Piriformis syndrome occurs due to compression or impingement of the sciatic nerve by hypertrophy or contracture of the piriformis muscle. The characteristic symptoms of pyramidal syndrome include gluteal pain radiating to the posterior aspect of the thigh that may be accompanied by paresthesias. As a frequent trigger, the patient may report a long period of sitting on a hard surface prior to the pain. The clinical case presents the PACE maneuver in which the patient resists the examiner's external rotation and hip abduction to 90° of flexion. It is considered positive if it reproduces the symptoms in the context of pyramidal syndrome.

A 40-year-old patient begins to feel discomfort in the right buttock after a prolonged car trip. Since then, he does not tolerate prolonged sitting due to recurrence of pain. Occasionally he feels numbness in the right lower limb that disappears when he gets up. He has a magnetic resonance imaging study and a hip X-ray, in which no abnormalities are reported. Examination of sensibility and osteotendinous reflexes shows no alterations. External rotation maneuvers and resisted abduction, with the hip in 90 degrees of flexion, reproduce the pain. The most probable diagnosis is:

Piriformis muscle syndrome with assessment of sciatic nerve using diffusion tensor imaging and tractography: a case report.

Piriformis muscle syndrome (PMS) is difficult to diagnose by objective evaluation of sciatic nerve injury. Here we report a case of PMS diagnosed by diffusion tensor imaging (DTI) and tractography of the sciatic nerve, which can assess and visualize the extent of nerve injury. The patient was a 53-year-old man with a 2-year history of continuous pain and numbness in the left leg. His symptoms worsened when sitting. Physical examination, including sensorimotor neurologic tests, the deep tendon reflex test, and the straight leg raise test, revealed no specific findings. The hip flexion adduction and internal rotation test and resisted contraction maneuvers for the piriformis muscle were positive. There were no abnormal findings on magnetic resonance imaging (MRI) of the lumbar spine. The transverse diameter of piriformis muscle was slightly thicker in affected side on MRI of the pelvis. A single DTI sequence was performed during MRI of the pelvis. Fractional anisotropy (FA) and the apparent diffusion coefficient (ADC) of the sciatic nerve were quantified at three levels using the fiber-tracking method. FA values were significantly lower and ADC values were significantly higher distal to the piriformis muscle. We performed endoscopic-assisted resection of the piriformis tendon. Intraoperatively, the motor-evoked potentials in the left gastrocnemius were improved by resection of the piriformis tendon. The patient's symptoms improved immediately after surgery. There was no significant difference in FA or ADC at any level between the affected side and the unaffected side 3 months postoperatively. MRI-DTI may aid the diagnosis of PMS.

X-rays and scans can fail to differentiate hip pathology from lumbar spinal stenosis: Two case reports.

Occasionally, hip pathologies may present alone or combined with lumbar spine pathology, especially lumbar stenosis. Although the history and clinical examination may help differentiate between the two, hip X-rays alone without accompanying magnetic resonance imaging (MRI) studies may prove unreliable. Case 1 - A 72-year-old male presented with the sudden onset of severe back and left posterior thigh pain. Straight leg raising test was positive at 70° (right) and 60° (left), and he had left lower extremity numbness and weakness. The lumbar MRI showed L5-S1 spinal stenosis. Although X-rays of both hips were negative, the MRI showed bilateral femoral neck fractures. He underwent screw fixation of the hip fractures and later underwent endoscopic decompression of the spinal stenosis. Case 2 - A 35-year-old male presented with low backache and right hip pain of 1 month's duration. The neurological examination was normal, except for positive straight leg raising bilaterally at 60°. The spine MRI was normal. However, despite negative X-ray of both hips, the hip MRI revealed avascular necrosis (AVN) of both femoral heads requiring subsequent orthopedic management. Hip pathology may mimic lumbar spinal stenosis. In the two cases presented, plain X-rays failed to document hip fractures (case 1) and AVN (case 2), respectively, both of which were later diagnosed on MRI studies.

Ischiofemoral impingement syndrome: a case report and review of literature.

The etiology of ischiofemoral impingement (IFI) syndrome, an unusual and uncommon form of hip pain, remains uncertain. Some patients demonstrate narrowing of the space between the ischial tuberosity and lesser trochanter from trauma or abnormal morphology of the quadratus femoris muscle. Combined clinical and imaging aid in the diagnosis. A 32-year-old female presented with a 3 years history of pain over the lower aspect of the right buttock, aggravated by movements of the right hip, and partially relieved with rest and medications. The right hip showed extreme restriction of abduction and external rotation. MRI of the right hip showed reduced ischiofemoral space and quadratus femoris space when compared to the left hip. The patient underwent endoscopic resection of the right lesser trochanter, with no recurrence of pain at 2 years. An unusual cause of hip pain, IFI syndrome, should be suspected when hip pain at extremes of movement is associated with signal abnormality of quadratus femoris muscle. Management is tailored to address the inciting factors that precipitated the IFI syndrome.

Femoroacetabular impingement

Signs and symptoms Pain is the most common complaint in those with FAI. It is experienced in a number of areas, making the diagnosis challenging, but commonly occurs in the groin, upper buttock/lower back, the buttock or beneath the buttock, side of the affected hip and posterior upper leg. Onset of symptoms has been reported to present in both an acute and more gradual manner. The pain is often significant enough to cause a decrease in activity level and movement. Some will also describe decreased range of motion of the affected hip. Another symptom is groin pain associated with activity and no prior history of trauma. Inability to perform activities such as high hip flexion or prolong sitting can also be seen in individuals with FAI. Cause

Greater Trochanteric Pain Syndrome -- History and Physical

Patients with greater trochanteric pain syndrome usually have lateral hip pain, tenderness over and around the greater trochanter, pain at end-range hip rotation, abduction or adduction, pain with resisted hip abduction, and a positive Patrick-FABER (flexion abduction external rotation) test. Patients usually suffer from chronic back pain radiating to the posterolateral aspect of the thigh, leg paresthesias, and tenderness over the iliotibial tract. [6] They will often complain of the inability to lay on the affected hip. The mean duration of symptoms before treatment ranges from 7.1 weeks to 4.4 years. Young adults (18 to 35 years old) with hip pain often present with non-specific symptoms and vague findings from the history and physical examination, which may lead to a misdiagnosis of GTPS or trochanteric bursitis. [1] [4]

Lumbosacral Facet Syndrome -- Differential Diagnosis

While at times difficult, an attempt should be made to differentiate lumbosacral facet joint syndrome from the above diagnoses at first with a history and physical examination. While a history of pain radiation to the lower extremity can point more towards radiculopathy or discogenic pain, providers should remember that such presentation may also indicate facetogenic pain, especially in facet joint cysts. Physical examination, while not always completely specific, may help point away from certain diagnoses in the differential. Pain with hip flexion, abduction, and external rotation (FABERE) and hip flexion, adduction, and internal rotation (FADIR) may point more towards sacroiliac and intraarticular hip pathology, respectively. A positive straight leg raise test may point more towards lumbosacral radiculopathy or discogenic pain. However, these tests are often nonspecific. While imaging with X-ray, CT, and MRI may be useful in evaluating spinal anatomy, these tests are also often nonspecific in diagnosing the true etiology of pain. Lumbar medial branch block, therefore, serves as the most reliable definitive diagnosis of the facet joint as the true etiology of a patient's low back pain.

Femoroacetabular Impingement -- Differential Diagnosis

Other hip conditions that are less urgent to address, but must be distinguished from FAI include osteonecrosis (avascular necrosis) of the femoral head, hip dysplasia, iliopsoas tendinitis, greater trochanteric bursitis, gluteal tendinopathy, arthritis, iliotibial band syndrome, snapping hip syndrome, and lumbar radiculopathy. [12] Osteonecrosis can be identified on MRI with edema involving the femoral head. If collapse or sclerosis is present, this may be seen on X-ray, CT, and MRI. Hip dysplasia is identified on X-ray as a shallow acetabulum and/or poor femoral head coverage. Iliopsoas tendinitis or internal snapping hip syndrome is identified clinically when snapping or popping is heard or felt within the medial groin. MRI findings may show edema at the tendinous insertion of the lesser trochanter. Greater trochanteric bursitis and gluteal tendinopathy often occur together and present with pain laterally over the greater trochanter, often described as greater trochanteric pain syndrome. Hip abductor weakness may be present with gluteal tendinopathy or tears. MRI will show edema around the greater trochanter and tendon insertion of the gluteus medius and minimus muscles. In external snapping hip syndrome, the iliotibial band is tight and snapping over the greater trochanter causing pain, and can be diagnosed clinically. Arthritis will manifest with hip pain and evidence of decreased joint space because of cartilaginous wear on weight-bearing X-rays. Spinal etiology is important to identify as well. Lumbar radiculopathy from spinal stenosis can result in groin or hip pain when nerve roots are compressed (usually involving the L1 nerve root). A history of back pain and numbness or tingling in the extremity is important information to obtain.

