DJD RA Transient Synovitis
Age 60% of men and 70% of women Common in ages b/n 25-50 Children Ages 2-12
older then age 65
Gender Equal between men and women More common in Females Males > Females
after age 50.
Men are more prevalent before
Medical 50% idiopathic. Idiopathic, environmental Injury, overuse, infection, or a
History Changes may be due to small factors problem that was present from
changes since birth, tissue birth (congenital), low grade
change with aging, repetitive fevers, allergies.
mechanical stress, impingement
b/n femur and labrum
Surgical Arthroscopic lavage and N/A N/A
Intervention debridement, osteotomies, THA
Medications NSAIDS, topical NSAIDS, Cycloxygenase NSAIDS
cream(capsaicin) type 2, Antirheumatoid drugs
Risk Factors Poor nutrition N/A N/A
High impact athletes such as
soccer, football, and hockey
Pain (location, Pain in hip, low back, and groin Bilateral pain in joint Location: Unilateral hip or
onset, quality, Pain with continued weight Most common in wrist groin pain is the most common
frequency, bearing and gait fingers knees and feet report. Medial thigh or knee
duration) Pain at night after daily activity Generalized pain and pain can also be experienced.
stiffness Onset: Acute or Insidious
Worse in morning Quality: Sharp
May last one hour after Frequency: Worst after
Duration: 7-10 days
Impairments Pain experienced in the groin Increase in temperature over Patient may have antalgic gait
and referred along the anterior joints pattern
thigh and knee in the L-3 Deformed joints
Stiffness after rest. Loss of appetite
Limited motion with a firm
capsular end feel.
Limited hip extension.
Decreased knee extension.
Impaired balance and postural
Functional Unable to rise from a chair, Inability to perform ADLS Patient may have difficulty
Limitations climb stairs, or squat Unable to stair climb walking independently.
Restricted ADLs Class III ACR Classification
of Functional Status: Able to
perform usual self care
activities but limited in
Observation Antalgic gait Swelling of joints, deformity, Hip in flexion with slight
anklylose, abduction and external
AROM Limited ROM with observable Same as DJD Mild Restriction, especially to
pain abduction & internal rotation.
Decreased flexion, limited
PROM Limited ROM with observable Same as DJD Pain at end range
Strength Normal strength Diminished strength due to N/A
Lab and Other Early evidence: Narrowed Joint Xrays, Serum N/A
Tests space Rheumathoid Factor
Subchondral bone sclerosis
Subchondral bone cysts
Precautions/Co N/A Care taken with stretch Primary care physician will
ntraindications Do Not over stretch around most probably advise to take
osteoporotic bone child’s temperature regularly
and be aware if the
temperature increases higher
that 99.50 F.
Do not overstressed
Prognosis Progressive disease Progressive disease Patients with TS usually
May affect organs experience marked
improvement within 24-48
Course of disorder may last 2-
Slight increased risk for later
development of osteoarthritis
Diagnosis Subjective history, physical Same (+) lab tests confirms
examination, radiologic DJD
findings, lab tests to rule out RA
PT intervention Maximal Protection Phase: Generally same as DJD Advise bedrest for 7-10 days,
Decrease pain at rest by Protect the joint allowing the patient to rest
applying slow oscillations Adequate rest to decrease with the hip in a non-weight
Decrease pain during WB inflammation bearing position.
activities by applying assistive Local heat, massage, and
device such as walker if older. aspirin.
Elevate chairs and toilet seats Partial weight bearing can be
to make rising from them less used when pain decreases.
painful Advise the patient not to bear
Decrease effects of stiffness weight on the affected limb.
and maintain ROM
Controlled Motion and Return to
Increase joint play and soft
tissue mobility by using glides
that stretch restricted capsular
tissue at the end of the range.
