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old is technological confusion that we've had, but we had to move over to, uh, the other blood form because the Advil was 100 registrations of good accommodate only hundreds of your back back onto zoom now, so the Remicade really is two talks. One is to tell you about how to be assessed young adults with hip pain and secondly, to tell you everything that you need to know from the Examiner, the white spot a few for Femara and stab it in billions. We'll go first with the assessment off a young adult with pain being you. Greetings from our ever expanding campus in Cambridge. And if you're walking here, you concert me. See are rapidly. It's it's It's been expanding over the last 10 years, so if you look at the hip, it's probably the most anatomically and biomechanically complex joint in the body. It's got a 28 different muscles, which are required to move it in a little three pains, and therefore, obviously it's subject to a significant amount of forces that are going through the joint now. Because of this anatomical and by mechanical complexity, really need on extensive physical examination for proper diagnosis off. What exactly is happening in that young adult? And if you look at the cause is off hip pain, then generally every 2 to 3 months, you almost have a new diagnosis, especially in the last decade off. Why patients maybe complaining off hip or groin pain. So therefore, you really need to have a systematic way off examining the hip joint. The other thing to consider is that just when we had got on top off Femara once tablet impingement and started understanding that probably all these extra articular hip impingement syndromes have been described. So the patient is complaining of pain. Anteriorly. You need to be thinking off substance and Benjamin really a source and binge mint off bacteria for Bill impingement on the patient has been complaining of pain. Posteriorly. You need to be thinking off this cure family impingement the deep through till central or the skill tunnel or hamstring syndrome. So all these new sandals, both anterior and posterior for baby, really need to be thinking off a swell. So simple way to think about hip groin pain is where exactly is the source of pain? Is it extra articular in origin? I eat coming from the abdomen, the urogenital system or isn't extra articular but musculoskeletal? I eat a tendon or a muscle or is it articular? I eat the labrum ligamentum TDs, articular cartilage. So if you divide them broadly into these three, then you really need. You can't rely on the standard, please matter of look, feel, move and get all the diagnosis because there are a number of diagnostic tests which will actually fill in each box off these extraarticular extraarticular musculoskelatal an articular so examination has to be extended and a bit more comprehensive to actually accommodate all those on. That's what we'll go through. So when you think of the young adult, if you have to think of it in four years, five positions and 21 steps to examining. So when we talk about layers, you've got the osteo chondroitin layer. You've got the capsular labor earlier. Next. Then comes the muscular tenderness there, and finally the neurovascularly. So these are the four layers that you're thinking about, and then you have to think about the in five positions of examination, which are standing position, the seated position, the supine position, lateral and pull position and that's how your examination will move. And then if you actually dissect down further, these are the 21 steps to a physical examination of the hip in those five positions, and we'll go through each one of them in a bit of detail now. So when the patient is standing up, the first thing is obviously you look at where is the general location of pain, and the patient would do that by pointing with one finger all they'll do the classical see sign, that is, where is the hip hurt? They'll say, Doc, my pulse here. Second thing you want to assess once you're standing is their kid. Abnormalities often help, and that would help actually detect any problems of the Kingdom attic chain. And then you would do the trend in books test as well, which will actually tell you the function off the AB doctors. And all this is done once the patient is standing. The next thing. A lot of patients that actually come to clinic with hyper mobility on do you need to check for the nine signs of hyper mobility and get them a score as well, while they're still in the standing position. Then you will inspect the him from the front side and back. And also look at this fine the Belviq built and any obvious laxity. Once that is done in the standing position, you will get the patient to sit down and you will do in the seated position a quick vascular lymphatic, a neurological examination. I could lead do it at that state so that you don't forget that on you do an SLR, the rule out right foot pain as well. But the important thing that you will also do from the hip point of view, is passive internal and external rotation till you get a gentle endpoint and you would compare that bilaterally. Once a patient is sitting down, then this is where it actually starts different. You get the patient to lie down on. The first thing you'll do is inspect for leg length discrepancy. Once you've done that, the palpitation differs on. There are full bony points that you need to palpate on three muscle groups that you will need to assess the full body points Are the Bumex emphasis for any other related issues or symptoms or any information around the Bumex advice is you're actually about with the and you superior. I like spine for any tendonitis there, The greater Trochanter and also the associating area for any tenderness is there. And finally, the skull Juvaro city, because the heart strings attached there. Then you will go for checking the strength of the abductors and any tenderness around there. The 80 doctors on the