Hip pain

Clinical examination Clinical tests are adapted to identify the source of pain as intra-articular or extra-articular. The flexion-abduction-external rotation (FABER), internal range of motion with overpressure (IROP), and scour tests show sensitivity values in identifying individuals with intra-articular pathology ranging from 0.62 to 0.91. Medical imaging Projectional radiography ("X-ray") is the first imaging technique of choice in hip pain, not only in older people with suspected osteoarthritis but also in young people without any such suspicion. In this case plain radiography allows categorization as normal hip or dysplastic hip, or with impingement signs, pincer, cam, or a combination of both. Need for clinical correlation Imaging of the hip needs to be complementary to the clinical history and physical examination because it is well known that imaging findings do not always correlate with the presence of pain and vice versa.

Neurology_Adams

Maneuvers in the lateral decubitus position yield less information but are useful in eliciting joint disease. In cases of sacroiliac joint disease, abduction of the upside leg against resistance reproduces pain in the sacroiliac region, sometimes with radiation of the pain to the buttock, posterior thigh, and symphysis pubis. Hyperextension of the upside leg with the downside leg flexed is another test for sacroiliac disease. Rotation and abduction of the leg evoke pain in a diseased hip joint and with trochanteric bursitis. A helpful indicator of hip disease is the Patrick test: With the patient supine, the heel of the offending leg is placed on the opposite knee and pain is evoked by depressing the flexed leg and externally rotating the hip.

InternalMed_Harrison

The straight leg–raising (SLR) maneuver is a simple bedside test for nerve root disease. With the patient supine, passive flexion of the extended leg at the hip stretches the L5 and S1 nerve roots and 113 CHAPTER 22 Back and Neck Pain 4th Lumbar vertebral body 5th Lumbar vertebral body 4th Lumbar pedicle L4 root Protruded L4-L5 disk L5 Root S1 Root S2 Root Protruded L5-S1 disk FIguRE 22-3 Compression of L5 and S1 roots by herniated disks. (From AH Ropper, MA Samuels: Adams and Victor’s Principles of Neurology, 9th ed. New York, McGraw-Hill, 2009; with permission.) the sciatic nerve. Passive dorsiflexion of the foot during the maneuver adds to the stretch. In healthy individuals, flexion to at least 80° is normally possible without causing pain, although a tight, stretching sensation in the hamstring muscles is common. The SLR test is positive if the maneuver reproduces the patient’s usual back or limb pain. Eliciting the SLR sign in both the supine and sitting positions can help

Femoroacetabular impingement

Diagnosis Clinical evaluation is the first step in diagnosis, but will rarely lead to the diagnosis on its own, due to inconsistent and vague nature of the pain. Childhood and current activity should be inquired about. Physical exam should also involve assessing passive internal rotation of the hip during flexion, as range of motion is reduced in proportion to the size of a cam lesion. Flexing the hip to 90 degrees, adducting, and internally rotating the hip, known as the FADDIR test, should also be performed. It is positive when it causes pain. The FABER test should also be performed, this test involves flexing, abducting, and externally rotating the hip. The FABER test is useful when diagnosing concurrently with a labral pathology and is considered positive if the position elicits pain. Additional non-invasive ways to observe possible FAI is changes in gait that include a lower peak hip extension and internal rotation to compensate for bony growth. X-ray

Pathogenesis and contemporary diagnoses for lateral hip pain: a scoping review.

Recent advances in diagnostic imaging techniques and soft tissue endoscopy now allow for precise diagnosis and management of extra-articular hip pathology. The aim of this scoping review is to present an evidence-based update of the relevant literature focussing only on the pathoanatomy, clinical assessment and the diagnosis of pathology in the peritrochanteric space. A literature search was performed on PubMed to include articles which reported on the anatomy and diagnosis of greater trochanteric pain syndrome, trochanteric bursitis, gluteus medius tears and external snapping hip syndrome. A total of 542 studies were identified, of which 49 articles were included for full text analysis for the scoping review. Peritrochanteric space pathology can be broadly classified into (1) greater trochanteric pain syndrome (GTPS), (2) abductor tears and (3) external snapping hip syndrome. Anatomically, gluteus medius, gluteus minimus and tensor fascia lata work in conjunction to abduct and internally rotate the hip. The anterolateral part of the gluteus medius tendon is more prone to tears due to a thin tendinous portion. Increased acetabular anteversion has also been shown to be associated with gluteal and trochanteric bursitis. In terms of clinical examination, tests which were found to be most useful for assisting in the diagnoses of lateral hip pain were the single-leg stance, resisted external derotation of the hip, hip lag sign and the Trendelenburg's test. Dynamic ultrasound along with guided injections and MRI scan do assist in differentiating the pathology and confirming the diagnosis in patients presenting with lateral hip pain. Finally, the assessment of baseline psychological impairment is essential in this group of patients to ensure outcomes are optimised. Lateral hip pain used to be a poorly defined entity, but advances in imaging and interest in sports medicine have led to a better understanding of the pathology, presentation and management of this cohort of patients. A thorough appreciation of the anatomy of the abductor musculature, specific clinical signs and imaging findings will lead to an appropriate diagnosis being made and management plan instituted. IV.

Piriformis syndrome

Piriformis syndrome may also be associated with direct trauma to the piriformis muscle, such as in a fall or from a knife wound. Diagnosis Piriformis syndrome occurs when the sciatic nerve is compressed or pinched by the piriformis muscle of the hip. It usually only affects one hip at a given time, though both hips may produce piriformis syndrome at some point in the patient's lifetime, and having had it once greatly increases the chance that it will recur in one hip or the other at some future point unless action is taken to prevent it. Indications include sciatica (radiating pain in the buttock, posterior thigh, and lower leg) and the physical exam finding of tenderness in the area of the sciatic notch. If the piriformis muscle can be located beneath the other gluteal muscles, it will feel noticeably cord-like and will be painful to compress or massage. The pain is exacerbated with any activity that causes flexion of the hip including lifting, prolonged sitting, or walking.

InternalMed_Harrison

The crossed SLR sign is present when flexion of one leg reproduces the usual pain in the opposite leg or buttocks. In disk herniation, the crossed SLR sign is less sensitive but more specific than the SLR sign. The reverse SLR sign is elicited by standing the patient next to the examination table and passively extending each leg with the knee fully extended. This maneuver, which stretches the L2-L4 nerve roots, lumbosacral plexus, and femoral nerve, is considered positive if the patient’s usual back or limb pain is reproduced. For all of these tests, the nerve or nerve root lesion is always on the side of the pain.

InternalMed_Harrison

Forward bending is often limited by paraspinal muscle spasm; the latter may flatten the usual lumbar lordosis. Flexion at the hips is normal in patients with lumbar spine disease, but flexion of the lumbar spine is limited and sometimes painful. Lateral bending to the side opposite the injured spinal element may stretch the damaged tissues, worsen pain, and limit motion. Hyperextension of the spine (with the patient prone or standing) is limited when nerve root compression, facet joint pathology, or other bony spine disease is present. Pain from hip disease may mimic the pain of lumbar spine disease. Hip pain can be reproduced by internal and external rotation at the hip with the knee and hip in flexion or by compressing the heel with the examiner’s palm while the leg is extended (heel percussion sign).

Sciatica -- History and Physical

Another maneuver is the crossed straight leg test, similar to the straight leg raise test but is conducted on the asymptomatic leg instead. The crossed straight leg test is considered positive if the patient reports pain in the symptomatic leg while the asymptomatic leg is at a 40° angle, representing a central disc herniation with severe nerve root irritation. L3 radiculopathy includes weakness of hip adduction, knee extension, and sensory pain in the anteromedial dermatome of the thigh. Ankle dorsiflexion weakness and absent patellar reflex are present in L4 radiculopathy. Hip abduction and big toe extension weakness show L5 radiculopathy. S1 nerve root compression presents as absent ankle reflexes.

Hypertrophy of the tensor fascia lata: A pseudotumor due to lumbar radiculopathy.

