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CMAC222
Session 07
Disorders of the Hip, Buttock and Groin
Chinese Medicine Department
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Sacroiliac Joint Fixations
Strain of Adductors
Osteoarthritis of the Hip Joint
Lateral Thigh Pain
Hip/Buttock/Groin
Topics
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The hips can be confusing as there are many structures around the hip.
Also other structures can mimic or present as hip pain
Apply the KISS principle and rule the most likely out first and then move onto less likely situations
Orthopaedic Physical Assessment is paramount when dealing with hip pathologies
When in doubt refer for imaging
Before We Get Started
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Argosy Publishing, 2015
In Class Have a look at
Visible Body
Visible Body Muscle Premium
Just log in with your Endeavour details
Explore the Pelvis Anatomy
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Pelvis Bones
Netter, 2014, Plate 330
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Female Pelvis
Netter, 2014, Plate 331
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Male Pelvis
Netter, 2014, Plate 331
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Hip Ligaments - Posterior
Netter, 2014, Plate 333
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Hip Ligaments - Anterior
Netter, 2014, Plate 333
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Hip Joint Opened
Netter, 2014, Plate 474
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Psoas and Illiacus Muscles
Netter, 2014, Plate 483
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Superficial and Deeper Muscles
Netter, 2014, Plate 482
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Sacral and Coccygeal Plexus
Netter, 2014, Plate 486
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Deep Muscles of the Hip
Netter, 2014, Plate 486
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Anterior View of the Pelvis
Magee, 2014, p691-2
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Chinese Anatomy - Hip
Deadman, et al, 2007, p603, 605
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GB29
Deadman, et al, 2007, p446
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Jingjin involved in Hip
Kendall, 2002, p224
1. Bladder Channel: (Superficial layers)
2. Gall Bladder (Side stabilisers of hip)
3. Stomach Channel (Psoas)
4. Kidney Channel – (Adductors of leg)
5. Spleen and Liver (inner thigh and pelvic floor
See the Muscle Distribution (Kendall)
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See a hip and thigh dissection here
(Not to be viewed in class)
In your own time
Sapiens Medicus, 2013
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Chinese Med Aetiology
Marcus, 2004, p657, Legge, 2011, p270
HIPTrauma
Overuse
Poor Posture
Muscle Tightness
W/C/D invasion
Unknown
Anatomical variation
Inflammation
Previous Injury
Blood Stasis
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Reduced circulation
Acute micro
trauma
Disturbed Qi and
Blood flow
Trauma resulting
in hip problems
Pathogenesis
Marcus, 2004, p675, Legge, 2011, p270
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Pulling on the hip
Magee, 2014, p651-2
Anterior – Posterior superficial muscle group.
A: muscles and ligaments involved in posterior tilt and
B: muscles and ligaments involved in anterior tilt
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Pulling on the Hip
Magee, 2014, p651-2
Lateral Muscle System Inner Muscle Unit
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Pulling on the hip
Magee, 2014, p651-2
Posterior and Anterior Oblique Muscle System Deep Longitudinal Muscle System
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General Examinations
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See exactly where the patient has the pain and can it be reproduced
Get them to point to the painful area
Asymmetry
Tension
Deformities
Previous Surgeries
Gait analysis
Attitude
Observation
Legge, 2011, p268, Magee, 2004, p657
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Look
Feel
Move – Passive, active and restricted
Hip - Examination
Image: Reichert, 2011, p224Videos: British Journal or Sports Medicine (BJSM) 2010
See the Hip & Groin Examination
See the Range of Motion here
See the Manual muscle test
(Not to be viewed in class)
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Passive, active and restricted movements of the spine should be assessed.
These include:
Measuring Forward flexion
Extension
Side Flexion
Rotation
Move
Magee 2014, p571
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Passive, active and restricted movements of the hip joints should be assessed.
