Diagnosis of trochanteric bursitis versus femoral neck stress fracture.

Key Words: Hip, Physical therapy, Stress fracture, Trochanteric bursitis.

With more of the US population exercising, overuse injuries have increased in frequency.[1] Trochanteric bursitis results from friction between the bursa and the greater trochanter and can occur due to overuse.[2] Individuals with this condition may develop pain and tenderness in the lateral thigh, groin, and gluteal areas.[3] Treatment for trochanteric bursitis usually consists of rest, immobilization, anti-inflammatory medications, local heat, and local injection of corticosteroids.[4]

Stress fractures are a more severe overuse injury. Stress, or fatigue, fractures may occur when bone is subjected to "unaccustomed stresses for which it has not had time to become conditioned by the normal process of work hypertrophy."[5] Individuals who are "out of condition" or "out of training" and who begin activities such as long marches, running, or ballet dancing may be susceptible to stress fractures.[5]

Although initial descriptions of stress fractures related to military personnel, recently athletes have been identified as potential candidates for stress fractures.[1] Stress fractures in runners commonly occur in the pelvis, femur, tibia, and metatarsals.[1]

The purpose of this case report is to illustrate the importance of eliminating potentially serious diagnoses such as stress fractures from the list of possible diagnoses prior to physical therapy. The patient in this report was diagnosed with trochanteric bursitis of the hip instead of a femoral neck stress fracture, a condition that may require immediate surgical intervention once discovered.

According to Roberts and Williams,[6] trochanteric bursitis is the second most frequent cause of lateral hip pain, after osteoarthritis. The major criteria usually used for diagnosis of trochanteric bursitis are marked tenderness to deep palpation immediately above or posterior to the greater trochanter and relief of pain after peritrochanteric injection with a corticosteroid and local anesthetic.[3,7] Relief should be immediate and last as long as the anticipated duration of the anesthetic.[3]

Patients with trochanteric bursitis may experience increased pain with abduction and lateral (external) rotation of the hip, but not with medial (internal) rotation.[3] In addition, patients may report discomfort with resisted lateral rotation.[3] Passive medial rotation with the hip in a neutral position is usually not symptomatic.[3]

According to Caruso and Toney,[7] if a peritrochanteric injection does not relieve the pain, the presence of other conditions (eg, herniated nucleus pulposus, lower spinal neoplasm, pelvic tumor, pelvic fracture, hip infection, avascular necrosis, stress fracture, bone or soft tissue tumor) should be considered. Magnetic resonance imaging (MRI) is used to identify these conditions.[7]

Traycoff[3] retrospectively studied 18 patients who were diagnosed with trochanteric bursitis and did not respond to a peritrochanteric injection, but had complete relief of pain following a neuroblockade (eg, lumbar root block, lumbar facet block, intercostal block). These patients were categorized with "pseudotro-chanteric bursitis."[3] The most common causes of the pseudotrochanteric bursitis were lumbar radiculopathy (L-2, L-3), lumbar facet syndrome with referred pain, and entrapment neuropathies.[3] One of the less common causes was undisplaced femoral neck fractures.[3]

Treatment of trochanteric bursitis frequently consists of heat, ultrasound,[8](pp304-305) nonsteroidal anti-inflammatory drugs (NSAIDs), and injections with corticosteroids.[6] If the pain persists, other diagnoses should be considered, such as a tight tensor fasciae latae muscle, radiating pain from a lumbar disk or facet disease, hip fracture, radiating pain from the knee, lateral femoral cutaneous nerve entrapment, and bone tumor.[6] A sudden onset of hip pain suggests the presence of a septic hip; a herniated nucleus pulposus; hip fracture; or trochanteric, ischial, or iliopectineal bursitis.[6]

Stress fractures are generally characterized by a sudden onset of pain and a recent change in activity level.[1] In the early stages, localized pain that worsens with activity and improves with rest is present.[1]

