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CMAC222

Session 07

Disorders of the Hip, Buttock and Groin

Chinese Medicine Department


Sacroiliac Joint Fixations

Strain of Adductors

Osteoarthritis of the Hip Joint

Lateral Thigh Pain

Hip/Buttock/Groin

Topics


The hips can be confusing as there are many structures around the hip.

Also other structures can mimic or present as hip pain

Apply the KISS principle and rule the most likely out first and then move onto less likely situations

Orthopaedic Physical Assessment is paramount when dealing with hip pathologies

When in doubt refer for imaging

Before We Get Started

4© Endeavour College of Natural Health endeavour.edu.au

Argosy Publishing, 2015

In Class Have a look at

Visible Body

Visible Body Muscle Premium

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Explore the Pelvis Anatomy

http://inst.visiblebody.com.ezproxy.endeavour.edu.au:2048/index.html

http://muscle.visiblebody.com.ezproxy.endeavour.edu.au:2048/


Pelvis Bones

Netter, 2014, Plate 330


Female Pelvis



Male Pelvis



Hip Ligaments - Posterior



Hip Ligaments - Anterior



Hip Joint Opened



Psoas and Illiacus Muscles



Superficial and Deeper Muscles



Sacral and Coccygeal Plexus



Deep Muscles of the Hip



Anterior View of the Pelvis

Magee, 2014, p691-2


Chinese Anatomy - Hip

Deadman, et al, 2007, p603, 605


GB29

Deadman, et al, 2007, p446


Jingjin involved in Hip

Kendall, 2002, p224

1. Bladder Channel: (Superficial layers)

2. Gall Bladder (Side stabilisers of hip)

3. Stomach Channel (Psoas)

4. Kidney Channel – (Adductors of leg)

5. Spleen and Liver (inner thigh and pelvic floor

See the Muscle Distribution (Kendall)


See a hip and thigh dissection here

(Not to be viewed in class)

In your own time

Sapiens Medicus, 2013

https://www.youtube.com/watch?v=qiRT_LJ9c3U




Chinese Med Aetiology

Marcus, 2004, p657, Legge, 2011, p270

HIPTrauma

Overuse

Poor Posture

Muscle Tightness

W/C/D invasion

Unknown

Anatomical variation

Inflammation

Previous Injury

Blood Stasis


Reduced circulation

Acute micro

trauma

Disturbed Qi and

Blood flow

Trauma resulting

in hip problems

Pathogenesis

Marcus, 2004, p675, Legge, 2011, p270


Pulling on the hip

Magee, 2014, p651-2

Anterior – Posterior superficial muscle group.

A: muscles and ligaments involved in posterior tilt and

B: muscles and ligaments involved in anterior tilt


Pulling on the Hip

Magee, 2014, p651-2

Lateral Muscle System Inner Muscle Unit


Pulling on the hip

Magee, 2014, p651-2

Posterior and Anterior Oblique Muscle System Deep Longitudinal Muscle System


General Examinations


See exactly where the patient has the pain and can it be reproduced

Get them to point to the painful area

Asymmetry

Tension

Deformities

Previous Surgeries

Gait analysis

Attitude

Observation

Legge, 2011, p268, Magee, 2004, p657


Look

Feel

Move – Passive, active and restricted

Hip - Examination

Image: Reichert, 2011, p224Videos: British Journal or Sports Medicine (BJSM) 2010

See the Hip & Groin Examination

See the Range of Motion here

See the Manual muscle test

(Not to be viewed in class)

https://www.youtube.com/watch?v=Y_EZvm0iSno

https://www.youtube.com/watch?v=UfjQmhoCM5A

https://www.youtube.com/watch?v=UfjQmhoCM5A


Passive, active and restricted movements of the spine should be assessed.

These include:

Measuring Forward flexion

Extension

Side Flexion

Rotation

Move

Magee 2014, p571


Passive, active and restricted movements of the hip joints should be assessed.