Pseudotumor of the tensor fascia lata (TFL) consists of a rare, benign soft tissue mass/hypertrophy of the TFL that appears on the anterolateral aspect of the proximal thigh. Notably, this condition often mimics a malignant tumor and may be misdiagnosed as a sarcoma. A 45-year-old male presented with left hip/groin pain, swelling, and a painful mass on the anterolateral aspect of the left hip/thigh. The symptoms had started 3 months ago following an L1-S1 lumbar laminectomy/fusion. The initial diagnosis was hip disease, and the patient underwent a left MR arthrogram. When this study demonstrated a tear of the left anterosuperior acetabular labrum plus an increased alpha angle causing femoroacetabular impingement, the patient then underwent a left hip arthroscopy. However, as he continued to complain of the hip mass, he was referred to an orthopedic oncologist whose presumptive diagnosis favored a sarcoma. Nevertheless, the pelvic MRI scan and ultrasound (US) confirmed the diagnosis of hypertrophy of the left TFL (US left 33.4 mm vs. right 14.4 mm). The patient was first treated with 50 units of locally injected botulinum. As there was no symptomatic relief, the plan was to repeat the injection within the next few months. Hypertrophy of TFL may mimic a neoplasm such as a sarcoma and contributes to what appears to be a lumbar radiculopathy. However, MR and US imaging should readily identify TFL and rule out malignant lesions such as sarcomas.

[Degenerative rupture of the hip abductors. Missed diagnosis with therapy-resistant trochanteric pain of the hips and positive Trendelenburg sign in elderly patients].

The cases of four elderly patients with persistent trochanteric pain and tears of the gluteus medius and/or gluteus minimus tendons detected in magnetic resonance imaging (MRI) are presented. There was no history of local trauma in any patient but three patients had a positive Trendelenburg sign. Magnetic resonance imaging showed either an obvious discontinuity of the affected tendon or an increased T2 signal above, or less specifically lateral to the greater trochanter. The presence of an elongated tendon on MRI is most likely indicative of a partial rupture of the tendon. Pain and local tenderness over the lateral aspect of the hip in clinical examination is commonly attributed to trochanteric bursitis or trochanteric pain syndrome. Partial or complete tears of the gluteus medius and/or gluteus minimus tendons are thought to represent an unusual finding. However, the true incidence and the clinical significance of hip abductor degeneration and rupture remain to be determined. More studies are needed to examine the prevalence of ruptures in asymptomatic patients, to evaluate the subsequent risk for developing osteoarthritis of the hip (caused by impaired protective reflexes originating from proprioceptive nerve endings in muscle spindles) and to determine the risk for falls related to weakness of hip abduction. Furthermore, no data exist regarding the success rate of conservative treatment. Tears of the gluteus medius and minimus tendons in the elderly population are likely to be a more common cause of pain in the greater trochanteric region than previously thought. In patients who do not respond to conservative treatment, weakness of hip abduction (positive Trendelenburg sign) and new limping should point to the possibility of hip abductor ruptures. The most useful examination technique for diagnosis is MRI.

Pelvic deformity secondary to tensor fascia lata tightness associated with desmoid tumor.

The iliotibial band is a thick, condensed fascia that, when contracted, leads to a hip flexion, abduction, and external rotation contracture in addition to other joint contractures. Iliotibial band tightness occurs secondary to iliotibial band friction syndrome, which commonly occurs at the lateral femoral epicondylar region. However, a proximal cause of iliotibial band/tensor fascia lata friction syndrome leading to a secondary hip contracture is swelling around the hip; this swelling being a desmoid tumor has not been explicitly described in the literature. The authors present a rare case of a hip contracture in a 28-year-old active man who presented with a functionally disabling hip flexion contracture of 20° with further flexion possible up to 130°, a 45° abduction contracture, and a 20° external rotation contracture with further rotation possible up to 40° with a bony hard swelling in the left gluteal region. Ober’s test was positive. Opposite hip and spine examinations were normal. The goals of treatment were to establish the causality between the 2 and to diagnose the etiology of the gluteal mass. Radiographs were normal, with only a pelvic obliquity evident. Magnetic resonance imaging revealed an extra-articular mass abutting the iliac blade. Histopathology confirmed the mass to be a desmoid tumor in the left gluteal region. A wide surgical excision of the mass was performed with negative margins; no postoperative radiotherapy was administered. After rigorous physiotherapy, the hip deformity disappeared at 6 months and there was no evidence of recurrence at 2.5-year follow-up, with the patient able to sit cross-legged and squat.

Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome.

This study examined patients with greater trochanteric pain syndrome (GTPS) to determine the prevalence of gluteus medius pathology by utilizing magnetic resonance imaging (MRI), and to evaluate the presence of Trendelenburg's sign, pain on resisted hip abduction, and pain on resisted hip internal rotation as predictors of a gluteus medius tear in this group of patients. Twenty-four subjects with clinical features consistent with GTPS were recruited. A standard physical assessment was performed at study entry, including assessment of the 3 specific physical signs. Following this initial assessment, MRI of the affected hip was performed. A 1.5T whole body MRI system was utilized, with T1 and T2 fast spin-echo sequences performed in the coronal and axial planes. All MR images were reviewed in random order by a single radiologist. In 12 patients, the 3 physical signs were assessed at study entry and at 2 months by the same observer and the intraobserver reliability for each of the signs was calculated. All subjects were women (median age 58 years, range 36-75 years). The median duration of symptoms was 12 months (range 12-60 months). MRI findings were as follows: 11 patients (45.8%) had a gluteus medius tear, 15 patients (62.5%) had gluteus medius tendinitis (pure tendinitis in 9 patients and tendinitis with a tear in 6 patients), 2 patients had trochanteric bursal distension, and 1 patient had avascular necrosis of the femoral head. Trendelenburg's sign was the most accurate of the 3 physical signs in predicting a tendon tear, with a sensitivity of 72.7% and a specificity of 76.9%. Moreover, Trendelenburg's sign was the most reliable measure, with a calculated intraobserver kappa of 0.676 (95% confidence interval 0.270-1.08). The results support the hypothesis that gluteus medius tendon pathology is important in defining GTPS. In this series, trochanteric bursal distension was uncommon and did not occur in the absence of gluteus medius pathology. The physical findings suggest that Trendelenburg's sign is the most sensitive and specific physical sign for the detection of gluteus medius tears, with an acceptable intraobserver reliability. Further delineation with MRI, especially in patients with a positive Trendelenburg's sign, is recommended prior to any consideration of surgery in this group of patients. Finally, with the pathology of this condition defined, the challenge will be to devise and assess, by randomized controlled trial, an appropriate treatment strategy for this group of patients.

Surgery of a Rare Case of Multiple Synovial Osteochondromatosis of the Hip Joint.

Primary synovial osteochondromatosis of the hip is a benign disorder, which is not frequently seen clinically. The characteristic of this disease is proliferation of synovium and formation of loose bodies inside the joint. It is known that only the loose bodies derived from synovium were called synovial osteochondromatosis. Although it can take place in any joint, the knee is most commonly affected, involvement of the hip joint is relatively rare. We report a young man who has multiple synovial osteochondromatosis in his left hip. A 21-year-old young man, who had progressive pain and functional impairment of his left hip, came to our hospital. He complained that 2 years ago, he began to feel painful of his left hip joint when walking and squatting. Physical examination found that the motion range of the hip was obviously limited, with internal rotation, abduction in particular. The Harris hip score was just 38 points. X-ray shew multiple osteochondromatosis with mild degenerative osteoarthritis existing inside the hip joint. Magnetic resonance imaging shew that the synovial osteochondromatosis intersperse inside the hip joint. During the operation, posterolateral incision of the hip was chosen with dislocation of the femoral head for total exposure of the hip joint to debride extensive loose bodies and proliferative synovial tissue. Pulse irrigation was applied to flush out the residuals. More than 872 of osteochondromatosis were removed out of the hip joint (some small ones were sucked during the operation). The size of the loose bodies ranged from 3 cm × 3 cm × 2.5 cm to 0.2 cm × 0.2 cm × 0.15 cm. Post-operation radiography shew most pathological tissues were taken out. After the operation, the patient rehabilitated fast. The pain relieved and he could bear weight and walked 3 days postoperatively. 1 and 3 months postoperatively, the patient came to us for visit, and he said that he just had a relatively satisfactory function of his affected hip. He could walk, slowly run, and squat freely. But sometimes he could feel a bit painful on his left hip joint after long walking and fatigue. And sometimes he could feel and hear mild crepitus on the left hip joint. 12 months later, the patient came again and complained that the pain of his operated hip became a bit more serious than before since about 20 days ago. The range (internal rotation, abduction in particular) of this hip joint could not live up to normal, compared with the uninvolved hip in physical examination. X-ray shew osteoarthritis had become a bit severer. The patient accepted the suggestion of prospective total hip replacement. Multiple synovial osteochondromatosis is not a very uncommon condition. However, there may be unusual presentations. It can take place in any joint, the knee is most commonly affected, however, involvement of the hip joint is relatively rare as was seen in our patient.

Editorial Commentary: It Is Imperative to Fix Symptomatic Hip Gluteus Medius Tears at Time of Femoroacetabular Impingement: Why Ignore This Pain in the Butt?