With stress fractures of the femoral neck, localized tenderness may occur at the greater trochanter, as in trochanteric bursitis.[3] Injection with a local anesthetic, however, will not provide the complete relief of pain that occurs with trochanteric bursitis.[3]

Radiographs of femoral neck stress fractures are often negative.[9] Although there may be a delay of several days with radionuclear scanning before a fracture will be positive,[9] the bone scan (bone scintigraphy) appears to be the optimum radiologic test for facilitating early diagnosis, especially in the presence of negative radiographs.[1,3,10,11]

Fullerton and Snowdy[10] classified femoral neck fractures into one of three groups: (1) tension-side fractures, (2) compression-side fractures, and (3) displaced femoral neck fractures. Tension-side fractures on the superior side of the femoral neck may have negative radiographs, but positive bone scintigraphy, in the early stages.[10] Patients with tension-side sclerosis are treated with bed rest or crutches, depending on the severity of the condition.[10] If a fracture line develops, internal fixation is indicated.[10]

In the presence of a tension-side cortical break without displacement, complete bed rest is appropriate.[10] Internal fixation with multiple Knowles pins, however, is indicated with any widening of the cortical break.[10] Tension-side fractures with any opening of the fracture require fixation with two Knowles pins and a compression screw.[10]

Compression-side fractures on the inferior side of the femoral neck initially usually have negative radiographs and positive bone scintigraphy.[10] If sclerosis is present without an overt fracture, bed rest is indicated.10 When hip pain is absent at rest, gradual progressive weight bearing and increased activity are begun. [10] With an overt fracture line, bed rest is indicated.[10] Any widening of the fracture line, however, would require stabilization with multiple Knowles pins.[10] Displaced fractures are considered an orthopedic emergency.10 Early reduction and internal fixation with two Knowles pins and a compression screw are necessary.[10]

Fullerton and Snowdy[10] advocated bone scintigraphy as the ultimate diagnostic test to give early confirmation of clinically suspected stress fractures of the femoral neck. Bone scintigraphy is expensive but less costly than a displaced femoral neck would be in terms of financial impact or disability.[10]

Johansson et al[11] examined the complication rate and prognosis of femoral neck stress fractures in relation to activity level and delay in diagnosis. Twenty-three patients (16 recreational athletes, 7 elite athletes) with femoral neck stress fractures were followed up at an average of 6.5 years after injury.[11] The delay in diagnosis of the fracture ranged from 3 to 104 weeks.[11]

Overall, 50% of the subjects in the study by Johansson et al[11] reported a decreased activity level after the fracture, and all of the elite athletes had reduced their activity to recreational level after the injury. The authors emphasized that early diagnosis and treatment, including use of bone scintigraphy, may prevent displacement of femoral neck stress fractures.[11]

Thus, the clinical diagnosis of trochanteric bursitis may be confirmed with a peritrochanteric corticosteroid injection.[3,7] Failure to relieve pain may indicate an undiagnosed pathological condition and warrants further investigation.[7] In the presence of negative radiographs, the diagnosis requires bone scintigraphy or MRI evaluations (for soft tissue pathology).[1,3,10,11] These tests may facilitate early diagnosis and treatment of a potentially serious condition.

Case Report

Previous History

This 46-year-old white man worked in a mostly sedentary job as a medical researcher. He was a recreational runner on flat surfaces until 6 years ago when he developed knee pain. After developing knee pain, he continued to exercise using a stationary bicycle. He had no known major illnesses or surgeries.

The patient resumed running 6 months ago (5 1/2 years after he stopped running). Gradually, he developed "tightness" in his right hip. After returning home from a running session 2 months ago, he experienced sudden pain in his right hip. The patient went to an emergency department, where he was diagnosed by a physician as having a "muscle strain." He was advised to see an orthopedist if his symptoms did not improve within 3 weeks.