These include:

Flexion

Abduction

Adduction

Extension

Medial rotation of the hip

Lateral rotation of the hip

Move

Magee 2014, p660-2


Groin (gently) and thigh for important structures and for tenderness

Pubic symphysis

Inguinal ligament

Illiopsoas

Adductor insertions and muscle bellies

Tensor fascia lata (TFL)

Gluteus medius and minimus muscle and tendon

Trochanteric bursa

Lower back intervertebral segments and muscles

Palpation

Legge 2011, p268-9,Image: Reichert, 2011, p229


Sacrum and sacroiliac joints (SIJ)

Posterior Superior Iliac Spine (PSIS)

Gluteus maximus

Piriformis

Around the trochanter – bursa, gluteus medius and minimus tendons

Lateral thigh for iliotibial band (ITB) tightness and tenderness

Iliac Crests

Ischial Tuberosity

Palpation

Legge 2011, p268-9,Images: Reichert, 2011, p230


Sciatic Nerve Variations

Magee, 2014, p727


Forward flexion of the spine 40°to 60°

Extension of the spine 20°to 35°

Rotation of the spine left and right 3°to 18°

Side flexion of the spine left and right 15° to 20°

Flexion of the hip 100°to 120°

Abduction of the hip 30° to 50 °

Adduction of the hip 30°

Extension of the hip 0°to 15°

Medial rotation of the hip 30° to 40°

Lateral rotation of the hip 40° to 60°

Movements Stressing SIJ

Magee 2014, p659


Medial Vs Lateral Rotation

Magee 2014, p697


X-ray

USS

CT Scan

MRI

Blood work (inflammatory markers such as ESR and CRP)

Lumbar puncture

Questioning

Evaluation Measures including Gait analysis, Harris Hip Function Scale, Iowa Functional Hip Evaluation

See handouts

Imaging and Investigations

Image: SMART imagebase 2015


Sacroiliac Joint Fixations


1. The sacroiliac joints are found between the sacrum and the ilium on each side just medial to the Posterior Superior Iliac Spine (PSIS)

2. While not as prone to problematic disorders they can be strained from traumatic and postural causes as well as some forms of arthritis

Sacroiliac Joint

Legge, 2011, p263Image: SMART imagebase 2015


Primary test: Gilets test, forward flexion test

Other tests: Weber Barstow manoeuvre, Gapping test

Sacroiliac Joint Fixations special tests


Tends to be located over the joint around BL 28 and the ligaments especially around BL 30

Can radiate - lower part of body, groin, buttocks

Worse during sitting, standing up and at the end range of passive lumbar rotation

Check for active trigger points in QL, piriformis, gluteus medius and minimus and L5/S1 disorder

Legge suggests BL 28 needled medial to lateral into the joint and combined with BL 30 with estim across these two

Choose appropriate distal points

Location and Treatment

Legge, 2011, p263


1. The PSIS is quite large (around 2 cun) and can be divided into 4, find the two most tender points and needle into the joint

2. Use a minimum of 75 mm needles. Needle in the direction of GB 29ish

3. This needle insertion can be difficult and feel restricted due to the vast amount of ligamentous tissue in the joint

4. Gillet's Test and Gapping Test may be positive

Callison adds in

Callison 2009,Image: Netter, 2014, plate 333


Strain of Adductors


S/S

Pain – usually in groin / worse for restricted adduction.

Adductor longus is the most commonly strained.

Tenderness over the origin on the pubic bone.

Treatment

Disperse stagnation and restore healthy qi & blood circulation.

Rest injury until pain & tenderness disappears.

Initially 2-3 treatments per week and revaluate as patient improves. Will depend on grade of strain.