The hip can have a multitude of different pathologies leading to different symptoms. Greater trochanteric pain syndrome, historically attributed to bursitis, has been largely found to be associated with lesions of the gluteus medius and minimus tendons, and the prevalence of gluteus medius pathology in patients with femoroacetabular impingement (FAI) is as high as one-third of the FAI population. If a patient is found to have significant clinical symptoms of both FAI and a gluteus medius tear, it is imperative to fix both pathologies. The most important diagnostic predictor in hip arthroscopy is not magnetic resonance imaging but a well-executed history and physical exam. We use a quadrant approach: the medial quadrant accounts for adductor bursitis, adductor tears, pudendal neuralgia, or sports hernias. The posterior quadrant may account for a hamstring tear, lumbar radiculopathy, ischiofemoral impingement, or in rare cases piriformis syndrome. The anterior quadrant accounts for more intraarticular pathologies including FAI, Labral tears, osteoarthritis, avascular necrosis, or iliopsoas bursitis. The lateral quadrant would include greater trochanteric pain syndrome, gluteus medius and minimus tears, external snapping hip syndrome and iliotibial band syndrome. By using this systematic approach and using the magnetic resonance imaging to confirm the diagnosis, we may accurately determine patients' hip pathologies.

Arthroscopic repair of delaminated acetabular articular cartilage in femoroacetabular impingement.

Lesions to articular cartilage can be difficult to treat and directly impact surgical outcome in hip arthroscopy. This article describes a direct cartilage suture repair technique for a young, active individual with full-thickness acetabular cartilage delamination. Lesions of this type are commonly seen with femoroacetabular impingement. A 17-year-old boy presented with bilateral hip pain greater in the right than left. Arthroscopic intervention for the right hip included direct cartilage repair for the cartilage lesion, osteoplasty for femoroacetabular impingement, repair for an anterior labral tear, capsular plication for iliofemoral ligament laxity, and psoas lengthening. Twelve weeks postoperatively, a standard capsular plication, osteoplasty, and chondroplasty were performed on the left hip. At follow-up, the patient reported feeling 95% normal. He noted that the right and left hips were essentially the same. Symptoms consisted of stiffness after prolonged sitting and mild pain following sports. The patient reported being pain free 90% of the time, with pain 2/10 at worst. He scored a 96 on the modified Harris Hip Score, 93 on the Hip Outcome Score Activities of Daily Living subscale, and 81 on the Hip Outcome Score Sports subscale. Overall, the patient was satisfied with the outcome. The direct cartilage repair, in addition to osteoplasty, anterior superior labral repair, iliofemoral capsular plication, and psoas lengthening, produced an excellent outcome in this young, active patient.

Greater trochanteric pain syndrome

Diagnosis A doctor may begin the diagnosis by asking the patient to stand on one leg and then the other, while observing the effect on the position of the hips. Palpating the hip and leg may reveal the location of the pain, and range-of-motion tests can help to identify its source. X-rays, ultrasound and magnetic resonance imaging may reveal tears or swelling. But often these imaging tests do not reveal any obvious abnormality in patients with documented GTPS. Prevention Because wear on the hip joint traces to the structures that support it (the posture of the legs, and ultimately, the feet), proper fitting shoes with adequate support are important to preventing GTPS. For someone who has flat feet, wearing proper orthotic inserts and replacing them as often as recommended are also important preventive measures.

Physical therapy management of a patient with persistent groin pain after total hip arthroplasty and iliopsoas tenotomy: a case report.

<bBackground</b: Hip impingement syndrome can occur after total hip arthroplasty (THA). Nonoperative treatment is inconsistently recommended, and surgical options include iliopsoas tenotomy. The current case report describes the unique case of a patient with persistent groin pain after THA and iliopsoas tenotomy.<bCase Description</b: The 72-year-old male had persistent groin pain after right THA and an unsuccessful iliopsoas tenotomy. He had pain and limited right hip range of motion during active and passive hip flexion, abduction, and external rotation. Treatment consisted of high-grade joint mobilization to improve the range of motion of the right hip and an exercise program.<bOutcomes</b: The patient was treated for six visits over 3 weeks. Clinically important improvements were noted in pain, function, and perceived level of improvement. Pain during hip flexion improved on the Numeric Pain Rating Scale, and function improved on the Lower Extremity Functional Scale. Improvements in the range of motion and strength were also observed. At 6-month follow-up, he reported maintenance of improvements.<bDiscussion</b: Joint mobilization and exercise were effective for improving range of motion, groin pain, and function in a patient with a 4-year history of persistent groin pain after THA and subsequent iliopsoas tenotomy.

Advanced Imaging Adds Little Value in the Diagnosis of Femoroacetabular Impingement Syndrome.

Femoroacetabular impingement (FAI) syndrome is an increasingly recognized source of hip pain and disability in young active adults. In order to confirm the diagnosis, providers often supplement physical examination maneuvers and radiographs with intra-articular hip injection, magnetic resonance imaging (MRI), or magnetic resonance arthrography (MRA). Since diagnostic imaging represents the fastest rising cost segment in U.S. health care, there is a need for value-driven diagnostic algorithms. The purpose of this study was to identify cost-effective diagnostic strategies for symptomatic FAI, comparing history and physical examination (H&P) alone (utilizing only radiographic imaging) with supplementation with injection, MRI, or MRA. A simple-chain decision model run as a cost-utility analysis was constructed to assess the diagnostic value of the MRI, MRA, and injection that are added to the H&P and radiographs in diagnosing symptomatic FAI. Strategies were compared using the incremental cost-utility ratio (ICUR) with a willingness to pay (WTP) of $100,000/QALY (quality-adjusted life year). Direct costs were measured using the Humana database (PearlDiver). Diagnostic test accuracy, treatment outcome probabilities, and utilities were extracted from the literature. H&P with and without supplemental diagnostic injection was the most cost-effective. Adjunct injection was preferred in situations with a WTP of >$60,000/QALY, low examination sensitivity, and high FAI prevalence. With low disease prevalence and low examination sensitivity, as may occur in a general practitioner's office, H&P with injection was the most cost-effective strategy, whereas in the reciprocal scenario, H&P with injection was only favored at exceptionally high WTP (∼$990,000). H&P and radiographs with supplemental diagnostic injection are preferred over advanced imaging, even with reasonable deviations from published values of disease prevalence, test sensitivity, and test specificity. Providers with low examination sensitivity in situations with low disease prevalence may benefit most from including injection in their diagnostic strategy. Providers with high examination sensitivity in situations with high disease prevalence may not benefit from including injection in their diagnostic strategy. Providers should not routinely rely on advanced imaging to diagnose FAI syndrome, although advanced imaging may have a role in challenging clinical scenarios. Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Femoral osteotomy to improve range of motion in residual deformity of perthes disease: A case report.

The treatment strategies for residual deformity of Perthes disease are not established. This is a case report of a 15-year-old boy. He developed right Perthes disease (lateral pillar classification group B) when he was 10 years old and underwent varus femoral osteotomy of the right side. At 12 years of age, he developed left Perthes disease (lateral pillar classification group B) and underwent varus femoral osteotomy of the left side. Postoperatively, he was treated with partial weight bearing of the left leg with crutches. At 15 years, range of motion (ROM) of his left hip was markedly limited at 30° flexion, 10° abduction, 70° external rotation, and -20° internal rotation, and he was having difficulty maintaining a sitting position. Stulberg group V was noted on plain radiography. Computed tomography (CT) showed collapse of the load-bearing part of the femoral head on the coronal plane, but the ball-shape was maintained in the posterior femoral head on sagittal and transverse sections. Valgus-flexion-internal rotation osteotomy was performed to improve ROM. Left hip ROM improved to 90° flexion, 20° abduction, 50° external rotation, and 40° internal rotation immediately after the surgery. He was able to sit 10 months postoperatively but was left with a limp and limited ROM in the left hip at 60° flexion. Chondroplasty was performed during the plate removal surgery at 10 months postoperatively, which improved hip flexion to 100° immediately after the surgery. The patient was left with limited ROM of 60° flexion of the left hip at the final observation. Femoral osteotomy to improve ROM could be an option for residual deformity of Perthes disease.

Evaluation of the patient with hip pain.