Preferring not to wait, the patient obtained an appointment with an osteopath about 1 week after the onset of pain. The patient told the osteopath that he was "feeling better and was able to ambulate for 6 hours without difficulty"; however, he had not resumed running. According to the patient, the osteopath performed a Patrick's test,[12] which is used to detect pathology in the hip or sacroiliac joints. The test was negative. An ultrasound treatment was performed on the right hip, and the patient was referred to a radiologist for roentgenograms. The initial plain x-ray film of the right hip taken 3 weeks after the onset of pain was reported as negative (Fig. 1).

[Figure 1 ILLUSTRATION OMITTED]

When the patient returned to the osteopath the same day, his condition had deteriorated to the point at which he needed crutches to ambulate. The osteopath referred the patient to a physiatrist with a specialty in sports medicine and prescribed Medrol [R] Dosepak [TM](*) (corticosteroid) for 6 days. The physiatrist examined the patient the next day, reviewed the x-ray films, discontinued the Medrol [R] Dosepak [TM] started the patient on ibuprofen, and referred the patient for physical therapy. A diagnosis of "right hip trochanteric bursitis with adductor, internal and external rotation, iliopsoas, and rectus strain" was established by the physiatrist.

The patient began outpatient physical therapy 1 month after the onset of pain. The physical therapy referral was for "modalities as needed, hip stretching, progressive resistive exercises, and pool therapy as needed." There was also a precaution written on the prescription to look for signs of avascular necrosis or stress fracture.

The patient was treated for four sessions during the next 3 weeks with moist heat to the right hip; stretching exercises for the iliotibial band and the quadriceps femoris, iliopsoas, and adductor muscles; and resistive exercises for hip flexion, extension, adduction, and abduction with 2.27 kg (5 lb) of resistance. He was given written instructions for the exercise program.

The patient went away on a 2-week vacation after the fourth physical therapy session (1 1/2 months after the onset of pain), during which time he "felt okay" with ambulation and his home exercise program. After the vacation, he returned to the physiatrist and was given a prescription to continue physical therapy for "hip flexion, adduction, external rotation, and internal rotation stretching and resistive exercises." The patient scheduled a physical therapy appointment at the University of Pittsburgh Medical Center Physical Therapy Department, which was closer to his workplace.

One week before the patient was scheduled to resume physical therapy, he ran a few steps to catch a bus and developed immediate, severe pain in his right hip to the point at which he "could barely walk." As a result, the patient decided to ambulate with one crutch. One week later (2 1/2 months after the onset of pain), the patient was seen for physical therapy at the University of Pittsburgh Medical Center Physical Therapy Department.

Interview Data

The patient was evaluated by a physical therapist (DLJ) after being referred for physical therapy by the physiatrist with the diagnosis of "right hip trochanteric bursitis with internal and external rotation strain and generalized hip deconditioning." The physical therapy referral was for "modalities as needed, hip stretching, and progressive resistive exercises.

The patient complained of pain in his (1) right groin, (2) right medial and lateral thigh to midthigh, and (3) right anterior tibial area. Pain at the time of the evaluation was described as a "2 out of 10" on a scale of 0 (no pain) to 10 (maximal pain). Symptoms were aggravated with prolonged ambulation and side lying on the right hip.

According to the patient, his pain was greatest in the morning. For example, he needed a crutch to walk from the bed to the bathroom. He was applying heat and performing stretching exercises in the morning with good results.

Physical Examination and Data

At the completion of the interview, an evaluation was performed.

Standing posture. The patient stood with both lower extremities laterally rotated, especially on the right side. Based on observation, all pelvic landmarks were level and the lumbar lordosis was slightly decreased.

Inspection. Atrophy was noted in the right lateral buttock region. No edema or ecchymosis was observed.

Palpation. No tender areas were palpated in the right hip or gluteal region. A small, nontender area with increased tissue hardness was palpated distal to the right greater trochanter (approximately 6.4 cm [2 1/2 in] long by 3.8 cm [1 1/2 in] wide).

