, firm end feel (supine, 90/90 position) and pain with overpressure into IR. His non-symptomatic side also lacks IR, but not as severe. He has a history of LBP and partial tear of the ipsilateral quadriceps (1 year ago). He is fairly strong except some mild weakness in gluteus medius and TFL. I thought his flexibility would be worse, but he is just slightly tight in adductors, rectus femoris, and TFL/ITB.
Given his age, could this be early OA? OR is it just capsular tightness from the quadriceps injury. Any other possible diagnoses?
Sarah

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Re: Early Capsular Pattern of the Hip - August 26, 2005 2:49:00 PM   
Randy Dixon

 

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Why is he seeing you?

What I mean is he didn't come in complaining of lack of IR. What is hurting him and what can't he do?

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Re: Early Capsular Pattern of the Hip - August 26, 2005 2:54:00 PM   
srcase

 

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He has groin pain with lateral movements, bending low and lifting. He cannot play soccer or other high level gait/sporting activities.
I suspect some lumbar involvement. Another weird finding is that he has almost no lumbar extension in standing, but can extend in sitting and prone. I thought he had hip flexor tightness but his iliopsoas is normal length. Could a tight rectus femoris account for lack of standing lumbar extension?
Sarah

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Re: Early Capsular Pattern of the Hip - August 27, 2005 3:58:00 AM   
nari

 

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Sarah

Is his RF tight? What happens in prone knee bend?
What happens with slump? SLR in sidelying and sitting? what limits his extension in standing - pain or a loss of awareness of the movement and nothing happens?
Sorry, more questions...

Nari

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Re: Early Capsular Pattern of the Hip - August 27, 2005 7:38:00 AM   
Jon Newman

 

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Sarah,

How long has he had the pain and has he had a regionally similar pain in the past? If so how many times and since when?

You mention that he can't extend in standing. Is pain limiting the movement or he literally cannot extend?

A possible idea would be a hernia of some sort that depends on gravity and position to exacerbate symptoms.

I assume he's seen his MD. What did the MD have to say--what diagnosis did he come with?

jon

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Re: Early Capsular Pattern of the Hip - August 27, 2005 9:16:00 AM   
Randy Dixon

 

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I am working on a theory about mobility/stability for my own simple brain. The fact that he can't extend while standing but can while sitting or prone makes me think a pelvic instability. You can humor me by placing an SI belt on him and testing him.

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Re: Early Capsular Pattern of the Hip - August 27, 2005 9:29:00 AM   
Randy Dixon

 

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Also have you considered musculoskeletal myth #7.

Osteitis Pubis:

Presenting complaints include the insidious development of progressively worsening pain--unilateral or bilateral groin (inguinal), medial thigh, testicular, scrotal, perineal, suprapubic, anterior pubic area, and/or hip--along with restricted motion. Pain is often described as sharp, stabbing, or even burning and is exacerbated by running, pivoting (especially one-legged), twisting, climbing stairs, kicking, sit-ups, leg raises, or Valsalva maneuvers (2-19). Patients may have difficulty lying in bed at night (5,14). If instability is present, patients may describe an audible or palpable clicking sensation at the symphysis pubis with certain activities (eg, arising from a seated position, turning in bed, or walking on uneven surfaces) (6,9,10,13,14,19). Rest usually relieves the symptoms, but not entirely.

Physical exam. Usually, tenderness is present on palpation of the area over the pubic symphysis (4-18), and there may be either unilateral or bilateral discomfort with palpation over the superior (rectus abdominus) and/or inferior (adductors) pubic rami (2,4-6,11-15). Hip motion can be restricted because of surrounding muscle spasm, especially of the adductors (2,5,6,10,12,14,15). Passive hip abduction or resisted hip adduction and flexion may elicit pain (2,5,6,8-16,18,19). Specific tests, such as the lateral pelvic compression or cross-leg tests, are often positive (6,9,10,12,14). Trendelenburg's test, if positive, indicates weak hip abductors (12). In severe cases, patients may demonstrate a wide-based (antalgic) gait disturbance, with the hips and knees partially flexed (6,9,10,14,17).

Imaging. Plain radiographs (AP and lateral) of the pelvis are an integral component in the diagnostic workup. However, it is important to realize that most abnormalities are not specific for osteitis pubis, and radiographs can lag behind clinical symptoms by as much as 4 weeks (9,11-13,16,17).

Early in the course, it is not uncommon for radiographs to be normal (2,6,7,9-11,17). After about 4 weeks, findings such as unilateral or bilateral fraying or roughening of the marginal periosteum and widening of the symphysis joint space may be seen (2-19). As the disease progresses over several months, radiographic changes include reactive sclerosis of adjacent pubic bones, erosion and resorption of the symphysis margins, and widening of the joint space (2-10,12-19). Bilateral, symmetric rarefaction and cortical bone destruction are common findings (7-9,14,16,17). Gradual reossification with complete restoration of the joint is associated with healing and can take several months. Residual sclerosis, osteophytes, and cysts may occur (3-8,14). Additional one-legged, standing flamingo views are beneficial if instability is suspected (3-5,8,12,13,19). Instability is defined as greater than 2 mm of height difference between the superior rami of the symphysis (4,13,19). Many experts also recommend sacroiliac joint films since they are frequently involved in the process (3,5,8,12-14).