These include:
Flexion
Abduction
Adduction
Extension
Medial rotation of the hip
Lateral rotation of the hip
Move
Magee 2014, p660-2
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Groin (gently) and thigh for important structures and for tenderness
Pubic symphysis
Inguinal ligament
Illiopsoas
Adductor insertions and muscle bellies
Tensor fascia lata (TFL)
Gluteus medius and minimus muscle and tendon
Trochanteric bursa
Lower back intervertebral segments and muscles
Palpation
Legge 2011, p268-9,Image: Reichert, 2011, p229
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Sacrum and sacroiliac joints (SIJ)
Posterior Superior Iliac Spine (PSIS)
Gluteus maximus
Piriformis
Around the trochanter – bursa, gluteus medius and minimus tendons
Lateral thigh for iliotibial band (ITB) tightness and tenderness
Iliac Crests
Ischial Tuberosity
Palpation
Legge 2011, p268-9,Images: Reichert, 2011, p230
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Sciatic Nerve Variations
Magee, 2014, p727
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Forward flexion of the spine 40°to 60°
Extension of the spine 20°to 35°
Rotation of the spine left and right 3°to 18°
Side flexion of the spine left and right 15° to 20°
Flexion of the hip 100°to 120°
Abduction of the hip 30° to 50 °
Adduction of the hip 30°
Extension of the hip 0°to 15°
Medial rotation of the hip 30° to 40°
Lateral rotation of the hip 40° to 60°
Movements Stressing SIJ
Magee 2014, p659
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Medial Vs Lateral Rotation
Magee 2014, p697
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X-ray
USS
CT Scan
MRI
Blood work (inflammatory markers such as ESR and CRP)
Lumbar puncture
Questioning
Evaluation Measures including Gait analysis, Harris Hip Function Scale, Iowa Functional Hip Evaluation
See handouts
Imaging and Investigations
Image: SMART imagebase 2015
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Sacroiliac Joint Fixations
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1. The sacroiliac joints are found between the sacrum and the ilium on each side just medial to the Posterior Superior Iliac Spine (PSIS)
2. While not as prone to problematic disorders they can be strained from traumatic and postural causes as well as some forms of arthritis
Sacroiliac Joint
Legge, 2011, p263Image: SMART imagebase 2015
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Primary test: Gilets test, forward flexion test
Other tests: Weber Barstow manoeuvre, Gapping test
Sacroiliac Joint Fixations special tests
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Tends to be located over the joint around BL 28 and the ligaments especially around BL 30
Can radiate - lower part of body, groin, buttocks
Worse during sitting, standing up and at the end range of passive lumbar rotation
Check for active trigger points in QL, piriformis, gluteus medius and minimus and L5/S1 disorder
Legge suggests BL 28 needled medial to lateral into the joint and combined with BL 30 with estim across these two
Choose appropriate distal points
Location and Treatment
Legge, 2011, p263
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1. The PSIS is quite large (around 2 cun) and can be divided into 4, find the two most tender points and needle into the joint
2. Use a minimum of 75 mm needles. Needle in the direction of GB 29ish
3. This needle insertion can be difficult and feel restricted due to the vast amount of ligamentous tissue in the joint
4. Gillet's Test and Gapping Test may be positive
Callison adds in
Callison 2009,Image: Netter, 2014, plate 333
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Strain of Adductors
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S/S
Pain – usually in groin / worse for restricted adduction.
Adductor longus is the most commonly strained.
Tenderness over the origin on the pubic bone.
Treatment
Disperse stagnation and restore healthy qi & blood circulation.
Rest injury until pain & tenderness disappears.
Initially 2-3 treatments per week and revaluate as patient improves. Will depend on grade of strain.
Strain of Adductors
Legge, 2011, p278
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Strain of Adductors
Legge, 2011, p278
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Strain of Adductors
Adductor longus is the adductor most frequently involved – usually from sporting injury
Legge, 2011, p277
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Primary test: Adductor strength test
Other tests: n/a
Weakness/Strain of Adductors special tests
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1. Acupuncture
2. Ah shi (if not too tender)
3. Trigger point in muscle if palpable
4. Local pt. LR 11
5. Distal pts. LR 5, 8
6. Exercises to increase muscle length & strength
Treatment
Legge, 2011, p278
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Special point
Main action:turns on gluteus medius and minimus if weak.
Indications:Lower back pain, hip pain, ITB syndrome, hip bursitis. If due to weakness.
Location:On lateral line, midway between the iliac crest and the greater trochanter. Approximately 2 cun posterior to GB 29.
Needle deeply 2-3 inches with 2 needles in the area. Stimulator can be used between them.
Reaves, 2009, p.171
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Osteoarthritis of the Hip Joint
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The most common presenting problem with the hip joint
Common in middle-aged or elderly women (overweight)
Acupuncture effective to reduce pain and increase mobility
Pain often referred to the groin, trochanter, inner thigh or knee and buttock
FABER test will be positive
Xray and further scans if suspected
Local points and a Bi syndrome analysis approach
Osteoarthritis of the Hip Joint
Legge, 2011, p280
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Primary test: Rule out Bursitis been acute consistent and sore to touch
Other tests: Faber test
Osteoarthritis of the Hip Joint special tests
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Principle points:
GB 29 & GB 30 (local points)
GB 40 (distal point, Yuan-Source Point and dispersing action)
BL 62 (Opening point of Yang-Qiao)
SP 6 (resolve damp, invigorate Qi)
Supplement points:
GB 27 or GB 28 (radiating pain); SP 3 & ST 36 (with dampness); BL 30 (with Cold); GB 43 & ST 44 (with heat)
Treatment
Kahn, 2009, pg80
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Lateral Thigh Pain
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Primary test: Rarely primary, would present as result of other conditions
Other tests: n/a
Lateral Thigh Pain special tests
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Hip Pain?