Lumbar range of motion. Lumbar active range of motion (ROM) in a standing position appeared to be within normal limits based on visual inspection. The patient reported a feeling of "tightness" in his right anterior hip area with both trunk extension and rotation to the right. Because the patient had normal, pain-free lumbar ROM, the physical therapist believed that the lumbar spine was not the source of the problem.

Lower-extremity range of motion. The patient's active ROM was measured with a goniometer. Standard test positions and normal values for ROM testing were used.[13] The ROM was symmetrical and within normal limits[13] in the lower extremities, except for right hip abduction and bilateral medial rotation. Supine active hip abduction was 34 degrees on the right side (normal = 45 [degrees]) and 45 degrees on the left side. Sitting active hip medial rotation was 14 degrees on the right side and 24 degrees on the left side (normal = 45 [degrees]). The patient did not report pain in either hip with active hip abduction or medial rotation.

Lower-extremity strength. Manual muscle testing of the lower extremities was graded on a five-point scale (Tab. 1). [14] The patient's lower-extremity strength was within normal limits (5 / 5)[14] bilaterally, except for the right hip (Tab. 2). Resisted right hip extension, medial rotation, and lateral rotation reproduced the patient's symptoms.

Table 1.
Key to Muscle Grading for Manual Muscle Testing[14]

Test Performance                               Grade

Ability to hold test position against gravity
and maximum pressure                           5/5

Same as above, except holding against
moderate pressure                              4+/5 or 3+/5

Some as above, except holding against
minimum pressure                               4-/5 or 3+/5

Ability to hold test position against gravity  3/5

Gradual release from test position against
gravity ar ability to move the part toward
test position against gravity almost to
completion or to completion with slight
assistance                                     3-/5

Ability to move part through partial arc of
motion with gravity lessened: moderate
arc, 30%                                       2+/5

Ability to move part through partial arc of
motion with gravity lessened: small arc,
20%                                            2/5

In muscles that can be seen or palpated, a
feeble contraction may be felt in the
muscle but there is no visible movement
of the part                                    2-/5 or trace

No contraction felt in muscle                  0
Table 2.
Manual Muscle Testing[14] Results for the Right Hip(a)

Motion            Strength  Pain

Flexion           4/5       No
Extension         4/5       Yes
Adduction         4/5       No
Abduction         4/5       No
Medial rotation   4/5       Yes
Lateral rotation  3/5       Yes

(a) Physical therapy evaluation performed at the University of Pittsburgh Medical Center Physical Therapy Department 2 1/2 months after the onset of pain.

Special tests. Straight-leg-raising tests[8](pp92, 297) and femoral nerve stretch tests[8](pp655-656) were negative bilaterally.

Gait. The patient was ambulating independently without an assistive device; however, he stated that he used one crutch to ambulate when the pain intensified. His gait was antalgic with an asymmetrical stance time, that is, the patient spent less time weight bearing on the right lower extremity during the stance phase of gait as compared with the left lower extremity. In addition, the patient shifted his trunk to the right when weight bearing on the right lower extremity during gait.

Overall, the assessment revealed atrophy of the right lateral buttock; absence of point tenderness over the greater trochanter; decreased active hip medial rotation and abduction on the right; painless and weak right hip flexors, abductors, and adductors; and painful and weak right hip extensors, medial rotators, and lateral rotators.

Treatment

The overall goal of physical therapy was to return the patient to his prior level of function. The short-term goals were (1) to decrease right hip pain to 1 to 2 out of 10 with limited activity within the first 4 weeks, (2) for the patient to ambulate independently without any assistive device, and (3) for the patient to be independent with his home exercise program.

The patient was given a trial of continuous ultrasound to the right anterior and lateral hip at 1.5 W/[cm.sup.2] for 5 minutes. The patient's prior home exercise program was reviewed and modified, in addition to providing him with new exercises. The patient had continued to perform his previous physical therapy home exercise program consisting of stretching and resistive exercises with 2.27 kg of resistance. The initial treatment plan included determining whether progress was apparent after several treatments. If there was no progress, a consultation from the Spine Team of the University of Pittsburgh Medical Center Physical Therapy Department would be obtained.