Hip pain is a common and disabling condition that affects patients of all ages. The differential diagnosis of hip pain is broad, presenting a diagnostic challenge. Patients often express that their hip pain is localized to one of three anatomic regions: the anterior hip and groin, the posterior hip and buttock, or the lateral hip. Anterior hip and groin pain is commonly associated with intra-articular pathology, such as osteoarthritis and hip labral tears. Posterior hip pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, and less commonly ischiofemoral impingement and vascular claudication. Lateral hip pain occurs with greater trochanteric pain syndrome. Clinical examination tests, although helpful, are not highly sensitive or specific for most diagnoses; however, a rational approach to the hip examination can be used. Radiography should be performed if acute fracture, dislocations, or stress fractures are suspected. Initial plain radiography of the hip should include an anteroposterior view of the pelvis and frog-leg lateral view of the symptomatic hip. Magnetic resonance imaging should be performed if the history and plain radiograph results are not diagnostic. Magnetic resonance imaging is valuable for the detection of occult traumatic fractures, stress fractures, and osteonecrosis of the femoral head. Magnetic resonance arthrography is the diagnostic test of choice for labral tears.

Femoroacetabular impingement

X-ray Projectional radiography ("X-ray")is often considered first line for FAI. Anterior-posterior pelvis and a lateral image of the hip in question should be attained. A 45-degree Dunn view is also recommended. Other modalities MRI imaging may follow, particularly if there is no specific evidence on radiographs, producing a three-dimensional reconstruction of the joint for better definition, to evaluate the hip cartilage, or measure hip socket angles (e.g. the alpha-angle as described by Nötzli in 2-D and by Siebenrock in 3-D). MR arthrogram had been used in the past, as it was more sensitive for picking up soft tissue lesions; however, due to improvement in technology, MRI is now considered comparable for picking up such lesions. CT is not usually used due to radiation exposure and no benefit above MRI. It is possible to perform dynamic simulation of hip motion with CT or MRI assisting to establish whether, where, and to what extent, impingement is occurring.

Missed positional gluteal compartment syndrome in an obese patient after foot surgery: a case report.

Gluteal compartment syndrome is an uncommon condition and can be difficult to diagnose. It has been diagnosed after trauma, vascular injury, infection, surgical positioning, and prolonged immobilization from drug or alcohol intoxication. The diagnosis is based on clinical findings and, in most cases, recognizing these symptoms and making a diagnosis early is critical to a complete recovery. A 53-year-old male who underwent left foot surgery had severe pain to his contralateral hip and posterior gluteal compartment radiating to the right lower extremity immediately postoperative. He was positioned supine with a "bump" placed under his right hip to externally rotate his operative leg during the surgery. Due to the patient's complex past medical history, a presumptive diagnosis of a herniated disc and/or compression of the sciatic nerve was made as a cause for the patient's pain. This resulted in a misdiagnosis period of 36 h until the patient was diagnosed with unilateral gluteal compartment syndrome. Performing a fasciotomy was decided against due to the increased risk of complications. The patient was treated with administration of IV fluids and closely monitored. On post-op day 6, the patient was discharged. At three months post-op, the patient was walking without a limp and he had no changes in his peripheral neurologic examination compared to his preoperative baseline. Gluteal compartment syndrome is a surgical emergency that must be considered postoperatively especially in obese patients with prolonged operation times who experience acute buttock pain. The use of positional bars or "bumps" in the gluteal area should be used with caution and raise awareness of this complication after orthopedic surgeries.

The syndrome of the central L-3-herniated disc with special emphasis on motor involvement.

Literature about the clinical characteristics of herniation of the lumbar intervertebral disc is profuse. Due to their predominant frequency, attention was almost entirely devoted to the L-4 and L-5 prolapses. As clinical accuracy still remains a very important target, specially in departments where myelography is not used for the diagnosis of this entity, the authors thought it of interest to describe the clinical picture of the L-3-herniated disc. Special stress is placed on the motor involvement. Fourteen cases form this series. They were all central soft herniations. Cases of spondylotic narrow spinal canal were excluded. The special features were their predominance in people above 50 years old and the compromise of the hip abductors and internal rotator muscle groups making it impossible for the patient to stand on the affected limb (Trendelenburg sign). An abnormal knee jerk was a frequent accompaniment. Contrary to common knowledge the quadriceps muscle strength was almost unaffected. Sensory disturbances were not useful for location. The L-3 section of the lower lumbar spine is the narrowest explaining the reason why 3/4 of the patients had a more or less complete cauda equina syndrome. It was therefore a very dangerous herniation that crippled quickly, needing usually an emergency operation with all the risks involved in this older age group of patients.

Complex Regional Pain Syndrome Caused by Lumbar Herniated Intervertebral Disc Disease.

Most cases of complex regional pain syndrome (CRPS) occur after some inciting injury. There are a few cases of CRPS after an operation for disc disease. CRPS from a mild herniated intervertebral disc (HIVD) without surgical intervention is even rarer than CRPS after an operation for disc disease.A 22-year-old man was transferred to a pain clinic. He had continuously complained about back and right leg pain. He presented with a skin color change in the right lower leg, intermittent resting tremor, stiffness, and swelling in the right leg. He complained of a pulling sensation and numbness in his right buttock, posterior thigh, lateral calf, and ankle. This symptom was in accordance with L4/5 radiculopathy. Magnetic resonance imaging (MRI) also showed L4/5 HIVD that was central to the bilateral subarticular protrusion.He was diagnosed as having CRPS, which fits the revised International Association for the Study of Pain (IASP) criteria. He fulfilled 4 symptom categories (allodynia, temperature asymmetry and skin color change, sweating changes, decreased range of motion and motor dysfunction) and 3 of 4 sign categories (allodynia, temperature asymmetry and skin color changes, decreased range of motion and motor dysfunction). The bone scan and thermography also revealed CRPS.For the past 2 months, we have performed intensive treatments. But, he never became pain-free and walking for 5 minutes led to persistent leg pain. We decided to perform percutaneous nucleoplasty, which can directly decompress a HIVD. On the next day, he achieved dramatic symptom relief. The visual analog scale (VAS) score improved to 3, compared to the VAS score of 9 at the first visit. The skin color change, allodynia, and tremor in the right leg disappeared, and the temperature asymmetry normalized. Motor weakness of the right leg also recovered.We report an unusual case of CRPS that was caused by L4/5 HIVD without a history of trauma or surgery. It has a clear causal relationship between HIVD and CRPS and definitively fits in the newly revised IASP criteria. In conclusion, mild HIVD can cause CRPS without any trauma. And percutaneous nucleoplasty can be considered as a treatment option.


The approach is questionable due to lack of sufficient data. The correct answer could be respiratory polygraphy, especially in the case of an obese patient, which we do not know, but it could also be correct 2 (echocardiogram) in the case of suspicion of associated cardiopathy, less frequent but also possible. The association of COPD with OSAHS is a frequent cause of COPD deterioration, greater than that which would correspond to functional impairment.

The approach is questionable due to lack of sufficient data. [HIDDEN], especially in the case of an obese patient, which we do not know, but it could also be [HIDDEN] in the case of suspicion of associated cardiopathy, less frequent but also possible. The association of COPD with OSAHS is a frequent cause of COPD deterioration, greater than that which would correspond to functional impairment.

In a patient with mild chronic obstructive pulmonary disease (COPD) in stable phase, polyglobulia and respiratory insufficiency are evident. In the chest X-ray there are no notable alterations. Which of the following procedures would you consider performing first to rule out the coexistence of other diseases that may justify the findings described?

Acute exacerbation of chronic obstructive pulmonary disease

In one-third of all COPD exacerbation cases, the cause cannot be identified. Diagnosis The diagnostic criteria for acute exacerbation of COPD generally include a production of sputum that is purulent and may be thicker than usual, but without evidence of pneumonia (which involves mainly the alveoli rather than the bronchi). Also, diagnostic criteria may include an increase in frequency and severity of coughing, as well as increased shortness of breath. A chest X-ray is usually performed on people with fever and, especially, hemoptysis (blood in the sputum), to rule out pneumonia and get information on the severity of the exacerbation. Hemoptysis may also indicate other, potentially fatal, medical conditions. A history of exposure to potential causes and evaluation of symptoms may help in revealing the cause the exacerbation, which helps in choosing the best treatment. A sputum culture can specify which strain is causing a bacterial AECB. An early morning sample is preferred.

Obstructive lung disease

The diagnosis of COPD is established through spirometry although other pulmonary function tests can be helpful. A chest X-ray is often ordered to look for hyperinflation and rule out other lung conditions but the lung damage of COPD is not always visible on a chest x-ray. Emphysema, for example, can only be seen on CT scan. The main form of long term management involves the use of inhaled bronchodilators (specifically beta agonists and anticholinergics) and inhaled corticosteroids. Many patients eventually require oxygen supplementation at home. In severe cases that are difficult to control, chronic treatment with oral corticosteroids may be necessary, although this is fraught with significant side effects.