Strain of Adductors

Legge, 2011, p278


Strain of Adductors

Legge, 2011, p278


Strain of Adductors

Adductor longus is the adductor most frequently involved – usually from sporting injury

Legge, 2011, p277


Primary test: Adductor strength test

Other tests: n/a

Weakness/Strain of Adductors special tests


1. Acupuncture

2. Ah shi (if not too tender)

3. Trigger point in muscle if palpable

4. Local pt. LR 11

5. Distal pts. LR 5, 8

6. Exercises to increase muscle length & strength

Treatment

Legge, 2011, p278


Special point

Main action:turns on gluteus medius and minimus if weak.

Indications:Lower back pain, hip pain, ITB syndrome, hip bursitis. If due to weakness.

Location:On lateral line, midway between the iliac crest and the greater trochanter. Approximately 2 cun posterior to GB 29.

Needle deeply 2-3 inches with 2 needles in the area. Stimulator can be used between them.

Reaves, 2009, p.171


The most common presenting problem with the hip joint

Common in middle-aged or elderly women (overweight)

Acupuncture effective to reduce pain and increase mobility

Pain often referred to the groin, trochanter, inner thigh or knee and buttock

FABER test will be positive

Xray and further scans if suspected

Local points and a Bi syndrome analysis approach


Legge, 2011, p280


Primary test: Rule out Bursitis been acute consistent and sore to touch

Other tests: Faber test

Osteoarthritis of the Hip Joint special tests


Principle points:

GB 29 & GB 30 (local points)

GB 40 (distal point, Yuan-Source Point and dispersing action)

BL 62 (Opening point of Yang-Qiao)

SP 6 (resolve damp, invigorate Qi)

Supplement points:

GB 27 or GB 28 (radiating pain); SP 3 & ST 36 (with dampness); BL 30 (with Cold); GB 43 & ST 44 (with heat)

Treatment

Kahn, 2009, pg80


Lateral Thigh Pain


Primary test: Rarely primary, would present as result of other conditions

Other tests: n/a

Lateral Thigh Pain special tests


Hip Pain?

Magee 2014, p694


Common cause of pain in lateral thigh

Pain is outside the joint area

ITB syndrome and lateral knee pain patient may have undiagnosed bursitis

Can present with snapping or popping on the trochanter as the ITB moves over the inflamed bursa

Gluteal muscles insert in this area and the pain can radiate into the buttock and down the ITB

Some people report worse pain when lying on affected side during sleep

Pain can range from dull to sharp

Trochanteric Bursitis

Reaves, 2009, p187


Usually chronic with insidious onset or from direct trauma

With the patient side lying press directly on the greater trochanter with the whole palm

You may be able to palpate the bursa to feel spongy, but always compare to other side

Change in biomechanics of walking running, abnormal pronation or supination

Trochanteric Bursitis

Reaves, 2009, p187Image: SMART imagebase, 2015


OA of the hip

Labrum tears and other joint capsule lesions

Sciatic pain

Other soft tissue lesions

ITB syndrome

Differential Diagnose

Reaves, 2009, p188


1. Anti-inflammatory medication

2. Rest

3. Stretching the ITB

4. Biomechanics – orthotics

5. Ultrasound, massage

6. Heat

7. Steroid injections into the bursa

Treatments

Reaves, 2009, p188Image: La Quaintrelle


Use four needles superior, inferior, anterior and posterior to the bursa

Electrical stimulation may be considered with the needles adjacent to the bursa

Moxa also applicable

Laser over the area

Appropriate adjacent and distal points

Surround the Dragon

Reaves, 2009, p192


Acute 2 x per week for 3 weeks then re-evaluate. Most cases without complications will have good results in 6 treatments

More chronic continue treatment at least once weekly after the first three weeks

Prognosis

Reaves, 2009, p189


Thorough case history to rule out other causes

Fracture

Labral tears

Perthe’s Disease (Aseptic necrosis of the hip)

Osteoporosis and corticosteroid use

Sensory or Motor problems

Pregnancy

Lymph nodes

Local nerves (femoral and Sciatic)