The first treatment consisted of the evaluation, an ultrasound treatment as described earlier, and a review of the patient's exercise program (Tab. 3). In light of the recent exacerbating event (running for the bus), the patient was advised to discontinue the resistive exercises. The patient was instructed to continue his stretching program because he was asymptomatic with these exercises.

Table 3
Physical Therapy Program far the Right H;pa

Visit
No.     Exercises                                     Ultrasound

1       Discontinued previous resistive exercises     Yes
        (leg lifts in all Four planes)
        Reviewed home stretching program
        Sitting inner thigh/groin stretch
        Side-lying quadriceps femoris muscle
        stretch
        Supine iliotibial band stretches
        Kneeling hip flexor stretch
        Supine hamstring muscle stretches with
        leg on wall

2       Added to home stretching program              Yes
        Standing gastrocnemius muscle stretch
        Standing soleus muscle stretch
        Initiated isometric exercises for
        strengthening
        Supine hip adduction with towel roll
        Supine hip lateral rotation with red TB(b)
        (hook-lying)
        Sitting hip medial rotation with red TB

3       Progressed isometric exercises at home        Yes
        from red to green TB
        Initiated passive stretching
        Supine hip abduction with contract-relax
        Prone hip medial rotation with contract-relax
        Supine hip lateral rotation (hook-lying)
        Hip distraction

4       Added stretch for short hip adductors in      Yes
        kneeling
        Continued home isometric exercises with
        green TB
        Continued passive stretching

5       Continued home isometric exercises with       Yes
        green TB
        Continued passive stretching

6       Progressed home isometric exercises to        No
        blue TB
        Added isometric sitting hip lateral rotation
        with green TB
        Continued passive stretching

(a) Patient received treatment at the University of Pittsburgh Medical Center Physical Therapy Department from 2 1/2 to 3 months after onset of pain.

(b) Thera-Band [R] (TB), The Hygenic Corporation, Akron, OH 44310 (progression from least to most resistance is yellow, red, green, blue, black, silver, and orange).

Over the next six treatment sessions (Tab. 3), the patient's exercise program was progressed to include isometric hip exercises with elastic bands and increasingly stronger resistance. Passive hip stretches by the physical therapist with contract-relax techniques were initiated during the third treatment session. On the fifth visit, the patient reported having experienced severe increased pain (8-9/10) in the right hip during the previous night. He also complained of pain radiating to the right foot. The patient believed that the exacerbation was due to the fact that "he was on his feet for 10 hours the day before."

At the time of the fifth physical therapy visit, the patient reported that his pain level was 3 to 4 out of 10 with ambulation. The patient still ambulated with the gait deviations described earlier. Hip abduction ROM was now symmetrical and within normal limits. In addition, hip medial rotation on the right side had increased from 14 degrees at the time of the initial evaluation to 21 degrees (left medial rotation was 24 [degrees]). The ultrasound treatments were discontinued after the fifth session at the patient's request.

During the sixth visit, manual muscle testing[14] of nine muscle groups surrounding the right hip revealed no strength deficits (5/5). The only movement that reproduced pain was resisted hip lateral rotation. The patient reported the same pain ratings as during his initial evaluation (2/10) and still ambulated with a crutch when needed.

Physical Therapy Spine Team Consultation

Because little change in the patient's pain level and gait pattern was apparent with the six physical therapy treatments, a consultation was obtained from the Spine Team of the Physical Therapy Department at the University of Pittsburgh Medical Center. The consultation was conducted 3 months after the onset of pain by a fellow staff member, who is both a chiropractor and a physical therapist (REE).

