Lumbar Pelvic Hip Differentiation

[Michael McMurray]

Here is a good article from Feb JAAOS (“The Yellow Journal”) : #1 Impact Factor Ortho Surgeons Journal – know what your referral sources are reading to be better communicators with our colleagues.

I’m always interested in how Orthopods make clinical decisions to rule out/in competing diagnoses.

Lumbopelvic-Hip/SIJ differentiation is always challenging.

Have a read – post your thoughts about how we as PTs differ from the decision making here discussed in the article.

Cheers

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[Justin Bittner]

I like how much emphasis was put on the patient’s subjective history at the beginning of this article. I feel this is an area that we excel in as physical therapists (more so than docs due to the duration of time we can spend with our patient) and a thorough history can direct and expedite our objective exam.

One thing from the History portion of this article I found interesting was that it talks about a patient reporting pain in the hip while lying on left side is likely indicative of trochantaric bursitis. For myself, I generally think of the that pain as a referral from a lumbar facet (thinking about the patient being side bent), and then look toward a glute tendinopathy. I feel like the research generally supports the lack of true trochanteric bursitis cases. Also, from the History portion, the article didn’t mention any correlation between L1-2 and groin pain. I have found that on several occasions.

I also use the Laslet cluster to rule out SIJ. The article did mention 2 of the 6 tests to rule in SIJ but did not mention the rest. This could be to expedite the exam. I thought it was interesting there was no mention as using the pubic percussion test for femoral neck stress fracture, especially based on its sensitivity.

For lumbar pathologies the article didn’t mention radiculitis vs. a true radiculopathy. Also, didn’t mention annular tears or facet dysfunction. It could just be a terminology thing and it was good to see the terms that MDs primarily use and are familiar with. I feel like my communication with MDs regarding these pathologies may need to change a little bit.

In regards to terminology, the article did not mention motor control dysfunction which is similar to Scott’s case this past weekend for the hip. Also a common disfunction in younger female population with low back pain. There may be a better way to communicate these findings to a doc if these are terms they do not use.

Overall, I thought the article was good. I liked how they really drive home that usually back and hip pathologies are not in isolation and typically both display pathologies that need to be treated together to obtain full resolution of symptoms. I feel that, as physical therapists, we experts at identifying hip and lumbar pathologies and their correlation. Its nice to see that MDs are looking at these things as well. I always like to give patients a pie chart analogy to explain findings (“70% hip, 30% lumbar”) so they know why I’m treating both.

[Kyle Feldman]

Hey Justin. We had a lengthy conversation about radicular pain here a few weeks ago. The director here has worked a lot with neuro MDs and they are very strong on saying that in order to have radicular pain you have to have a radiculopathy. So by the medical definition, radiculitis is a stage of radiculopathy and not a lesser degree or something different. This may be why they don’t differentiate in the paper, because if you have radicular pain it is a radiculopathy (and apparently you do not need hard signs to call it one. it would just be a less severe case).

This concept was new to me coming here but I agree it is a terminology difference.

Great pie chart idea. I have been using that myself. Using it for the driver location as well as the type of pain (nociceptive, neurogenic, centrally evoked, etc.)

[Justin Bittner]

Thanks for the information, Kyle. Perhaps, I will be using radiculopathy more often in my assessments instead of radiculitis. Maybe the assessment portion of my exams will be sound more like “radiculopathy with/without signs of nerve root compression including myotomal weakness/sensation loss/diminished reflexes”.

Does that sound better than “L5 radiculitis”?

[Kyle Feldman]

I had the same education as you up to this point so I would always use what you have been doing. But from what I have learned here, that seems to fit more with the lingo the neuro MDs are using.

[Justin Bittner]

Thanks, will do. I think it makes sense to have the whole medical team on the same page to provide the best care to the patient. So we should at least know the differences in our language to prevent miscommunications.

[Scott Resetar]

Cool article. In regards to the clinical reasoning, obviously there is a ton of mention in there for imaging, which we don’t rely on as much. Its very interesting that their way of thinking is so based on “What can surgically correct on this person”.

As Justin mentioned, you don’t see much mention of facet joint dysfunction. It may be that this isn’t a common area to do a surgery, whereas we see it quite a bit as the source of dysfunction.

The most interesting thing to me were the stats on THA and low back pain. I think the articles that they cite are a great marketing opportunity to physicians. Read this nugget:

“In a retrospective study of 3,206 patients with hip OA (566 of whom also had LBP) who underwent THA, Prather et al reported that, although all of the
patients had improved pain and hip scores, the patients without LBP had greater improvement in function and pain relief, incurred fewer medical charges per episode of care, and spent fewer days in the hospital per episode of care compared with the patients who had LBP”

I would take this article to any hip specialist and say that they should send their prospective hip surgery patients to me to treat their LBP because it will improve their surgical outcomes.

Here are a few other hot takes from this article that I think are interesting:

“The inability of a patient to lie on his or her side is likely caused by trochanteric bursitis rather than lumbar radiculopathy or intra-articular hip pathology.” – I’m don’t always think this is the case, as the mild lumbar sidebend in this position can also exacerbate lumbar symptoms.

“If a limb-length discrepancy exists, blocks should be placed under the patient’s short leg to obliterate pelvic obliquity before observing spinal alignment.” – This is interesting because I think I would like to see their normal alignment and how they move throughout their day first, and then see what happens with a heel lift second. Many times the person had no pain for years despite the leg length discrepancy.

“Trendelenburg test also may be positive in patients with L5 radiculopathy
as a result of the innervation of the gluteus medius and minimus.” – I don’t consider this much in my clinical reasoning. Clinical pearl noted! Check L5 with all trandelenburgers.

The best sentence in the whole article – “Care should be taken to correlate a patient’s diagnostic tests with his or her history and physical examination because positive findings increase with patient age.”

“Leriche syndrome, which is a form of internal iliac artery stenosis, can result in buttock and thigh pain.” – A great thing to add to our differential as a vascular source of pain!!! I expect this on all clinical reasoning forms for buttock and thigh pain.

I know this is a novel.

[August Winter]

As several other commenters have already talked about, I like the emphasis on a thorough subjective history, and the importance of correlating imaging findings with the rest of the examination. I also liked the consideration for the interplay between hip and low back pain and pathology.

The article discusses the importance of palpation of structures and discusses some assessment of muscular strength and length, but overall I thought this area was the most lacking in the objective assessment. There was no mention of possible trigger point referrals despite discussing the muscle areas which they frequently develop. Considering trigger point injections are not an uncommon intervention to be provided in the pain management setting I wonder if surgeons as a group do not look at trigger points as an important pain producer. Glute min trigger point sure looks like L5 radiculopathy, definitely something that I would hope would be mentioned in a review like this.

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