New York State Medical Treatment Guidelines for Hip and Groin Disorders in workers compensation patients

This guideline encompasses the hip and groin disorders outlined in this section.This section does not provide an in-depth review of other notable disorders, such as lumbar radiculopathy and lumbar spinal stenosis, which may manifest as posterior and lateral hip pain. However, these conditions are important considerations in the differential diagnosis of hip pain and symptoms.

For a more comprehensive discussion of these disorders, refer to the NYS WCB Mid and Low Back Injury Medical Treatment Guidelines.Other factors to consider in the diagnostic process involve inguinal hernias, femoral hernias, atherosclerotic irregularities, aneurysms, avulsion fractures (particularly involving the sartorius and rectus femoris), femoral mononeuritis, tumors, cancers, crystal arthropathies (such as gout, pseudogout, hydroxyapatite), and infections, including septic arthritis.

 

Introduction

History Taking and Physical Examination

The foundation for diagnostic and therapeutic procedures is established and guided by the history-taking and physical examination.If there is inconsistency between the results of clinical evaluations and those of other diagnostic procedures, priority should be given to the objective clinical findings.The medical documentation should adequately record the following:

History of Present Injury

In terms of the injury’s mechanism, this encompasses information about when symptoms first appeared, their development over time, and any symptoms resulting from adjustments in posture or function due to the hip/groin injury.

Connection to employment: This involves indicating the likelihood that the illness or injury is associated with the workplace.

Previous work-related and non-work-related injuries: This pertains to injuries in the same area, along with details about any specific prior treatments.

Capacity to carry out job responsibilities and daily life activities; and,

Factors that worsen or alleviate symptoms; not restricted to the hip/groin area.

 

Past History

Previous medical history encompasses, but is not restricted to, conditions such as neoplasm, gout, arthritis, and diabetes;

The review of systems covers a range of symptoms, including but not confined to those associated with rheumatologic, neurologic, endocrine, neoplastic, and other systemic diseases. If relevant, it should also encompass gastrointestinal and genitourinary aspects (with attention to any incontinence problems) as well as pertinent musculoskeletal areas.

History of tobacco use.

Occupational and recreational activities, including a record of barotrauma history.

Previous imaging examinations;

History of prior surgeries.

 

Physical Examination

When examining a joint, it is essential to include the joint below the affected area, incorporating the opposite side for comparative analysis.The physical examination should involve employing recognized tests and examination techniques that are relevant to the joint or area under consideration, including:

Observational assessment;

Touch examination;

Assessment of range of motion and motion quality (both active and passive), addressing any concerns related to abnormal internal or external rotation, as well as the presence of clicking, popping, or catching during movement.

Evaluation of strength, identifying any weaknesses or signs of atrophy.

Examination of joint integrity and stability.

Assessment for deformity or displacement, including the identification of leg length discrepancies.

If relevant to the injury, examination of the integrity of distal circulation.

If pertinent to the situation, a neurological examination (e.g., assessing sensory and motor function, reflexes) as clinically indicated.

If relevant, evaluate for testicular tenderness or swelling.

Evaluate gait and weight-bearing status.

 

Red Flags

Specific discoveries, often referred to as “red flags,” prompt suspicion of potentially serious medical conditions.The assessment, encompassing both history and physical examination, should involve an evaluation for red flags.In the hip/groin region, these findings or indicators may encompass fractures, dislocations, infections or inflammation, tumors, systemic rheumatological disorders, and neurological compromise.Further evaluation, consultation, or urgent/emergency intervention may be warranted, and the New York Hip/Groin Injury Medical Treatment Guidelines encompass alterations in clinical management prompted by the identification of “red flags.”

Diagnostic Testing and Testing Procedures

A single diagnostic imaging procedure may yield either equivalent or distinct information compared to that acquired through other procedures.Hence, the judicious selection of a single diagnostic procedure, its complementary use in combination with other procedure(s), or a well-planned sequential order in multiple procedures will guarantee optimal diagnostic accuracy, minimize adverse effects on patients, and promote cost-effectiveness by preventing duplication or redundancy.

Each diagnostic imaging procedure exhibits a substantial percentage of specificity and sensitivity for different diagnoses.None of them possesses characteristics specifically indicative of a particular diagnosis.The selection and interpretation of imaging procedure results should be grounded in the clinical information acquired through history-taking and physical examination.

If a diagnostic procedure, when combined with clinical information, furnishes enough data for an accurate diagnosis, the performance of a second diagnostic procedure exclusively for diagnostic purposes would be redundant.Simultaneously, a follow-up diagnostic procedure—potentially a repetition of the initial one—could serve as a complementary diagnostic measure if the rehabilitation physician, radiologist, or surgeon notes that the initial study was of insufficient quality for a diagnosis. This becomes necessary if the first or previous procedures, along with clinical information, fail to yield an accurate diagnosis. The choice of a procedure over others typically relies on factors such as availability, a patient’s tolerance, and the treating practitioner’s familiarity with the procedure.

It is acknowledged that in certain cases, the clinical course and monitoring the progress of treatment may necessitate the repetition of imaging studies and other tests.It can be beneficial to repeat diagnostic procedures, such as imaging studies, throughout the course of care for reassessment or staging of pathology. This is particularly relevant in cases of symptom progression or evolving findings, before surgical interventions and therapeutic injections when deemed necessary, and post-operatively to monitor the healing process.Concerning CT examinations, it’s important to acknowledge that repeating procedures leads to a rise in cumulative radiation dose and the associated risks.

When deemed necessary, the following studies can be employed for a more in-depth assessment of hip and groin injuries, guided by the mechanism of injury, symptoms, and patient history.

 

Diagnostic Criteria and Differential Diagnosis

The majority of hip disorders can be effectively diagnosed through a combination of history, physical examination, and radiographs. When the diagnosis of a hip and groin disorder remains uncertain, magnetic resonance imaging (MRI), with or without gadolinium, is typically the preferred imaging method for diagnosing various intraarticular and extraarticular pathologies.Additional imaging techniques encompass ultrasound, computed tomography (CT) imaging, postoperative radiography, as well as magnetic resonance and CT arthrography.

The healthcare provider conducting the initial evaluation of a patient experiencing hip or groin pain should aim to establish a specific and explanatory diagnosis.It is essential to conduct a review of systems that encompasses the knee, spine, abdomen, and genitourinary tract in cases involving hip or groin pain.When examining a patient with hip or groin pain, the focus should primarily be on the hip joint, incorporating a thorough assessment of pertinent adjacent structures, mirroring the approach taken in the review of systems.Serious potential disorders encompass infections, tumors, or systemic rheumatological conditions.