During the examination of the patient's right hip, the consultant found a marked restriction of medial rotation in a neutral starting position of 0 degrees of hip flexion, as well as with the hip flexed to 90 degrees. Rotation in both positions produced sharp pain. Right hip abduction was minimally restricted when compared with the other side but elicited no pain. Right hip lateral rotation was restricted and painful, yet flexion and extension were at full range and elicited no symptoms or abnormal end-feel. Right hip ROM was assessed based on visual inspection in comparison with the left side.

Based on the hip ROM limitations, the consultant determined that the patient had a noncapsular pattern of restriction of the right hip.[15](p84) In his textbook on diagnosis of soft tissue lesions, Cyriax referred to the concepts of capsular and noncapsular patterns of restriction to differentiate between arthritic and nonarthritic conditions.[15](p81)

A capsular pattern is a pattern of limitation of motion characteristic of a specific joint when a lesion involves either the joint capsule or the synovial membrane.[15](p81),[16] A capsular pattern of the hip indicating arthritic changes, for example, is defined as gross limitation of flexion, abduction, and medial rotation; slight limitation of extension; and little or no limitation of lateral rotation.[15](p84) In the early stages of joint involvement, only medial rotation may be painful and restricted.[17]

A noncapsular pattern is any pattern of restriction that differs from the capsular pattern of the specific joint.[15](p84) Conditions such as ligamentous adhesions, internal derangements, or extra-articular limitations (such as a hematoma or cyst) may have a noncapsular pattern,[15](pp85-86)

This patient had limited hip medial rotation and abduction, which was consistent with Cyriax's definition of a capsular pattern of restriction. Lateral rotation, however, was moderately restricted in this patient and contrary to the definition of a capsular pattern, which includes little or no limitation of lateral rotation. Flexion and extension were not limited and were also inconsistent with the gross limitation of flexion and slight limitation of extension that were expected with a capsular pattern of restriction.

This observation of a noncapsular pattern, coupled with the duration of nonresponsive treatment, dictated further investigation by the consultant. Avascular necrosis, fracture, or a loose body were suspected.

Further diagnostic testing could have been bone scintigraphy, computed tomography (CT) scan, or MRI. Although bone scans and CT scans are good for bone studies, the MRI provides excellent imaging of soft tissue.[8](p96) Because a loose body was one of the possible diagnoses, MRI was chosen. Figure 2 is the MRI image of the right hip taken 3 months after the onset of pain. The diagnosis was nondisplaced, complete stress fracture of the femoral neck.

[Figure 2 ILLUSTRATION OMITTED]

The results of the consultation and MRI were communicated to the referring physiatrist. Roentgenograms of the right hip were retaken by the physiatrist the day after the MRI to confirm the diagnosis (Fig. 3). The patient was admitted to the hospital and placed under the care of an orthopedic surgeon. Treatment was immediate open reduction internal fixation (ORIF) with a dynamic hip screw plate.[dagger] Figure 4 shows the x-ray film of the right hip taken the day after surgery.

[Figure 3-4 ILLUSTRATIONS OMITTED]

The patient was hospitalized for 6 days. Inpatient physical therapy consisted of ambulation with crutches touch-down weight bearing on the right lower extremity (foot touching the floor but no weight bearing through the extremity). Postoperative exercise was limited due to excessive drainage from the incision site. Two postoperative lower-extremity Doppler tests were negative for thrombosis.

Following discharge, the patient was referred for outpatient physical therapy consisting of gentle ROM exercises and ambulation. At the outpatient evaluation conducted by the physical therapist (DLJ) 19 days after surgery, the patient stated that his "leg felt great." He complained, however, of lower-extremity edema and right knee pain. The patient had not been exercising at home due to the edema.

The evaluation revealed the following: (1) generalized edema of the entire right lower extremity, ranging from 0.32 to 3.8 cm (1/8-1 1/2 in) greater than in the left lower extremity, (2) supine active hip flexion of 30 degrees (normal = 120 [degrees]),[13] (3) supine active hip abduction of 30 degrees (normal = 45 [degrees]), [13] (4) supine active knee flexion of 69 degrees (normal = 135 [degrees]), [13] (5) a decreased right posterior popliteal pulse, and (6) a substantially decreased temperature of the entire right lower extremity, based on palpation.