Magee 2014, p694
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Common cause of pain in lateral thigh
Pain is outside the joint area
ITB syndrome and lateral knee pain patient may have undiagnosed bursitis
Can present with snapping or popping on the trochanter as the ITB moves over the inflamed bursa
Gluteal muscles insert in this area and the pain can radiate into the buttock and down the ITB
Some people report worse pain when lying on affected side during sleep
Pain can range from dull to sharp
Trochanteric Bursitis
Reaves, 2009, p187
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Usually chronic with insidious onset or from direct trauma
With the patient side lying press directly on the greater trochanter with the whole palm
You may be able to palpate the bursa to feel spongy, but always compare to other side
Change in biomechanics of walking running, abnormal pronation or supination
Trochanteric Bursitis
Reaves, 2009, p187Image: SMART imagebase, 2015
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OA of the hip
Labrum tears and other joint capsule lesions
Sciatic pain
Other soft tissue lesions
ITB syndrome
Differential Diagnose
Reaves, 2009, p188
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1. Anti-inflammatory medication
2. Rest
3. Stretching the ITB
4. Biomechanics – orthotics
5. Ultrasound, massage
6. Heat
7. Steroid injections into the bursa
Treatments
Reaves, 2009, p188Image: La Quaintrelle
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Use four needles superior, inferior, anterior and posterior to the bursa
Electrical stimulation may be considered with the needles adjacent to the bursa
Moxa also applicable
Laser over the area
Appropriate adjacent and distal points
Surround the Dragon
Reaves, 2009, p192
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Acute 2 x per week for 3 weeks then re-evaluate. Most cases without complications will have good results in 6 treatments
More chronic continue treatment at least once weekly after the first three weeks
Prognosis
Reaves, 2009, p189
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Thorough case history to rule out other causes
Fracture
Labral tears
Perthe’s Disease (Aseptic necrosis of the hip)
Osteoporosis and corticosteroid use
Sensory or Motor problems
Pregnancy
Lymph nodes
Local nerves (femoral and Sciatic)
Major bold vessels in the groin
Cautions
Anzaldua, 2010, p119, Magee, 2014 pp 625-6
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Referred Pain
Magee, 2014, p676, 732
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Sacral Dermatomes
Magee, 2014, p676
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A PubMed search on 23rd September 2015 revealed very limited research
Many results were in Chinese with no abstract available
Level of Evidence
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CMAC222
Session 7
Special Tests of the Hip, Buttock and Groin
Chinese Medicine Department
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Bony Landmarks
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Muscles acting on the Hip
Magee, 2014, p702
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Muscles acting on the Hip
Magee, 2014, p702
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FABER Test
To asses hip joint pathologies, iliopsoas spasm, or sacroiliac joint dysfunction
1. Patient supine
2. Contralateral leg straight
3. Examiner places one hand on test knee, other hand on contralateral ASIS
4. Foot is passively placed on opposite knee or above the knee then test knee is lowered to table
5. Pain in the buttock = sacroiliac origin
6. Leg does not reach table = adductor/iliopsoas contracture
7. Groin pain, no overpressure = hip pathology (no-specific)
Magee, 2014, p713-4Image: Goldsworthy, 2014
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Weber-Barstow Maneuver
Used to measure leg length asymmetry
1. Patient supine, knees flexed
2. Examiner palpates the medial malleoli with the thumbs
3. Patient then lifts the pelvis from the examining table and returns to the starting position
4. Examiner passively extends the patient’s legs and compares the position of the malleoli using the borders of the thumbs
5. Positive = different levels indicate asymmetry
Magee, 2014, p720-1Image: Goldsworthy, 2014
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If one leg is shorter than the other the examiner can determine where the difference is by measuring the following:
From the iliac crest to the greater trochanter of the femur
If this angle is less than 120⁰ = coxa vara
More than 135⁰ = coxa valga
From the greater trochanter of the femur to the knee joint line on the lateral aspect = femoral shaft shortening
From the knee joint line on the medial side to the medial malleolus = tibial shaft shortening
Weber-Barstow Maneuver Cont.