Major bold vessels in the groin

Cautions

Anzaldua, 2010, p119, Magee, 2014 pp 625-6


Referred Pain

Magee, 2014, p676, 732


Sacral Dermatomes

Magee, 2014, p676


A PubMed search on 23rd September 2015 revealed very limited research

Many results were in Chinese with no abstract available

Level of Evidence


CMAC222

Session 7

Special Tests of the Hip, Buttock and Groin

Chinese Medicine Department


Bony Landmarks


Muscles acting on the Hip

Magee, 2014, p702


FABER Test

To asses hip joint pathologies, iliopsoas spasm, or sacroiliac joint dysfunction

1. Patient supine

2. Contralateral leg straight

3. Examiner places one hand on test knee, other hand on contralateral ASIS

4. Foot is passively placed on opposite knee or above the knee then test knee is lowered to table

5. Pain in the buttock = sacroiliac origin

6. Leg does not reach table = adductor/iliopsoas contracture

7. Groin pain, no overpressure = hip pathology (no-specific)

Magee, 2014, p713-4Image: Goldsworthy, 2014


Weber-Barstow Maneuver

Used to measure leg length asymmetry

1. Patient supine, knees flexed

2. Examiner palpates the medial malleoli with the thumbs

3. Patient then lifts the pelvis from the examining table and returns to the starting position

4. Examiner passively extends the patient’s legs and compares the position of the malleoli using the borders of the thumbs

5. Positive = different levels indicate asymmetry



If one leg is shorter than the other the examiner can determine where the difference is by measuring the following:

From the iliac crest to the greater trochanter of the femur

If this angle is less than 120⁰ = coxa vara

More than 135⁰ = coxa valga

From the greater trochanter of the femur to the knee joint line on the lateral aspect = femoral shaft shortening

From the knee joint line on the medial side to the medial malleolus = tibial shaft shortening

Weber-Barstow Maneuver Cont.

Magee, 2014, p720-1


Weber Barstow Findings

If malleoli even, no need to proceedIf malleoli is lower one side, then check tibial tuberosity and ASISPossible findings:1. Lower malleolus on right, with level tibial tuberosities =

longer right tibia2. Lower malleolus on right, with lower right tibial

tuberosity, but level ASISs = longer right femur3. Lower malleolus on right, with lower right tibial

tuberosity and lower right ASIS = left lumbar



Initially sacrum nutates up to 60⁰ of forward flexion

Innominate bones continue to rotate anteriorly

Sacrum begins to counternutate

At this point the sacroiliac joint is vulnerable to instability problems

Excessive counternutation is more likely to occur in patients who have tight hamstrings

Forward Flexion

Magee, 2014, p659-60


Forward Flexion

1. Examiner palpates the PSISs

2. Patient bends forward slowly

3. Symmetry of the PSIS superiorly is noted

4. PSIS’s should move upward equally in relation to the sacrum towards each other

5. Positive = PSIS does not move or moves late or not as high

6. This means the ilium is fixatedMagee, 2014, p659-60


Trendelenburg Test

Used to assess weak gluteus medius or QL

1. Standing on one leg, lift one knee and observe for a drop of the iliac crest on that side

2. Positive test: pelvic stability is lost and the hip drops on the unsupported side = weak contralateral glute med

3. A: Negative test

4. B: Positive test

Magee, 2014, p729Images Magee, 2014 p730 Goldsworthy 2014


1. Magee, D, 2014, Orthopedic Physical Assessment Sixth Edition, Elsevier Saunders, St Louis, Missouri

2. Nucleus Medical Media, 2015, Tear involving superior labrum of the left hip – Medical exhibit, viewed 25th September 2015, <http://ebsco.smartimagebase.com>

3. O’Donnell, J, Economopooulos, K, Singh, P, Bates, D, Pritchard, M, 2014, The ligamentum teres test, a novel and effective test in diagnosing tears of the ligamentum teres, American Journal of Sports Medicine, vol. 42. no 1, pp 138-143, viewed 25th September 2015, http://ajs.sagepub.com/content/42/1/138.full.pdf+html

4. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (1 of 7): Introduction & back exam, viewed 16th September 2015, https://www.youtube.com/watch?v=Y_EZvm0iSno

5. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (2 of 7): Inspection & range of motion, viewed 16th September 2015, https://www.youtube.com/watch?v=WpM8h4mCLCc

6. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (6 of 7): Special tests, viewed 16th September 2015, https://www.youtube.com/watch?v=HzlAUaovrKY

7. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (7 of 7): Labral tear, viewed 16th September 2015, https://www.youtube.com/watch?v=Rtp4oz0_3YY

8. Goldsworthy, E, 2014, FABER Test, Private Collection

9. Goldsworthy, E, 2014, Weber-Barstow Manoeuvre 1, Private Collection

10. Goldsworthy, E, 2014, Weber-Barstow Manoeuvre 2, Private Collection

11. Goldsworthy, E, 2014, Weber-Barstow Manoeuvre Findings 1 Private Collection

12. Goldsworthy, E, 2014, Weber-Barstow Manoeuvre Findings 2, Private Collection

13. Goldsworthy, E, 2014, Weber-Barstow Manoeuvre Findings 3, Private Collection

14. Goldsworthy, E, 2014, Approximation Test, Private Collection

15. Goldsworthy, E, 2014, Gapping Test, Private Collection

16. Goldsworthy, E, 2014, Trendelenburg Sign/Test, Private Collection

References


Practice pelvis examination

Palpation of sacrum and hip, buttock and groin

Needle points of the hip

Sacroiliac joint needling

Psoas and iliacus points & GB 26 and GB 27

BL 54 & GB 30 – compare the two

Points in hip

Surround the Dragon at the Greater trochanter

BL 31 & 32

Shiqizhuixia (L5/S1)

Jiankua with electro

Practical


1. Netter, F, 2014, Atlas of Human Anatomy Sixth Edition, Icon Learning Systems, Teterboro, NJ

2. Argosy publishing, 2015, Visible Bodys’ Human Anatomy Atlas, Viewed 24th June 2015, <http://www.visiblebody.com>

3. Argosy publishing, 2015, Visible Bodys’ Muscle Premium Anatomy Atlas, Viewed 24th June 2015, <http://www.visiblebody.com>

4. Legge, D 2011, Close to the Bone – The treatment of painful musculoskeletal disorders with acupuncture and other forms of Chinese medicine 3rd Edition, Sydney College Press, Woy Woy

5. Marcus, A, 2004, Foundations for Integrative Musculoskeletal Medicine: An East-West Approach, North Atlantic Books, Berkeley California

6. Baldry, P, 2005, Acupuncture, Trigger Points and Musculoskeletal Pain 3rd Edition, Churchill Livingstone Elsevier

7. Reichert, B, 2011, Palpation Techniques Surface Anatomy for Physical Therapies, Thieme, New York

8. Shao-jie, L, 2008, Acupuncture for Musculoskeletal Injury 2nd Edition, Peoples Medical Publishing House, Beijing

9. Kendall, D, 2002, Dao of Chinese Medicine, Understanding and Ancient Healing Art, Oxford University Press, Hong Kong

10. Callison, M 2012, Motor Point Index – An Acupuncturist’s Guide to Locating and Treating Motor Points, AcuSport Seminar Series LLC Sports Medicine Acupuncture, San Diego, California, viewed 24th June 2015, <http://www.amazon.com>

11. Neil – Asher, 2008, The Concise Book of trigger Points 2nd Edition, North Atlantic Books, Berkeley, California

12. Maciocia, 2005, The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists 2nd Edition, Elsevier: Churchill Livingstone,

