Upper Leg and Hip
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Upper leg and hip pain may be due to referred pain from the lower back. Hip pain can also refer pain up to the lower back and down into the groin.
Differential diagnosis of muscular upper leg and hip pain includes:
referred pain from the lower back,
hip flexor dysfunction (psoas and iliacus [sometimes considered together as the iliopsoas] and rectus femorus),
hip extensor dysfunction (hamstring/gluteals),
adductor and abductor dysfunction,
disorders of the iliotibial (IT) band.
Non-muscular causes include radiculopathies, SI dysfunction, bone disorders, and osteoarthritis, labral diseases of the hip (labral tears), bursitis, IT band dysfunction, and hernia (Figure 11-1).
Iliac Crest Height
Assess the iliac crest height, comparing height from side to side.
If one sacroilial crest is higher on one side (and no scoliosis), perform a leg pull on that side.
Have the patient perform a straight leg raise to 20 degrees.
Grasp the patient’s ankle and provide a caudal traction (away from the hip) while the patient takes three belly breaths, then relaxes.
If there is no discomfort with the leg pull, repeat these steps with gentle oscillations back and forth, while maintaining traction.
FABER (Flexion ABduction External Rotation) or Patrick Testing
Tests the IT band, internal rotators, and hip flexors.
Decreased range of motion or pain in the groin may imply a hip pathology (labral tear, osteoarthritis, adductor weakness/iliopsoas dysfunction, IT band, bursitis, hip flexors)
If ROM induces symptoms, palpate painful region to locate etiology:
Anterior: hip flexors
Posterior: hip extenders (hamstrings, piriformis, gluteals)
Lateral: IT band or trochanteric bursitis
If you cannot palpate the pain, consider hip joint derangement (osteoarthritis, labral dysfunction)
Performing the Test
With the patient supine, the involved leg is placed with the hip flexed and abducted, and the lateral malleolus is moved to rest on the contralateral thigh just superior to the knee.
While stabilizing the opposite pelvis at the anterior superior iliac spine (ASIS), a force is applied toward the table to the involved knee to further the hip’s external rotation and abduction.
If this induces pain, think hip joint disease (osteoarthritis, labral tear), iliopsoas spasm, or sacroiliac joint dysfunction.
If this maneuver does NOT induce pain, move the leg into internal rotation, with the involved knee pointing toward the opposite shoulder, and apply pressure.
If this maneuver reproduces the patient’s pain, think IT band, trochanteric bursitis, or hip extender (hamstring, piriformis, gluteal) dysfunction.
Palpate the region of discomfort to try to reproduce symptoms.
If not severely tender, perform stretch/relax treatment on the involved muscle groups.
If severely tender, perform reciprocal inhibition (shown below, pages 159-161).
Remember the Rules
1. Move to a position of less pain and apply trigger point care.
2. Stretch the SHORTENED muscle.
3. Treat the region (above and below pain).
4. Tape to support neutral position.
5. Support definitive treatment (physical therapy, orthopedics, neurosurgery).
If pain is not severe:
Posterior Leg Pain (Hamstrings, Piriformis, Gluteals)
With the patient supine, lift the affected leg, keeping the knee straight until an end point is reached.
Rest the patient’s ankle on your shoulder. With the other hand, grasp the thigh just proximal to the knee. If the discomfort is too great, this movement can be performed with the knee slightly bent.
Instruct the patient to try to lower their leg toward the table against your shoulder, using 10% effort for three belly breaths.
Have the patient relax and move the hip into further flexion.
Repeat this cycle for a total of three contract-relax cycles.
Piriformis (Tight Hip Extensor Sometimes Causing Sciatica)
Have the patient flex their hip and knee on the involved side.
Place your hands on the patient’s knee and ankle and move the knee toward the opposite shoulder to the end point.
Have the patient use 10% effort to try to externally rotate the leg by moving both the knee and the ankle against you while taking three belly breaths.
Have the patient relax while you move the knee further toward the opposite shoulder.
Repeat these steps for a total of three stretch-relax cycles.
To perform this treatment with the patient prone:
Have the patient put the feet together and flex the involved knee.
Move the involved ankle externally (internal rotation of the thigh) until it reaches an end point.
Provide resistance while you instruct the patient to use 10% effort to move the ankle to the midline against your hand and take three belly breaths.
Have the patient relax while you move the ankle further away from the midline.
Follow these steps for three stretch-relax cycles.
A soft tissue release can also be done here by applying pressure to the piriformis region with your fist while moving the patient’s ankle and hip into external and internal rotation.
Reciprocal Inhibition When Severe Pain Is Present for Posterior Leg Pain