Mobilisation with movement to
increase IR, Flexion, Extension
activities with progressive
Pt. Education on decreasing
wear and tear on the joint
1. Goodman, Fuller, Boissonnault. Pathology: Implications for the Physical Therapist. 2003. pg.941- 943
2. Goodman, Snyder. Differential Diagnosis in Physical Therapy. 2000. pg.453-458
3. Kisner, Kolby. Therapeutic Exercise. 2002. pg. 394-399
4. Levange, Norkin. Joint Structure and Function. 2005. pg. 386
1. O’Sullivan, S. Physical Rehabilitation. 5th edition. Philadelphia, PA: F.A. Davis Company; 2007 Pages: 1057-1083
2. Rothstein, J. The Rehabilitation Specialist’s Handbook. 3rd Edition. Philadelphia, PA: F.A. Davis Company; 2005: 192-199
3. Kisner, C & Colby, L. Therapeutic Exercise Foundations and Techniques, 4th Ed. Philadelphia, PA: F.A. Davis Company, 2002: 300-
1. Richardson, J & Iglarsh A. Clinical Orthopaedic Physical Therapy. Philadelphia, PA: W.B. Saunders Company; 1994: 367, 380-381
Non- Neuromuscular Pain at the Hip
Cancer The other pain
Spinal Metastases To the femur or lower pelvis may appear as hip pain
GS456 Very rare to metastasize to the synovium with the exception of myeloma and lymphoma
Osteoid Osteoma Young adult
GS456 Small benign painful tumor
GFB912-913 Usually on the proximal femur or in the pelvis
Pt. complains of dull hip, thigh pain that is worse at night
Observable antalgic gait
Restricted hip motion
Ewing’s Sarcoma Most common ages 5-16 and more common in boys
Pg367 GS Very rare in African Americans
GFB917-918 Any bone may be involved but primarily femur, pelvis, tibia, ulna, metatarsals
Pt. presents with a painful, soft, tender mass on the area
Chondrosarcoma Most common in men ages 40- 60
GFB 921-922 Cartilage tumor
GS 368-369 Idiopathic onset
Very localized pain at beginning but may metastasize to lungs or other bones
Osteoporosis Gender: Most common in women (post menopausal). Major concern if found in men
GFB 871 Risk Factors: Gender, Age, Family History, body size, Ethnicity, Physical Inactivity, Tobacco, Alcohol, Meds,
KC 101-103 Diet, Depression
Lab Tests: Bone density scan
Ask questions related to risk factors.
Maintain bone strength by strengthening
Use low intensity for 6-8 weeks.
Progress intensity and volume very gradually
Therex focusing on balance and Posture
Avoid high impact activities
Avoid LE torsional movements of the hips
Medication side effects (communicate with physician)
Stress Reactions and Can be caused at femur or pelvis
Stress Fracture More common in women (athletic or military)
GS468 Can occur with poor eating habits, secondary amenorrhea,
and low estrogen levels
1. Goodman, Fuller, Boissonnault. Pathology: Implications for the Physical Therapist. 2003.
2. Goodman, Snyder. Differential Diagnosis in Physical Therapy. 2000.
3. Kisner, Kolby. Therapeutic Exercise Foundations and Techniques, 4th Ed. Philadelphia, PA: F.A. Davis Company, 2002
4. Prentice, W.E. Therapeutic Modalities in Rehabilitation.3rd edition. 2005
Greater Trochanteric Bursitis Iliopectineal Bursitis
Age: Not biased. However, older patients may have a tear of the Not biased
gluteus medius bursitis.
Gender: Not biased Not biased
Medical History: Contusion (trauma), overuse, gout, RA or infection. Overuse Associated with RA, overuse.
includes bursal irritation due to friction by the iliotibial band,
which is an extension of the tensor fascia lata muscle.
Surgical History: Rarely occurs. However, bursectomy may take place. Rarely occurs. However, bursectomy may take
Medications: Acetaminophen, NSAIDS and/or steroid injection Acetaminophen, NSAIDS and/or steroid
Pain: 6 -Location: lateral hip and may radiate down the ipsilateral Location: Anterior groin pain. Also, due to close
thigh to the knee when the iliotibial band rubs over the proximity of femoral nerve, pain may radiate
trochanter down the anterior thigh.
-Onset: Pain with rest and movements that stretch or Onset: Pain with rest and movements that stretch
compress tissue especially hip flexion and internal rotation. or compress tissue especially hip flexion and
-Quality: Severe over bursa area internal rotation.
-Frequency: when stretch, compress or move the affected -Quality: Severe over bursa area
structure -Frequency: when stretch, compress or move the
-Duration: when sleeping on involved side. Discomfort may affected structure
be experience after standing asymmetrically for long periods -Duration: when sleeping on involved side.
with the affected hip elevated and adducted and pelvis
dropped on the opposite side. Ambulation and climbing
stairs aggravates the condition.
Impairments/Function Ambulation and climbing stairs. Inability to do the Ambulation and climbing stairs. Inability to do
al Limitations: provoking activity. the provoking activity.
Disabilities: N/A N/A
Observation: Acute stage: antalgic gait. Acute stage: antalgic
Chronic stage: trendelenburg Chronic stage: trendelenburg
Palpation: Tenderness, sensitive and painful to touch over greater Tenderness, sensitive and painful to touch over
trochanter. anterior groin
AROM: Limited due to pain but not in a capsular pattern. Limited due to pain but not in a capsular pattern
PROM : Limited due to pain but not in a capsular pattern Limited due to pain but not in a capsular pattern
Strength: Weak Gluts Weak due to pain
Motor control, tone, WFL N/A
Special tests: Sign of the Buttock: if positive may indicate a pathology N/A
behind the hip joint (ie. bursitis). The pt. lies supine and the
examiner passively performs a straight leg raise. The
examiner then flexes the knee to see whether hip flexion
increases. If hip flex does not increase when the knee is
flexed, it is a positive sign. (Magee)
Ober’s Test: Assess the TFL for contracture. The patient is
in side lying with lower leg flexed at hip and knee for
stability. The examiner passively abducts & extends the pts
upper leg with the knee straight or flexed to 90۫ and then
lowers the limb. The examiner is required to stabilize the
pelvis while performing this test, therefore, if tenderness is
over the greater trochanter this may lead to bursitis.