Active ROM exercises for right llip llexioll and abduction were initiated. The patient was also instrcuted in isometric exercises for the gluts al, quadriceps femoris, hamstring, and hip abductor muscles. After 3 weeks (six treatments), the patient was able to perform (1) resistive exercises for the right hip (0.45 kg [3 lb]), knee (3.18 kg [7 lb]), and ankle (2.27 kg [5 lb]) and (2) 10 repetitions of isokinetic exercise in a sitting position for right concentric knee flexion and extension at 60 [degrees], 90 [degrees], 120 [degrees] 150 [degrees], and 180 [degrees]/s. Furthermore, the patient's objective measurements had improved: (1) The decrease in edema ranged from 0.32 to 2.23 cm (1/8-7/8 in), (2) right hip flexion increased to 49 degrees, (3) right hip abduction increased to 45 degrees, (4) right knee flexion increased to 112 degrees, (5) the posterior popliteal pulses were symmetrical, and (6) the lower-extremity temperature was symmetrical except for the foot, which remained cool to touch. Five weeks after surgery, the patient was ambulatory without an assistive device or weight-bearing restrictions. A roentgenogram obtained 6 weeks after surgery (4 1/2 months after onset of pain) revealed a healing femoral neck stress fracture with good alignment (Fig. 5).

[Figure 5 ILLUSTRATION OMITTED]

Discussion

According to Traycoff,[3] hip abduction and lateral rotation--but not medial rotation--are painful in patients with trochanteric bursitis. Resisted hip lateral rotation also may cause discomfort.[3] During the physical therapy evaluation at the University if Pittsburgh Medical Center, hip medial rotation and abduction were limited and all active movements were pain-free. Instead of experiencing pain with resisted lateral rotation, as expected with trochanteric bursitis,[3] resisted hip extension, lateral rotation, and medial rotation were all painful.

When the Spine Team consultant evaluated the patient, hip medial and lateral rotation were restricted and painful. Hip abduction was minimally limited and painless. The presence of a noncapsular pattern of restriction of the right hip, accompanied by the lack of tenderness to deep palpation at the greater trochanter,[3,7] the gait limitations, and the duration of nonresponsiveness to physical therapy, were not consistent with the diagnosis of trochanteric bursitis and warranted the MRI. Perhaps a peritrochanteric injection may have resulted in earlier diagnosis and treatment of the femoral neck fracture.

Changes in the health care delivery system have resulted in a deemphasis on diagnostic testing. Subsequently, a greater number of patients may be seen in physical therapy with potentially undiagnosed pathology. Thus, physical therapists have to make the first-order decision of whether the patient is a candidate for physical therapy.

Most physical therapists do not have access to imaging equipment to rule out contraindications and must therefore rely entirely on the clinical examination. In our experience, Cyriax's[15][p84] concepts of capsular and noncapsular patterns of restriction of motion are examples of clinical examination procedures that may be useful in identifying patients requiring further diagnostic evaluation.

Little research exists addressing the reliability and validity of Cyriax's evaluation system.[16] Hayes et al[18] recommended retaining the concept of a loss of ROM but abandoning Cyriax's proportional definition of a capsular pattern based on their reliability and validity study of 79 patients with osteoarthritis of the knee. A study by Pellechia et al,[16] however, provided evidence supporting the intertester reliability of Cyriax's evaluation system. In their study, two experienced physical therapists, using Cyriax's model, classified 19 out of 21 patients with shoulder pain into the same diagnostic categories.[16]

More research, however, is needed to support or disprove Cyriax's theories.

The cost of this case if the fracture had displaced would have been considerable, in terms of both the quality of life for this particular patient and the economic impact. Displaced femoral neck fractures are surgical emergencies.[10] Operative fixation within the first 12 hours postinjury results in approximately 25% avascular necrosis, which increases to 100% in 1 week.[19] Thus, it is necessary to eliminate potentially serious diagnoses from the list of possible differential diagnoses.