Respiratory disease

Neonatal diseases Pulmonary diseases may also impact newborns, such as pulmonary hyperplasia, pulmonary interstitial emphysema (usually preterm births), and infant respiratory distress syndrome. Diagnosis Respiratory diseases may be investigated by performing one or more of the following tests Biopsy of the lung or pleura Blood test Bronchoscopy Chest X-ray CT scan, including high-resolution computed tomography Culture of microorganisms from secretions such as sputum Ultrasound scanning can be useful to detect fluid such as pleural effusion Pulmonary function test Ventilation–perfusion scan Epidemiology

High-resolution computed tomography

The lung bases are often inconsistent in appearance in patients due to the potential for atelectasis causing positional ground glass or consolidative opacities. When the patient is positioned prone, or on their belly, the lung bases can expand further and help distinguish atelectasis from early fibrosis. In patients with normal chest radiographs, prone scans have been found useful in 17% of cases, particularly in excluding posterior lung abnormalities. In patients with abnormal findings on chest radiographs, prone scans are only useful in 4% of cases. The scans may be more useful in patients with basilar predominant disease processes, such as asbestosis and idiopathic pulmonary fibrosis. See also X-ray microtomography References External links High-Resolution Computed Tomography in Interstitial Lung Disease Hi-res chest CT diagnostic algorithm Understanding High-Resolution Computed Tomography X-ray computed tomography Respiratory system imaging

Chronic obstructive pulmonary disease

Use of COPD Diagnostic Questionnaire alone or in combination with hand-held flow meters is appropriate for screening of COPD in primary care. Other tests A chest X-ray is not useful to establish a diagnosis of COPD but it is of use in either excluding other conditions or including comorbidities such as pulmonary fibrosis, and bronchiectasis. Characteristic signs of COPD on X-ray include hyperinflation (shown by a flattened diaphragm and an increased retrosternal air space) and lung hyperlucency. A saber-sheath trachea may also be shown that is indicative of COPD.

Diffuse panbronchiolitis

In the differential diagnosis (finding the correct diagnosis between diseases that have overlapping features) of some obstructive lung diseases, DPB is often considered. A number of DPB symptoms resemble those found with other obstructive lung diseases such as asthma, chronic bronchitis, and emphysema. Wheezing, coughing with sputum production, and shortness of breath are common symptoms in such diseases, and obstructive respiratory functional impairment is found on pulmonary function testing. Cystic fibrosis, like DPB, causes severe lung inflammation, excess mucus production, and infection; but DPB does not cause disturbances of the pancreas nor the electrolytes, as does CF, so the two diseases are different and probably unrelated. DPB is distinguished by the presence of lesions that appear on X-rays as nodules in the bronchioles of both lungs; inflammation in all tissue layers of the respiratory bronchioles; and its higher prevalence among individuals with East Asian lineage.

Pulmonary examination

The pulmonary examination or respiratory examination is the portion of the physical examination where the physician examines the respiratory system for signs of disease. It is performed as a part of a complete physical examination, or the physician may choose to perform a focused respiratory exam. Classically, it is performed after the HEENT examination, and consists of four stages: inspection, palpation, percussion, and auscultation. If there are signs of respiratory disease, the physician may order additional tests including medical imaging, such as a chest X-ray or CT scan, or laboratory tests, such as a complete blood count. The information gathered from the physical examination, along with the medical history, is synthesized in order to produce a differential diagnosis and treatment plan. References Medical treatments

Pulmonary hypertension

Exclude other diseases If the echocardiogram is compatible with a diagnosis of pulmonary hypertension, common causes of pulmonary hypertension (left heart disease and lung disease) are considered and further tests are performed accordingly. These tests generally include electrocardiography (ECG), pulmonary function tests including lung diffusion capacity for carbon monoxide and arterial blood gas measurements, X-rays of the chest and high-resolution computed tomography (CT) scanning. Ventilation/perfusion scintigraphy If heart disease and lung disease have been excluded, a ventilation/perfusion scan is performed to rule out CTEPH. If unmatched perfusion defects are found, further evaluation by CT pulmonary angiography, right heart catheterization, and selective pulmonary angiography is performed. CT scan

Routine chest radiographs in exacerbations of chronic obstructive pulmonary disease. Diagnostic value.

Routine admission chest radiographs were abnormal in 35 (14%) of 242 patients hospitalized with an exacerbation of chronic obstructive pulmonary disease and resulted in management changes that were appropriate and clinically significant in only 11 cases (4.5%). Based on our analysis of clinical variables predictive of significant radiographic abnormalities and our assessment of clinically important findings, we propose the following indications for admission chest radiographs in patients with an acute exacerbation of chronic obstructive pulmonary disease: white blood cell count above 15 x 10(9)/L and polymorphonuclear leukocyte count above 8 x 10(9)/L, history of congestive heart failure, history of coronary artery disease, chest pain, or edema. In view of the low yield of clinically significant abnormalities, we believe that routine chest radiographs need not be performed in this patient population. The use of selective criteria could eliminate unnecessary studies while assuring recognition of important new radiographic abnormalities.

Pulmonology

Surgical procedures Major surgical procedures on the heart and lungs are performed by a thoracic surgeon. Pulmonologists often perform specialized procedures to get samples from the inside of the chest or inside of the lung. They use radiographic techniques to view vasculature of the lungs and heart to assist with diagnosis. Treatment and therapeutics Medication is the most important treatment of most diseases of pulmonology, either by inhalation (bronchodilators and steroids) or in oral form (antibiotics, leukotriene antagonists). A common example being the usage of inhalers in the treatment of inflammatory lung conditions such as asthma or chronic obstructive pulmonary disease. Oxygen therapy is often necessary in severe respiratory disease (emphysema and pulmonary fibrosis). When this is insufficient, the patient might require mechanical ventilation.

Investigation in chronic lung disease - Too much, too little, just right!

Lung problems are common in general practice. History and examination are invaluable; however considered selection of investigations can assist the clinician to reach a diagnosis. To outline the indications for common respiratory investigations to assist in selecting the most appropriate investigation for a clinical problem related to chronic lung disease. The vast majority of problems related to chronic lung disease can be assessed with a full history and examination, a plain chest X-ray, a spirometer and a pulse oximeter. Chest X-ray should always be the initial radiological test. It can distinguish pneumonia from bronchitis and diagnose breathlessness caused by pneumonia, heart failure, pneumothorax, pleural effusion and interstitial lung disease. Computerised tomography scanning is not a useful test in investigation of symptoms such as breathlessness or cough when a chest X-ray is normal. Spirometry can be useful in the evaluation of chronic cough, wheezing, breathlessness or chest pain. Baseline oximetry should be performed on all dyspnoeic patients and those with abnormal spirometry.

Respiratory compromise

Although respiratory compromise may develop de novo during hospitalization in patients without preexisting lung disease, in other patients, it develops as a complication of chronic respiratory diseases, such as chronic obstructive pulmonary disease (COPD). Although respiratory failure is caused by a heterogeneous group of processes, there are subsets of patients who manifest similar physiologic patterns of deterioration Impaired control of breathing – e.g. opioid overdose Impaired airway protection – e.g. cerebrovascular accident (CVA) Parenchymal lung disease – e.g. Acute Respiratory Distress Syndrome (ARDS) Increased airway resistance – e.g. COPD exacerbation Hydrostatic pulmonary edema – e.g. left ventricular heart failure Right ventricular failure – e.g. acute pulmonary embolism

Helical computed tomography and alternative diagnosis in patients with excluded pulmonary embolism.

A clinical diagnosis of pulmonary embolism (PE) is confirmed objectively in 20-30% of patients. Helical computed tomography (CT) can allow an alternative diagnosis to be made. The frequency and validity of alternative diagnoses on helical CT in consecutive patients presenting with clinically suspected PE was assessed. In all 512 prospectively analyzed patients helical CT scan was performed, and apart from presence or absence of PE, pathologic changes in lung parenchyma, mediastinum, cardiovascular system, pleura and skeleton were recorded. When possible an alternative diagnosis was given and compared with the final diagnosis after 3 months follow-up. In 130 patients (25.4%) PE was excluded and an alternative diagnosis considered likely. In 123 of the 130 patients (94.6%) this diagnosis was unchanged at 3 months follow-up. The diagnoses included pneumonia (n = 67), malignancy (n = 22), pleural fluid (n = 10), cardiac failure (n = 10), COPD (n = 6) and a variety of other causes (n = 15). The diagnosis changed at follow-up in seven patients (5.4%). An initial diagnosis of pneumonia changed to malignancy in two patients and to pleuritis and cardiac failure in one patient each. In two other patients malignancy and chronic obstructive pulmonary disease (COPD) were ruled out and the diagnosis changed to pneumonia. In one patient the final diagnosis remained unknown after an initial suspicion of malignancy. In clinically suspected PE helical CT allows a reliable alternative diagnosis to be made in 25.4% of patients. This feature is an unique advantage in comparison with other diagnostic tests and supports the decision of taking helical CT as first line test in suspected PE.