Magee, 2014, p720-1
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Weber Barstow Findings
If malleoli even, no need to proceedIf malleoli is lower one side, then check tibial tuberosity and ASISPossible findings:1. Lower malleolus on right, with level tibial tuberosities =
longer right tibia2. Lower malleolus on right, with lower right tibial
tuberosity, but level ASISs = longer right femur3. Lower malleolus on right, with lower right tibial
tuberosity and lower right ASIS = left lumbar
Magee, 2014, p720-1Image: Goldsworthy, 2014
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Initially sacrum nutates up to 60⁰ of forward flexion
Innominate bones continue to rotate anteriorly
Sacrum begins to counternutate
At this point the sacroiliac joint is vulnerable to instability problems
Excessive counternutation is more likely to occur in patients who have tight hamstrings
Forward Flexion
Magee, 2014, p659-60
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Forward Flexion
1. Examiner palpates the PSISs
2. Patient bends forward slowly
3. Symmetry of the PSIS superiorly is noted
4. PSIS’s should move upward equally in relation to the sacrum towards each other
5. Positive = PSIS does not move or moves late or not as high
6. This means the ilium is fixatedMagee, 2014, p659-60
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Trendelenburg Test
Used to assess weak gluteus medius or QL
1. Standing on one leg, lift one knee and observe for a drop of the iliac crest on that side
2. Positive test: pelvic stability is lost and the hip drops on the unsupported side = weak contralateral glute med
3. A: Negative test
4. B: Positive test
Magee, 2014, p729Images Magee, 2014 p730 Goldsworthy 2014
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1. Magee, D, 2014, Orthopedic Physical Assessment Sixth Edition, Elsevier Saunders, St Louis, Missouri
2. Nucleus Medical Media, 2015, Tear involving superior labrum of the left hip – Medical exhibit, viewed 25th September 2015, <http://ebsco.smartimagebase.com>
3. O’Donnell, J, Economopooulos, K, Singh, P, Bates, D, Pritchard, M, 2014, The ligamentum teres test, a novel and effective test in diagnosing tears of the ligamentum teres, American Journal of Sports Medicine, vol. 42. no 1, pp 138-143, viewed 25th September 2015, http://ajs.sagepub.com/content/42/1/138.full.pdf+html
4. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (1 of 7): Introduction & back exam, viewed 16th September 2015, https://www.youtube.com/watch?v=Y_EZvm0iSno
5. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (2 of 7): Inspection & range of motion, viewed 16th September 2015, https://www.youtube.com/watch?v=WpM8h4mCLCc
6. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (6 of 7): Special tests, viewed 16th September 2015, https://www.youtube.com/watch?v=HzlAUaovrKY
7. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (7 of 7): Labral tear, viewed 16th September 2015, https://www.youtube.com/watch?v=Rtp4oz0_3YY
8. Goldsworthy, E, 2014, FABER Test, Private Collection
9. Goldsworthy, E, 2014, Weber-Barstow Manoeuvre 1, Private Collection
10. Goldsworthy, E, 2014, Weber-Barstow Manoeuvre 2, Private Collection
11. Goldsworthy, E, 2014, Weber-Barstow Manoeuvre Findings 1 Private Collection
12. Goldsworthy, E, 2014, Weber-Barstow Manoeuvre Findings 2, Private Collection
13. Goldsworthy, E, 2014, Weber-Barstow Manoeuvre Findings 3, Private Collection
14. Goldsworthy, E, 2014, Approximation Test, Private Collection
15. Goldsworthy, E, 2014, Gapping Test, Private Collection
16. Goldsworthy, E, 2014, Trendelenburg Sign/Test, Private Collection
References
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Practice pelvis examination
Palpation of sacrum and hip, buttock and groin
Needle points of the hip
Sacroiliac joint needling
Psoas and iliacus points & GB 26 and GB 27
BL 54 & GB 30 – compare the two
Points in hip
Surround the Dragon at the Greater trochanter
