hip and groin pain

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hip and groin pain by Mind Map: hip and groin pain

1. intrinsic factors

1.1. core and hip joints stability and strengthening

1.1.1. Core and back weakness have a high probability of causing hip pain. These deeper muscles stop working or become weak because of pain or injury, which can leads to long term difficulty in stabilizing the back. The body compensates for this lack of stability and this leads to other problems in the hip and groin, an increased load on the muscles of hip and buttock causing fatigue, and tightness. As a result, the hip and back muscles work harder to compensate for an unstable hip, and this can leads to hip and groin injuries (5,13,37,38).

1.2. Malignments of hip, knee, and ankle

1.3. Bursitis

1.3.1. bursa located between muscles, bones, and tendons working to decrease friction during movement. Bursitis is a painful condition associated with movement or touch depending on the extent of irritation and inflammation. For example, trochanteric bursitis is located on the outside of the hip joint, while iliopsoas bursitis causes pain in the groin and is increased when the hip is extended and rotated, and may be recognized by provocative testing (Ober's test). (6,7,8,9,11,36).

1.4. Osteoarthritis

1.4.1. The most common cause of hip pain in older athletes is osteoarthritis, but in general, arthritis can affect younger patients too. OA of the hip joint causes pain that progressively worsens with activity, and results in the development of a limping gait (10,11).

1.5. stress fracture

1.5.1. Stress fractures of the femoral neck or proximal femur can cause hip and groin pain and lead to development of necrosis in the femoral head if not found early (11). Athletes have a high risk of developing these type of fractures through running, and jumping (10,6).

1.6. acetabular labral tear

1.6.1. A torn labarum can cause chronic hip pain. This injury is associated with the groin. In addition, a more likely diagnosis of this damage is generally reflected in those who have typical pain for more than six months (10,33).

1.7. hip nerves

1.7.1. The two nerves that most likely to cause hip and groin pain are the sciatic nerve in the back and the femoral nerve in front. The Physiotherapist should clear these nerves in order during hip examination. The sciatic nerve often gets injured by compression of the piriformis muscle. So, an athlete may complain of an achy pain in the buttocks and sometimes associated posterior thigh pain. It is called piriformis syndrome (11). The femoral nerve often gets injured in different ways, such as through prolonged pressure, direct impact and fracture of a pelvic bone. It effects walking and sometimes cause uncomfortable sensations in the legs and feet (11, 12).

1.8. tendonitis

1.8.1. Tendonitis: passive stretching or active motion if pain is indicated in a specific direction will often help to detect a muscular injury (11).

1.9. apophyseal and epiphyseal

1.9.1. A lack of ossification of cartilaginous growth plates might cause apophyseal and epiphyseal injuries. Tendinitis is a more likely to be diagnosed in older athletes because of the closure of their growth plates (11,22).

2. Objective: Physiotherapist should conduct methodical physical examination that tests the several hip muscles to arrive at an exact diagnosis for the often unclear complaint of hip pain (11).

2.1. core examination

2.1.1. According to comfort (2010) from our group screening presentation, two tests could be used to examine strengthening and endurance of core muscles (14). PT should measure time ratio between back and abdominal muscles by prone hold test and sit-up hold. The optimal period is 72.5 +/- 32.6 sec(14).

2.2. bursitis examination

2.2.1. besides of provocative testing (Ober's test), PT examine that by asking the patient stand on affected leg and notice any pain, discomfort positon, tenderness by palpation or any swelling around hip and groin (15).

2.3. OA examination

2.3.1. PT examine gait in general, and notice any decrease of hip range of motion, crepitus, warm skin, and malalignment (16, 17, 35).

2.4. stress fracture exeamination

2.4.1. PT use fulcrum test besides of hop test. Most of cases showed both of tests are positive indication. So, imagine is requirement to confirm and differentiate between tests’ result (18, 34).

2.5. labrum examination

2.5.1. PT examine that by using couple of provocation tests besides of gait examination. For example, McCarthy, faber, anterior and posterior labral tear, impingement, and fitzgerald test (19, 21). However, labral tear test consider as effective one because it showed about 85% of accuracy(20).

2.6. apophysitis examination

2.6.1. PT should notice any swelling or soreness around hip joint (22).

2.7. tendonitis examination

2.7.1. PT after observation and palpation use certain provocation tests such as, leg length measurement, trendelenburg, thomas, hop, faber, and ober test. These tests help to determine and differentiate which part is causing the hip and groin pain(23).

2.8. nerve examination

2.8.1. PT use special neuro tests with consideration of sensory, motor, reflexes and neurodynamic integrity. For sciatica and femoral pathways examinations would apply slump, SLR, and femoral nerve tension test(24, 25).

3. External factors

3.1. shoes

3.1.1. According to Chris Sole (2016), shoes should be considered as one of the main causes of hip disorder, but are commonly overlooked during a subjective and objective examination. Shoes are manufactured according to different design criteria, such as protective, fashion, economic, and performance, depending on their proposed purpose (PowerPoint(2). Footwear has an effect on ground feedback, co-ordination, stability, energy, and loading (PowerPoint(2). However, four parts of shoes should be examined to determine if they are the cause of pain, these being heel height, outersole, midsole, and innersole (PowerPoint(2).

3.2. nutrition

3.2.1. Another important factor the PT must consider is nutrition. The three essential elements of food that elevate body energy levels are carbohydrate (CHO), protein, and fat, and all play a part in successful recovery from injury (nutrition (3). On the other hand, recovery time can be decreased or stalled by a lack of adequate nutrition which does not provide the body with sufficient calories, fat, and protein, or an excessive amount, which can lead to obesity. If this is the case, it can have bad consequences for a long time such as difficulties in breathing (respiratory failure) and a decreased white blood cell count, a consequence of which is weakened immune system, and increased a risk of infections, a reduction in body muscle mass, and fatigue (4,39).

3.3. environment

3.3.1. The environment also has a fundamental impact on personal condition, for example, cold or hot weather, playing ground, stress condition in the games from coaches, friends and fans. For example, These factors can all contribute to the occurrence of pain, as well as have a psychological impact on the success or failure of the treatment.

4. subjective history

4.1. HPC

4.2. Body chart

4.3. Aggravate and ease factors

4.4. 24 pattern

4.5. Past history

4.6. Special question

5. Physiotherapy’s treatment plan would be designed regarding to differential hip and groin diagnosis and clinical examination. In general, goal of treatment concentrations on exclusion of abnormal movements and renovation hip strengthening and coordination. Common physiotherapy approaches include strengthening, and stretching exercises and manual therapy techniques that used for rehabilitation protocol depend on hip and groin pain causes (28, 29). However, some cautions should be put in the management plan. For example, avoidance any activities that aggravate the symptoms during period of treatment (31). Also, avoid any weight bearing if was there a fracture (31).

5.1. 1) Stretching exercises such as Short adductor stretch, Long adductor stretch, Hip flexors, Tensor Fascia Latae Stretch,  Dynamic stretching(26, 27,32).

5.2. 2) Strengthening exercises such as Isometric or static exercises, Straight leg raise, Eccentric adduction, Hip adduction against gravity, Resistance band adduction, Hip abduction, Hip extension, Clam Exercise (26, 27,32).

5.3. 3) Hip mobilization, manipulation, traction positional release (30, 31,36)

5.4. 4) Cryotherapy(31)

5.5. 5) Heat therapy(31)

5.6. 6) Psychological side(31)

5.7. 7) TENS (31)

5.8. 8) Acupuncture(31)

6. TREATMENT