[Indications and value of chest radiography in patients with respiratory insufficiency (author's transl)].

Chest X-rays of patients with respiratory insufficiency provide different information depending on the stage of the disease. The indications for chest radiography should, therefore, be determined by whether the examination is intended to establish the diagnosis and causes of the respiratory disease, to arrive at the differential diagnosis or test the efficacy of treatment.

Influence of spirometry and chest roentgenography on the management of pulmonary outpatients.

Spirometry and chest roentgenography are frequently employed to evaluate patients with respiratory problems. To determine their impact on the management of outpatients with lung disease, both tests were performed on 100 consecutive patients (40 men and 60 women; mean age, 52 +/- 15 years) who returned for reevaluation 16 +/- 9 weeks after their previous clinic visit. Patients with obstructive (n = 45), restrictive (n = 35), and mixed (n = 20) lung diseases were initially assessed by history and physical examination and classified clinically as improved, stable, or worse. A clinical management plan (CMP) was formulated based on this initial evaluation. Changes in the proposed CMP due to spirographic or roentgenographic results were then noted. None of the 19 patients who were clinically improved and only two (3%) of the 64 clinically stable patients had a change in CMP. In contrast, five (29%) of the 17 patients whose conditions deteriorated clinically had their proposed CMP modified after review of the spirograms and roentgenograms. Therapy was intensified in three of the seven patients whose CMPs were modified, while in the other four, treatment was withheld because results of both tests were unchanged. These results indicate that routine spirograms and chest films have little influence on the CMP of clinically stable patients. However, unexpected roentgenographic and spirometric findings frequently alter the management of the individual whose condition has clinically deteriorated.

Chronic obstructive pulmonary disease

Acute exacerbations in COPD are often unexplained, and a study emphasizes the possibility of a pulmonary embolism as sometimes being responsible in these cases. Signs can include pleuritic chest pain, and heart failure without signs of infection. Such emboli could respond to anticoagulants. Other conditions COPD often occurs along with a number of other conditions (comorbidities) due in part to shared risk factors. Common comorbidities include cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, anxiety, and lung cancer. Metabolic syndrome has been seen to affect up to fifty percent of those with COPD, and significantly affects the outcomes. It is not known if it co-exists with COPD or develops as a consequence of the pathology. Metabolic syndrome on its own has a high rate of morbidity and mortality, and this rate is amplified when comorbid with COPD. Most people with COPD die from comorbidities and not from respiratory problems.

Emergency department

Asthma and COPD Acute exacerbations of chronic respiratory diseases, mainly asthma and chronic obstructive pulmonary disease (COPD), are assessed as emergencies and treated with oxygen therapy, bronchodilators, steroids or theophylline, have an urgent chest X-ray and arterial blood gases and are referred for intensive care if necessary. Noninvasive ventilation in the ED has reduced the requirement for tracheal intubation in many cases of severe exacerbations of COPD. Special facilities, training, and equipment An ED requires different equipment and different approaches than most other hospital divisions. Patients frequently arrive with unstable conditions, and so must be treated quickly. They may be unconscious, and information such as their medical history, allergies, and blood type may be unavailable. ED staff are trained to work quickly and effectively even with minimal information.

[Relation of peak flow and spirometry values in patients following bone marrow transplantation].

In about 30% of patients who were subjected to bone marrow transplantation, progressing interstitial and rarely obstructive pulmonary diseases can result in death. Early identification of curable diseases such as pulmonary changes during a "graft versus host reaction" would be desirable. Retrospective evaluation of 159 lung functions in 60 patients after bone marrow transplantation, however, revealed only moderate sensitivity of the peak flow value to vital capacity and FEV1, so that only pathological levels of this parameter will signify noticeable reductions in spirometric values.

Chest physiotherapy

Chest physiotherapy (CPT) are treatments generally performed by physical therapists and respiratory therapists, whereby breathing is improved by the indirect removal of mucus from the breathing passages of a patient. Other terms, include respiratory or cardio-thoracic physiotherapy. CPT are treatments which are performed on people suffering from mucus dysfunction in respiratory disease conditions like asthma, chronic obstructive pulmonary disease, bronchitis, bronchiectasis and cystic fibrosis. With these respiratory conditions, they all have a common requirement of chest physiotherapy to assist the mucus clearance due to defects with mucociliary clearance.

[The differential diagnosis of chronic bronchitis and emphysema from mutually supplemental functional and radiographic criteria].

In a retrospective study in 91 patients an attempt was made to differentiate the primary and/or predominating disorder "emphysema" or/and "chronic bronchitis" by independent evaluation of a number of X-ray signs and lung function criteria in routine diagnosis. Good congruency of the diagnosis from these two different aspects, could be established. Patients with 3 or more X-ray signs of emphysema were found to have larger lung volume and smaller diffusing capacities than those without. Vice versa, patients with functional diagnosis of predominant emphysema more often showed the full X-ray pattern of emphysema, than those with predominant "chronic bronchitis". In either method of diagnostic procedure, the occurence of the "small heart of emphysema" was obviously much more frequent in patients believed to have predominant or primary emphysema. Assessment of X-ray signs of changes of the lesser circulation can be obtained in a stage of the disease, when structural changes have become irreversible. Considering the different pathophysiologic pattern of predominant panacinar emphysema, the destruction of alveolar walls and, consequently of the capillary bed, is more likely to reduce DCO as well as cardiac output before pulmonary hypertension can develop. The X-ray signs resulting from this effect on the lesser circulation, exist in widened right hilar branch and abrupt narrowing of peripheral vessels, with a small heart and lack of prominence of the pulmonary trunk. In chronic bronchitis, however, signs of pulmonary hypertension are expected to occur early in the disease. The relevance of the X-ray changes of the heart size and the pulmonary circulation in both types of lung disease, could be confirmed by lung function data.

Pulmonary rehabilitation

Pulmonary rehabilitation, also known as respiratory rehabilitation, is an important part of the management and health maintenance of people with chronic respiratory disease who remain symptomatic or continue to have decreased function despite standard medical treatment. It is a broad therapeutic concept. It is defined by the American Thoracic Society and the European Respiratory Society as an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. In general, pulmonary rehabilitation refers to a series of services that are administered to patients of respiratory disease and their families, typically to attempt to improve the quality of life for the patient. Pulmonary rehabilitation may be carried out in a variety of settings, depending on the patient's needs, and may or may not include pharmacologic intervention.

[Significance of acute pulmonary embolism for the exacerbation of chronic obstructive pulmonary disease].

The clinical diagnosis of acute pulmonary embolism in patients with chronic obstructive pulmonary disease is often difficult because there is no characteristics sign of acute pulmonary embolic event. The presentation of an acute embolic event may mimic the symptoms of acute airway obstruction which is caused by different reasons. The presence of chronic obstructive pulmonary disease was recorded on a clinical history, physical examination, chest roentgenogram, and the result of pulmonary function studies. Among the 178 patients with chronic obstructive pulmonary disease in 49 patients (27.5 percent) were suspected of having pulmonary embolism. Pulmonary embolism was excluded by normal or low probability V/Q scan in 19 patients. Among 23 patients who demonstrated a high probability lung scan there was a high positive predictive value for pulmonary embolism effectively avoiding the need for further studies. Among the 7 patients with nondiagnostic or intermediate probability lung scan contrast-enhanced helical computed tomography was detected the pulmonary embolism in 3 patients. The present study was undertaken to better define the noninvasive clinical, laboratory, roentgenographic, lung scan, and computed tomography characteristics of acute pulmonary embolism in patients with chronic obstructive pulmonary disease.

Commonly prescribed drugs

The treatment of Ischemic Heart Disease can be divided into two directions: risk factor control and symptomatic relief. Commonly prescribed drugs for Ischemic Heart Disease Chronic Obstructive Pulmonary Disease (COPD) Chronic Obstructive Pulmonary Disease (COPD) is a disease that causes chronic respiratory problems by gradually blocking the respiratory tracts. The continuous exposure to toxic fumes produced by cigarettes, vehicle engines and other human activities leads to inflammation of the respiratory tract, causing the development of COPD. The problem will deteriorate over time if it is not well managed. It will eventually cause respiratory failure and death in the late stage. It is the third deadliest disease reported by WHO in 2019 and it accounted for 6% of total deaths.

[Usefulness of chest X-ray during cystic fibrosis exacerbation in adult patients].