13. O’Connor, J & Bensky, D (ed.) (1983) Acupuncture: a comprehensive text, Eastland Press, Chicago

14. Tan, R, 2003, Acupuncture 1, 2,3, Richard Tan OMD, San Diego California

15. Anzaldua, D, 2010, An Acupuncturist Guide to medial Red Flags & referrals, Blue Poppy Press, Boulder CO

16. Magee, D, 2014, Orthopedic Physical Assessment Sith Edition, Elsevier Saunders, St Louis, Missouri

17. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (3 of 7): Patient history & palpation, viewed 16th September 2015, https://www.youtube.com/watch?v=Y_EZvm0iSno

18. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (4 of 7): Range of motion, viewed 16th September 2015, https://www.youtube.com/watch?v=UfjQmhoCM5A

19. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (5 of 7): Manual muscle testing, viewed 16th September 2015, https://www.youtube.com/watch?v=Mdg1uP0kMbc

References


1. Sapiens Medicus, 2013, Anatomical dissection #25: Muscles, vessels & nerves of the hip and thigh, viewed 17th September 2015, https://www.youtube.com/watch?v=qiRT_LJ9c3U

2. Christian, 2010, -intense look- , viewed 14th August 2015, https://www.flickr.com/photos/chrisk4u/4296161164/in/photolist-7xCX3d-aDzcDc-7K6r4e-nsnunH-7tYtnM-7b8177-5SzGLP-ovuzjB-5dopRY-jXx3oV-7bb1pp-65dAGD-5wbyLE-c1UTf-dZCHd-rPKs3-c5ms5w-ktv52E-b41Sac-bKjhs4-ucYai1-nXXcKz-5MQvaL-aQGkvr-fFP9d4-eHD1Zw-kjpnVT-4of2zH-22HGSY-66w6Zs-bARqUG-u8Dgyp-oQmnu3-ts84dk-e77MQx-7m2Uwt-4uSwKT-hyKsuS-5kzXSw-7fPMpi-f6AiyV-beDgrZ-kxySS4-55pr2W-qAwhn2-6PfygR-6PH5CM-7GYFCy-uNxTdC-pF1Zf9

3. Nucleus Medical Media, 2015, Left Sacroiliac Joint Disruption – Medial Exhibit, 22nd September 2015, <http://ebsco.smartimagebase.com>

4. Nucleus Medical Media, 2015, Total Hip Joint Replacement Surgery (Full Version) – Medial Animation, 22nd September 2015, <http://ebsco.smartimagebase.com>

5. Nucleus Medical Media, 2015, Trochanteric (Hip) Bursitis – Medial Exhibit, 23rd September 2015, <http://ebsco.smartimagebase.com>

6. La Quaintrelle, 2014, Foam Rolling your ITB band, viewed 23rd September 2015, http://quillery.tumblr.com/post/105493932707/the-5-things-a-massage-therapist-will-probably

7. Koshy , 2010, Happy Farmer, viewed 23rd September 2015, https://www.flickr.com/photos/kkoshy/5156445007/in/photolist-8RE8sg-waqg4-ndeCxA-t3H9A-5kWf96-5mmMAe-6uHz7S-5J1Jcj-8EfDG7-B1FV4-Pshj8-ekhdMj-9UpFEx-MRr2s-pARJed-7rKz5M-nWTAJ9-b7oCrH-4ZCk3N-iiQPYB-8vBWnB-6enoYv-bv1H5g-7sad16-969bRP-6mCxRA-qjZvWs-7rSixD-q36A-rCRKro-xsApBR-6ehXeA-jNFb5r-7z2gzm-5gr521-fy2XiC-51U2Ep-qC9Npe-9jwJY3-rHcbJR-d3KLx-brqnPk-7QaJYd-5NRnYF-pncqQ6-94GknR-35Rt6q-7R7Ej6-vZvL6-5LUhPG

8. Reaves, W, Bong, C, 2009, The Acupuncture Handbook of Sports Injuries & Pain: A Four Step Approach to Treatment Hidden Needle Press Boulder Colorado

9. Cooper, Kahn & Zucker, T 2009. Acupuncture for musculoskeletal medicine, Lippincott Williams & Wilkins, Philadelphia.

References


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