Tutorial Case #1

Hip Joint Region Case Presentation – Part 1

History:Logan is a 38 year old athletic male complaining of an onset of right intermittent inner groin and thigh pain some three weeks ago after returning to jogging/running in preparation for a 35 and over basketball league. Logan’s symptoms are increasing in severity, frequency and duration. He has had no treatment to date except for resting from basketball over this past weekend. He is interested in an evaluation to determine if therapy can help his problem. His past history is significant for a groin pull 20 years ago during an intra-mural basketball game. He recalls that symptoms at that time were more severe than this current episode.

Following this previous incident, Logan took 3-6 months off to resolve his symptoms, however he did not receive any formal treatment. Six years ago, while skiing, Logan fell and suffered noticeable bruising in the upper thigh region the following day. He recalls limping for several months before the symptoms resolved. He works-out regularly with weights, swimming and stationary bicycle. He states he does not stretch with regularity. Logan’s job as a VP for an entertainment company is mainly sedentary. Logan has been HIV positive for 6 years and is currently on the ‘drug cocktail’ treatment. His T-cell count was approximately 220 at his last check-up one month ago. He lost his lover of 8 years to AIDS 8 months ago.

Examination: Subjective

Current History:38 y/o athletic male with onset of right inner groin/thigh pain 3 weeks ago with return to jogging/running in >35 basketball team. Symptoms are increasing in frequency and duration. No treatment to date except for resting from basketball.

Previous History:20 years ago reports a groin pull, in an intramural basketball game. Symptoms reported more severe at that time, than with the current episode. Recalls previous incident taking 3-6 months to resolve, without treatment. Reports skiing 6 years ago, when he fell injuring right hip with noticeable bruising in the upper thigh the next day. He remembers limping for several months before his symptoms resolved. He works-out regularly with weights, swimming, and stationary bike. He states he doesn’t stretch with regularity.

Social History:His job, as a vice-president for an entertainment company, is sedentary. He has been HIV positive for 6 years and is currently on the “drug cocktail” treatment. His T-cell count is approx. 220 at his last check-up one month ago. He lost his partner of 8 years to AIDS 8 months ago.

ROS: unremarkable except for AIDS

Aggravating factors:stepping up stairs, immediate increase pain, settles 3 minutes, “7” on pain scale

jogging, immediate pain, settles 5-10 minutes “7” on pain scale

Easing factors: lying supine with hip slightly flexed and pillow under thigh

AM: stiff on waking

Day: variable with activity

Night: awakes turning in bed

Special Questions:

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PT720/PT721 - Orthopedic Tutorial Case Presentations #1

Tutorial Case #1

GH: HIV positive

WL: 

Meds: ZDV, 3TC, Ritonravir, Tagamet,

Diagnostics: x-rays-none

Click: +

Lock: 

Cord:

CE:

Steroids: currently on anabolic steroids

Anticoagulants: 

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PT720/PT721 - Orthopedic Tutorial Case Presentations #1

Tutorial Case #1

Examination: Objective

Observations: Walks with mild antalgic gait; decreased stride length on right

Quick Tests: Squat-1/2 range, pain at the limit;

Stand on right leg 

Hop: unable

Range of Motion:

Passive: Flexion-120 degrees stiff capsular end-feel, painful

Extension – 5 degrees, stiff, painful

Adduction – full range painless

Abduction – 15 degrees, stiff capsular end-feel, painful

External Rotation – 35 degrees, stiff capsular end-feel

Internal Rotation – 5 degrees, stiff capsular end-feel, painful

Other Joints: RightLumbar Quadrant: 20% limited, increases right low back pain

Posterior-Anterior pressures L3-4 25% limited, increase low back/thigh pain

Knee:

Neurological: Unremarkable

Tension Tests: SLR L/R 80 degrees, hamstring limited

PKB full range painless

PNF full range painless

Palpation: marked tenderness adductor brevis, pectineus muscles, reproduces patient’s complaint.

Thickening deep paravertebrals, L2-L5 on the right

Special Tests: Thomas Test 20-degree hip flexion contracture on the right

FABRE + for reproduction of pain

Static Tests: 5/5 painless except adduction and flexion 4+/5 and painful

Learning Objectives for Part I

At the end of the first session of this case presentation the students should be able to:

1)discuss any unfamiliar terms

2)describe the anatomy of the hip joint

3)determine the reason for each special question

4)discuss the concave/convex principle as it relates to the hip joint;

5)demonstrate all ‘special tests’ (namely the Thomas and FABRE tests), neurological and tension tests;

6)outline the possible diagnoses for this patient;

7)discuss the incidence, pathogenesis, prognosis and typical medical/surgical management and rehab course for a person with:

  1. AVN
  2. OA
  3. Hip fracture

8)identify the Preferred Practice Patterns and ICD 9 Codes for this case according to the Guide;

9)plan an initial treatment for this patient;

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PT720/PT721 - Orthopedic Tutorial Case Presentations #1