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Re: Early Capsular Pattern of the Hip - August 27, 2005 12:02:00 PM   
srcase

 

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Randy, he's not that involved. Really the symptoms are not very irritable. He can do pretty high level functional exercises in the gym without increased pain.

Nari, I haven't looked at slump test mostly because the patient was just transferred to me from another facility because he didn't like his therapist and the athletic trainer he was working with (for one week) was fired.
So, my evaluation was fairly quick and I definitely need to look at neurodynamic testing a little more.

Jon, the current pain has been present for about 4 months. Standing lumbar extension is not limited by pain, he just can't go there. After reading all of your questions, I am thinking it is simply lack of hip extension that is limited him. Hence, the questions about early hip OA because he is certainly lacking IR, and most likely extension. Thomas test was negative for hip flexor tightness though, but I'm going to retest that one because I don't think he was at the edge of the table (we were in a cramped space).

I've only seen him once and I did a lot of hip joint mobs (lateral traction in flexion and IR, posterior capsule) and manual muscle stretching. That is something he hasn't had up to this point and he has had about 6 weeks of therapy already focusing mostly on strengthening exercises. I stretched him pretty aggressively and he felt better, so we'll see.
Sarah

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Re: Early Capsular Pattern of the Hip - August 28, 2005 4:35:00 AM   
Randy Dixon

 

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Hi Sara,

I wanted to ask some questions but I think I should clarify that I'm not challenging you just asking for my own education.

I don't think the above is necessary but people have been so touchy lately I wanted to be sure.

Why would a young, athletic man suddenly lose hip extension, or get disabling OA? How could rectus femoris tightness prevent back extension, at least if he can do it sitting or standing? Why did you dismiss the OP possibility? There is a continuum of injury on this diagnosis from mild to severe.

I ask because I am curious to your thought processes here. I'm kind of partial to the OP diagnosis. Here is my reasoning: Young male soccer player, the most common population for this diagnosis. Groin pain, pain or lack of hip IR, with pain on provocation. Probably inhibited glute med., unable to do cutting or lateral movements without pain. All these are good indicators.

Hx. LBP, which might suggest SIJ or pelvic dysfunctions, or might not. However the - standing back extension with the +sitting one suggests to me that with the pelvis supported back extension is possible. This to me suggests instability. Pelvic instability or movement dysfunction is correllated with OP. I can see how having a torn quadricep could lead to altered gait and biomechanics with uneven weight bearing on the pelvis, along with kicking and other unilateral LE movements causing OP.

Again, I'm just asking for my own education, trying to understand peoples approaches. For example, it comes as no surprise that Nari asks about neural tests.

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Re: Early Capsular Pattern of the Hip - August 28, 2005 1:11:00 PM   
srcase

 

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Randy,
No offense taken, I hope it didn't seem like I blew over your suggestion either. I guess I am not thinking pelvic problems because I did the 5 SI joint tests, as well as many single-leg functional hip excursion tests, and got no reproduction of the pain. What I did notice is decreased motor control and compensatory movements during the functional tests (for example he externally rotated his pelvic on his hip while doing a single-leg hip hike/drop on the involved side).
Lastly, my comment about the irritability of the involved tissue was relevant. I believe OP to be much more easily irritated and provoke more intense symptoms (sharp, burning pain). He describes only a dull ache and has difficulty even pinpointing what makes it better or worse (leading me to think possible lumbar/nueral issue).
The aggravating activities in OP are eerily similar though, so I will take another look!
Sarah

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Re: Early Capsular Pattern of the Hip - August 28, 2005 7:58:00 PM   
eam

 

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Hi Sarah,
I have limited IR on my left side, neg. Thomas Test, and actually increased hip extension. And I also have hip pain which flares up now and then. This weekend was one of those flare ups. I have had xrays and MRI done-all of which were unremarkable. To throw a little Sahrmann into this, maybe the femoral head is in the "anterior glide" position. Are his only aggravating activites, lateral movements, bending down and lifting? What about walking long distances? I would continue with the hip mobs, post.capsule. Try some of the Sahrmann hip tests. Just a few different ideas...
Erica

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Re: Early Capsular Pattern of the Hip - August 29, 2005 12:56:00 PM   
Shill

 

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Hey Erica,
How is your L spine? Just curious.
And Sarah, any chance his bilateral lack of IR is due to femoral anteversion? Any familial history of hip problems?
Steve

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