Imaging: N/A N/A
Items from Medical N/A N/A
PT diagnosis and/ or Control/decrease inflammation and promote healing Control/decrease inflammation and promote
problem list: Increase strength and ROM in hip muscles healing
Decrease pain Increase strength and ROM in hip muscles
Increase function for ADLs Decrease pain
Prevent any secondary complications Increase function for ADLs
Prevent any secondary complications
PT Interventions: See attached to answer more thoroughly 1. Implementation of flexibility exercise to
maintain/improve normal joint motion and length
2. Implementation of manual therapy for
maintenance of normal joint mechanics.
Soft tissue/massage tech and joint
oscillation to reduce pain and/or muscle
Biomechanical faults caused by joint
restrictions should be corrected with joint
mobilization to the specific restrictions
identified during the examination
3. Implementation of aerobic capacity/endurance
conditioning or reconditioning
4. Applications of thermal agents for pain
reduction, edema reduction and m. performance
hydrotherapy and sound agents
5. Patient/client education and
training/retraining for instrumental activities
of daily living (IADL)
Household chores, yard work, shopping caring
for dependents and home maintenance
Precautions: Heat Heat
Prognosis: Good Good
Red Flags (findings that Frequent abdominal pains, unexplained weight loss, bleeding Frequent abdominal pains, unexplained weight
would suggest change in in urine, vomiting, nausea, dizziness, night sweats, severe loss, bleeding in urine, vomiting, nausea,
Rx or referral to another headaches, balance changes, and sudden changes in dizziness, night sweats, severe headaches,
health care provider): vision/hearing. balance changes, and sudden changes in
Other Lateral hip pain may also stimulate L4 nerve root, therefore,
assessment of the lumbar spine should also be considered.
Typical/Most Common Interventions for Greater Trochanteric Bursitis
National PT board Book (O’sullivan): pg. 42
Implementation of flexibility exercise to maintain/improve normal joint motion and length of muscles.
Implementation of manual therapy for maintenance of normal joint mechanics.
Soft tissue/massage tech and joint oscillation to reduce pain and/or muscle guarding.
Biomechanical faults caused by joint restrictions should be corrected with joint mobilization to the specific restrictions identified during
Implementation of aerobic capacity/endurance conditioning or reconditioning
Applications of thermal agents for pain reduction, edema reduction and m. performance
o Cryotherapy, thermotherapy, hydrotherapy and sound agents
Patient/client education and training/retraining for instrumental activities of daily living (IADL)
o Household chores, yard work, shopping caring for dependents and home maintenance
Kisner & Colby: pg. 489-90
Management: Protection Phase
o Control inflammation and promote healing
Avoid doing the provoking activity; rest; decrease the amount & time walking or use an assistive device
o Patient education and cooperation are necessary to reduce repetitive trauma
Management: Controlled Motion Phase
o Once acute symptoms have decreased, begin an exercise program within tolerance or patient/tissue. Concentrate on regaining
balance in length, neuromuscular control, strength, and endurance in the muscles of the hip & rest of the lower extremity.
o Develop a balance on length & strength:
Stretch any muscles that are restricting motions with gently, progressive neuromuscular inhibition techs. Also, instruct pt. to
do self stretching techniques.
Begin developing neuromuscular control to train the involved muscles to contract & control alignment of the femur.
Once aware of the proper muscle control begin on strengthening the weakened muscles through the range.
o Develop stability & closed chain function:
Begin controlled WB exercises. Such as biking, partial WB & weight shifting in parallel bars.
o Develop muscle & cardiopulmonary endurance
Perform each exercise for 1-3 minutes before progressing to the next level of difficulty.
Do not exacerbate the pts. symptoms
o Patient education
Management: Return to Function Phase
o Progress strength & functional control:
Closed chain & functional training for balance & muscular endurance
Increase eccentric resistance & control speed
Use acceleration/deceleration, plyometric – patterns of motions
o Return to function:
Have pt. practice desired movements in the environment of a limited period. Progress with variability in the environment &
increase the intensity of the activities.
1. Kisner, C & Colby, L. Therapeutic Exercise Foundations and Techniques, 4th Ed. Philadelphia, PA: F.A. Davis Company, 2002: 489-90
2. O’Sullivan, S. National Physical Therapy Examination, Review & Study Guide. Evanston, IL: International Educational Resources, Ltd,
2007: 10, 42.
3. Magee, DJ. Orthopedic Physical Assessment, 4th Ed. St. Louis, MO: Elsevier Sciences, 2006: 597-98, 607-610, 630-632.
4. Richardson, J & Iglarsh A. Clinical Orthopaedic Physical Therapy. Philadelphia, PA: W.B. Saunders Company; 1994.