I recently had an interesting hip case come through the clinic. After practicing only six years, I've discovered there are some joints for which I have more clinical intuition, and the hip certainly isn't one of them. As a result I found the need to do some catching up.
Unfortunately, the referring physician was not much help in this case with a referring diagnosis of "hip pain". While interviewing the patient, he revealed the physician had spent approximately three minutes with him and performed no physical exam. The only diagnostic puzzle-piece we had was that he did not have any signs of OA on plain film.
During the examination the patient had focal hip pain that I gradually suspected was intraarticular in nature. I recently posted the case on MyPhysicalTherapySpace.com if you'd like to see it in more detail.
In researching the case, I found a very good article from the Journal of Bone and Joint Surgery on acetabular labral tears. The authors retrospectively examined sixty-six individuals with confirmed labral tears via arthroscopy to determine what clinical variables were most closely associated with the pathology. The clinical findings were as follows:
- 86 percent of the cases reported moderate to severe pain
- 92 percent reported symptoms localized to the groin and that activity worsened symptoms
- Only 39 percent had a Trendelenberg sign or observable limp
- 95 percent had a positive impingement sign of the hip
Although the clinical features of acetabular labral tears were useful, a more telling set of statistics emerged from this report:
- Nearly 20 percent of the patients were referred for a surgical procedure to a uninvolved site
- The patients were seen by an average of 3.3 providers prior to establishing a definitive diagnosis
- The average duration of symptoms from onset to successful diagnosis of the tear was 21 months
The findings of this study were directly applicable to this case. He and I had been discussing the likelihood that this was not a simple muscle strain as postulated during his initial visit. After a underwhelming four week follow-up experience with the referring orthopedist, I referred the frustrated patient to a physician known for performing an actual physical exam. An immediate MRA to the hip was ordered.
Not surprisingly, the MRA was positive for significant intraarticular pathology including a subchondral defect, moderate OA, and a fatty tumor encroaching upon the posterior branch of the obturator nerve. Labral pathology is questionable. The orthopedist suspects one may be present and will investigate this intraoperatively along with a surgical oncologist.
I think this provides a good example of how physical therapists can be a potential diagnostic gateway for our patients. Unfortunately, we can't take for granted the referring physician always brings their A-game to the exam room. Also if we are angling to be direct access providers, our clinical diagnostic skills will need to remain sharp. In this case, my exam certainly wasn't specific for the myriad of pathology present in this gentleman's hip. However it was sensitive enough to detect that there was certainly more to the story. Hopefully this story will have a happy ending.
Burnett, R.S. (2006). Clinical Presentation of Patients with Tears of the Acetabular Labrum. The Journal of Bone and Joint Surgery, 88(7), 1448-1457. DOI: 10.2106/JBJS.D.02806