Verify the real usefulness of chest X-ray during clinical exacerbation of cystic fibrosis (FC). The study was based on a group of 46 adult patients affected by FC. For every subject we selected one or more pair of chest films, of which the first was used as reference image (To), whereas the second (T1) was selected among the following controls, either in course of clinical obvious exacerbation, or during another routine control. The 64 pairs of chest films (32 representing phases of clinical stability, 32 documenting evolution towards clinical deterioration) were subjected to evaluation by two radiologists, who were first asked to judge if stability, improvement or worsening of the overall radiographic picture could be observed; then to estimate the improvement, worsening, stability or absence of the 12 radiographic signs, selected among those more frequently correlating with the acute phase of disease. The comprehensive radiological evaluation, which shows a statistically significant difference (p=0.012) between the two groups considered, weakly correlates with the patient clinical status. Among the patients with exacerbation, the radiographic picture appeared worsened in only 18/32 cases (sensibility 56%, specificity 78%), while on the contrary 7/32 clinically stable patients exhibited a radiographic deterioration. Among the considered radiographic-sings, some were exclusively observed during exacerbation (specificity 100%), but with low sensitivity (pneumothorax: 6%, increment of bronchiectasis: 9%, air space disease 22%); the most common alterations (mucoid impactions and bronchial wall thickening) were observed in both groups of patients. Our results demonstrate that there is not a precise correlation between the radiographic picture and the clinical manifestations of exacerbation and confirm the poor usefulness of chest X-ray in such a phase of disease. Chest X-ray is needed to exclude pnemothorax or extensive air space disease, rather then to accurately diagnose exacerbation.

Diaphragmatic breathing

Benefits The use of diaphragmatic breathing is commonly practiced, especially in those patients with chronic obstructive pulmonary disease, to improve a variety of factors such as pulmonary function, cardiorespiratory fitness, respiratory muscle length, and respiratory muscle strength. Specifically, diaphragmatic breathing exercise is essential to asthmatics since breathing in these patients is of the thoracic type in association with decreased chest expansion and chest deformity as a result of a deformed sternum like pectus excavatum (funnel chest); a shortened diaphragm, intercostals and accessory muscles from prolonged spasm causing stenosis of the major airways leading to an abnormal respiratory pattern. Relation to music Diaphragmatic breathing is also widely considered essential for best possible singing performance. Diaphragmatic breathing also allows wind instrumentalists to maximise intake of air, minimising the number of breaths required for progressing players.

[New guidelines for diagnosis and staging of chronic obstructive pulmonary disease].

A clinical diagnosis of chronic obstructive pulmonary disease (COPD) should be considered in any individual who has dyspnoea, chronic cough or sputum production and/or a history of exposure to risk factors for the disease. Spirometry is essential for the definite diagnosis of the disease. Differential diagnosis and co-morbidities such as osteoporosis, heart failure and lung cancer are important to consider and treat. The combined results of symptoms (few/many), lung function and the amount of exacerbations make up the risk of future exacerbations and risk of death of any given patient.

Non-invasive ventilation

Respiratory failure may develop after major surgery. NIV may be used in this setting during the recovery period. In those who have undergone mechanical ventilation on the intensive care unit and are considered at high risk of recurrence, NIV may be used to prevent this. However, if respiratory failure does develop, recommencement of mechanical ventilation is recommended over NIV to treat this. In those who were ventilated for hypercapnic respiratory failure, NIV may be used to facilitate the weaning process. Chronic/home use Chronic use of NIV ("home NIV") may be indicated for severe COPD. A review from 2021 demonstrated that the chronic use of non-invasive ventilation improves daytime hypercapnia, In addition, in stable chronic obstructive pulmonary disease, survival seems to be improved and there might be a short term benefit of health-related quality of life. Home NIV may also be indicated in people with neuromuscular disease and chest wall deformity.

[Potentialities of high-resolution computed tomography in diagnosis of pulmonary lesions after bone marrow transplantation in blood diseases].

To study characteristics of a skialogical picture of pulmonary parenchyma and roentgenomorphological signs of inflammatory changes before and after bone marrow transplantation (BMT); relationship between the data of high-resolution computed tomography (HRCT) and clinical data. HRCT (computer tomograph of the third generation "Somatom CR-3") was made in fever, changes in physical examination in patients (n = 28) after BMT from November 2001 to January 2003. BMT was made in myelomic disease, lymphogranulomatosis, acute leukemia, chronic myeloid leukemia, lymphosarcoma, autoimmune hemolytic anemia. Twenty four patients were examined before BMT. Of them, 18 patients had roentgenomorphological changes of the parenchyma, primarily, diffuse. Three patients were examined during conditioning, two cases had signs of toxic pulmonitis. One day after allo-BMT all the patients exhibited lowering of densitometric values of pulmonary tissue by 70 HU vs the baseline. Infectious affection of the lungs was diagnosed in 13 cases during day 0-100. From day 100 after allo-BMT 7 recipients were observed. In 6 cases the changes resulted from transplant against host reaction. Infectious affection of pulmonary tissue was observed in 1 case. Characteristic x-ray picture of pulmonary stroma in secondary disease was determined. For early diagnosis of pneumonia in myelotoxic agranulocytosis it is necessary to make examination by HRCT before BMT. HRCT of the chest is indicated in even minor changes in the clinical picture. It is necessary to perform a control over water-electrolyte balance and active respiratory exercise in the course of conditioning. Viral pneumonias show the picture of metainflammatory changes for a long time. Fungal pneumonias tend to recurrence at "previous site". HRCT examination of the pulmonary tissue provides more information about pulmonary tissue in patients with secondary disease.

Chronic obstructive pulmonary disease

In 2011, there were approximately 730,000 hospitalizations in the United States for COPD. Globally COPD in 2019 was the third leading cause of death. In low-income countries COPD does not appear in the top 10 causes of death; in other income groups it is in the top 5. History The name chronic obstructive pulmonary disease is believed to have first been used in 1965. Previously it has been known by a number of different names, including chronic obstructive bronchopulmonary disease, chronic airflow obstruction, chronic obstructive lung disease, nonspecific chronic pulmonary disease, diffuse obstructive pulmonary syndrome. The terms emphysema, and chronic bronchitis were formally defined as components of COPD in 1959 at the CIBA guest symposium and in 1962 at the American Thoracic Society Committee meeting on Diagnostic Standards.

[Difficult pneumonological diagnoses. I. Diagnoses that have not been established].

The authors show that the medical pneumologic practice meets cases in which, after the accumulation and interpretation of the clinical and paraclinical investigation results and after leaving aside the sets of the improbable, no certain diagnosis can be established. The possible reasons of this failure are: the physician's lack of experience in a radiographic chapter, lack of endowment of that medical unit, patient's refusal to be examined or the atypical evolution of the disease. The authors present two such cases, in which, due to the above-mentioned reasons, no certain diagnosis could be established.

Pulmonary rehabilitation

Medical uses The NICE clinical guideline on chronic obstructive pulmonary disease states that “pulmonary rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD (usually MRC [Medical Research Council] grade 3 and above)”. It is indicated not only in patients with COPD, but also in: Cystic fibrosis Bronchitis Sarcoidosis Idiopathic pulmonary fibrosis Before and after lung surgery It appears not to be harmful and may be helpful for interstitial lung disease. Aim To reduce symptoms To improve knowledge of lung condition and promote self-management To increase muscle strength and endurance (peripheral and respiratory) To increase the exercise tolerance To reduce length of hospital stay To help to function better in day-to-day life To help in managing anxiety and depression

[Early detection of chronic obstructive pulmonary disease by following individual annual changes in lung function].

The possibility of early detection of chronic obstructive pulmonary disease (COPD) was investigated among subjects whose lung function could be followed for more than ten years. Ten subjects aged 60 or more were selected from among about 1500 cases using the following diagnostic criteria; (1) subjects had complained of exertional dyspnea (2) chest X-ray abnormalities were suggestive of COPD (3) FEV1.0% was under 55%. Data on FVC/height, FEV1.0/height and FEV1.0% of these subjects were available for the previous ten years. Individual linear regression equations were estimated. Average annual changes of cases of obstruction were compared with those of normal cases, and individual deviations from the normal standard range were observed. Declines of the regression lines were as follows; FEV1.0/height: normal case--0.016 +/- 0.017, obstruction cases--0.038 +/- 0.018 (L/m/yr), FEV1.0%: normal cases 0.164 +/- 0.627, obstruction cases--1.522 +/- 0.638 (%/yr). Significant differences were observed between the normal and the obstruction cases (p < 0.01). FEV1.0% of all obstruction cases was under--2 SD of that of normal subjects. All individual FEV1.0% regression lines of the obstruction cases were outside +/- 2 RSD of the normal standard range more than 5 years before the onset of symptoms. Following individual annual changes in lung function was considered to be useful for the early detection of COPD.