flex is, and you also do a coffin balls at the same time once you're there. So that's all soft tissue examination for a young adult. These are the four bony points on three months less structures on the golf balls at the same time, the next step would be to do the Thomases test, as you do in terms of range of motion. And finally, you would check the full range of motion of the hip joint after you've done. The Thomas is test so internal and external rotation in 90 degrees of flexion and finally checking for the impingement. This on the favorite test. So the impingement test is done with a flexion, a deduction on internal rotation of the hip, and that would actually go Spain in deep in the groin. Sometimes if you've got Iliopsoas pathology and the labrum in world. You may also get a click or clunk. One's doing that. The second it is the favorite test, which is flexion, a reduction on external rotation and again that reduces the pain in the groin is well, So both these tests will be done once the patient is soup. I checking for impingement now before we go on to the next position. I think there are a couple of diagnosis, which you need to understand what exactly they are. And then we can tell you the tests of hard to examine to these conditions. So the first one is the skew from real impingement. Well, this was described by Johnson in 1977 following do hip replacements and one osteotomy. Essentially, the pathology here is that the distance between the lesser trochanter on the skin has reduced, and once that distance is reduced, what you've got in there is the cord greatest feminist muscle, and that gets inflamed. So it's a painful entrapment off the ordinary Decemberists muscle, which actually leads do bein on. That is what is given remembrance Mint is all about so in terms of the examination, any this which would actually reduce that distance, will probably gait pain. And that's what you're taking for. So there's no pattern. Want a clinical test prescription? Really, Benjamin, what you will do is a passive combined extension, a deduction, an external rotation of the limb. And what that does is approximates the lesser trochanter to the skin, aggravating the symptoms. And that actually leads to increase pain. And therefore you diagnosis capable inpatient. And sometimes you have resisted external rotation, which is painful as well. Signifying risk of Enbrel impingement. The next serum that you need to understand is the deep blue pill syndrome. Now the nominee later of the deep Blue Gill syndrome has changed from better forms syndrome to the deep blue gill syndrome. Just because there are lots of structures which are involved inside, ignore them trap mint and not only the performers, so the structures that would be involved in a sciatic nerve entrapment are the piriformis. Obviously, the fibers bandstand gaining the blood vessels. You could have the gluteal muscles, the hamstring muscles, the General I operator intervals complex. You can have vascular abnormalities on space occupying lesions as well, and it dumps of definition, the deep blue pill syndromes defined as pain in the butt off known discogenic origin. So, in terms of examining this area around austere aspect of the hip, you will start with palpitation on file. Beijing is done in the lateral position, which you would start with the soap opera say, grow a leg area. Then you wanted the sacroiliac joint. The beauty is Maximus origin. Then the better for Ms Months old, the sciatic know and the facets of the greater trochanter. So that's what your palpating. The other thing that we do in the latter position is, um, the active better for Ms Test, where we get the patient to lie down in the lateral position, get active a deduction and external rotation. Now, if you combine the active better for Ms Test Good, the seeded better form of Stretch Test, which is passive flexion a deduction with internal rotation, then the sensitivity is about 91% on specificity is about 80% for diagnosing deep luteal syndrome. And this is how you actually end up doing the seeded performance test. This was before this test. We do think should know induction on in terms of, please sleeping and the patient should then be competing with being in the posterior aspect of the hip joint. But that is done for the season for the lateral position of the active. Been for Ms Test this like doing it right? So now do you check, uh, s all the depo kills from So the basic lines down naturally speed for the and then you put planted that on us against my hands are lifted me up. So that's active. Should have for Ms Chest Osteo Anything on the patient complain of pain again in the posterior aspect. So if you combine these two than the specificity and the sensitivity for deep blue pill central is quite high and value examined the patient in the wrong position. But you're checking for femoral anteversion and also for erectus contractor. Finally, you need to think off any other sources of pain. That is, is the pain coming from the lumbosacral spine, the sacroiliac joint. Any gynecological causes any GI I causes and also the urogenital system. And these are all the extra articular causes which are known musculoskeletal. And now, recently, in 21 22 we've also got to pay attention to the spinal Belviq by mechanics because all these impingement syndromes beef Embron, Stabler's Benjamin all beat any of the extraordinary impingement syndromes. They're old dynamics and roads, so obviously the spine and the pelvis and how their position make a huge impact. Ongoing, pinched one c also need to be considering what exactly is happening in the spinal segment about Is it a fixed spine? Is that the hyper Mobil spine? Because that would actually make a difference to your hip examination on impingement as well. On that note, I'll stop so thank you very much for listening and I'll take questions. Keep this as an informal session. Now, if you have any questions, please do shot out, and I'll be happy to answer.