(*) The Upjohn Company, Kalamazoo, MI 49001.

([dagger]) Synthes, 1690 Russell Rd., Paoli, PA 19301.

References

[1] Sterling JC, Edelstein DW, Calvo D, Webb R. Stress fractures in the athlete: diagnosis and management. Sports Med. 1992;14:336-346.

[2] Krupp MA, Chatton MJ. Current Medical Diagnosis and Treatment. Lang Medical Publications; 1978:511.

[3] Traycoff RB. Pseudotrochanteric bursitis: the differential diagnosis of lateral hip pain.J Rheumatol. 1991;18:1810-1812.

[4] Haller CC, Coleman PA, Estes NC, Grisolia A. Traumatic trochanteric bursitis. Kans Med. 1989;90:17-18, 22.

[5] Salter RB. Textbook of Disorders and Injuries of the Musculoskeletal System. Baltimore, Md: Williams & Wilkins; 1983:415.

[6] Roberts WN, Williams RB. Hip pain. Primary Care. 1988;15:783-793.

[7] Caruso FA, Toney MAO. Trochanteric bursitis: a case report of plain film, scintigraphic, and MRI correlation. Clin Nucl Med. 1994;19:393-395.

[8] Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. Philadelphia, Pa: Lippincott-Raven Publishers; 1996:92, 96, 297, 304-305, 655-656.

[9] Brake D. Imaging of femoral neck stress fracture. Kan Med. 1994;95:49.

[10] Fullerton LR, Snowdy HA. Femoral neck stress fractures. Am J Sports Med. 1988;16:365-377.

[11] Johansson C, Ekenman I, Tornkvist H, Eriksson E. Stress fractures of the femoral neck in athletes: the consequence of a delay in diagnosis. Am J Sports Med. 1990;18:524-528.

[12] Hoppenfeld S. Physical Lxamination of the Spine and Extremities. Norwalk, Conn: Appleton-Century-Crofts; 1976:262.

[13] Minor MA, Minor SD. Patient Evaluation Methods for the Health Professional. Reston, Va: Reston Publishing Co Inc; 1985.

[14] Kendall FP, McCreary EK. Muscles: Testing and Function. 3rd ed. 1983.

[15] Cyriax J. Textbook of Orthopaedic Mediane, I: Diagnosis of Soft Tissue Lesions. 7th ed. London, England: Bailliere Tindall; 1978:81, 84-86.

[16] Pellechia GL, Paolino J, Connell J. Intertester reliability of the Cyriax evaluation in assessing patients with shoulder pain. J Orthop Sports Phys Ther. 1996;23:34-38.

[17] Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. Philadelphia, Pa: FA Davis Co; 1985:329.

[18] Hayes KW, Petersen C, Falconer J. An examination of Cyriax's passive motion tests with patients having osteoarthritis of the knee. Phys Ther. 1994;74:697-707.

[19] Rockwood CA, Green DP. Fractures, Volume 2. Philadelphia, Pa: JB Lippincott Co; 1984:1020.

DL Jones, PT, is Coordinator of Education, CORE Network, LLC, 6041 Forbes Tower, Pittsburgh, PA 15260 (USA) (jonesd@newton isd.upmc.edu); Clinical Assistant Professor, Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260; and a doctoral student in chronic disease epidemiology, Graduate School of Public Health, University of Pittsburgh. Address all correspondences to Ms Jones at the first address.

RE Erhard, DC, PT, is Assistant Professor, Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, and Head, Chiropractic and Physical Therapy Services, Comprehensive Spine Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213.

This case report was presented at Physical Therapy '96: American Physical Therapy Association Scientific Meeting and Exposition; June 14-18, 1996; Minneapolis, Minn.

This article was submitted November 9, 1995, and was accepted September 24, 1996.