BL 31 & 32
Shiqizhuixia (L5/S1)
Jiankua with electro
Practical
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1. Netter, F, 2014, Atlas of Human Anatomy Sixth Edition, Icon Learning Systems, Teterboro, NJ
2. Argosy publishing, 2015, Visible Bodys’ Human Anatomy Atlas, Viewed 24th June 2015, <http://www.visiblebody.com>
3. Argosy publishing, 2015, Visible Bodys’ Muscle Premium Anatomy Atlas, Viewed 24th June 2015, <http://www.visiblebody.com>
4. Legge, D 2011, Close to the Bone – The treatment of painful musculoskeletal disorders with acupuncture and other forms of Chinese medicine 3rd Edition, Sydney College Press, Woy Woy
5. Marcus, A, 2004, Foundations for Integrative Musculoskeletal Medicine: An East-West Approach, North Atlantic Books, Berkeley California
6. Baldry, P, 2005, Acupuncture, Trigger Points and Musculoskeletal Pain 3rd Edition, Churchill Livingstone Elsevier
7. Reichert, B, 2011, Palpation Techniques Surface Anatomy for Physical Therapies, Thieme, New York
8. Shao-jie, L, 2008, Acupuncture for Musculoskeletal Injury 2nd Edition, Peoples Medical Publishing House, Beijing
9. Kendall, D, 2002, Dao of Chinese Medicine, Understanding and Ancient Healing Art, Oxford University Press, Hong Kong
10. Callison, M 2012, Motor Point Index – An Acupuncturist’s Guide to Locating and Treating Motor Points, AcuSport Seminar Series LLC Sports Medicine Acupuncture, San Diego, California, viewed 24th June 2015, <http://www.amazon.com>
11. Neil – Asher, 2008, The Concise Book of trigger Points 2nd Edition, North Atlantic Books, Berkeley, California
12. Maciocia, 2005, The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists 2nd Edition, Elsevier: Churchill Livingstone,
13. O’Connor, J & Bensky, D (ed.) (1983) Acupuncture: a comprehensive text, Eastland Press, Chicago
14. Tan, R, 2003, Acupuncture 1, 2,3, Richard Tan OMD, San Diego California
15. Anzaldua, D, 2010, An Acupuncturist Guide to medial Red Flags & referrals, Blue Poppy Press, Boulder CO
16. Magee, D, 2014, Orthopedic Physical Assessment Sith Edition, Elsevier Saunders, St Louis, Missouri
17. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (3 of 7): Patient history & palpation, viewed 16th September 2015, https://www.youtube.com/watch?v=Y_EZvm0iSno
18. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (4 of 7): Range of motion, viewed 16th September 2015, https://www.youtube.com/watch?v=UfjQmhoCM5A
19. British Journal of Sports Medicine (BJSM), 2010, Hip & Groin Exam (5 of 7): Manual muscle testing, viewed 16th September 2015, https://www.youtube.com/watch?v=Mdg1uP0kMbc
References
© Endeavour College of Natural Health endeavour.edu.au 79
1. Sapiens Medicus, 2013, Anatomical dissection #25: Muscles, vessels & nerves of the hip and thigh, viewed 17th September 2015, https://www.youtube.com/watch?v=qiRT_LJ9c3U
2. Christian, 2010, -intense look- , viewed 14th August 2015, https://www.flickr.com/photos/chrisk4u/4296161164/in/photolist-7xCX3d-aDzcDc-7K6r4e-nsnunH-7tYtnM-7b8177-5SzGLP-ovuzjB-5dopRY-jXx3oV-7bb1pp-65dAGD-5wbyLE-c1UTf-dZCHd-rPKs3-c5ms5w-ktv52E-b41Sac-bKjhs4-ucYai1-nXXcKz-5MQvaL-aQGkvr-fFP9d4-eHD1Zw-kjpnVT-4of2zH-22HGSY-66w6Zs-bARqUG-u8Dgyp-oQmnu3-ts84dk-e77MQx-7m2Uwt-4uSwKT-hyKsuS-5kzXSw-7fPMpi-f6AiyV-beDgrZ-kxySS4-55pr2W-qAwhn2-6PfygR-6PH5CM-7GYFCy-uNxTdC-pF1Zf9
3. Nucleus Medical Media, 2015, Left Sacroiliac Joint Disruption – Medial Exhibit, 22nd September 2015, <http://ebsco.smartimagebase.com>
4. Nucleus Medical Media, 2015, Total Hip Joint Replacement Surgery (Full Version) – Medial Animation, 22nd September 2015, <http://ebsco.smartimagebase.com>
5. Nucleus Medical Media, 2015, Trochanteric (Hip) Bursitis – Medial Exhibit, 23rd September 2015, <http://ebsco.smartimagebase.com>
6. La Quaintrelle, 2014, Foam Rolling your ITB band, viewed 23rd September 2015, http://quillery.tumblr.com/post/105493932707/the-5-things-a-massage-therapist-will-probably
7. Koshy , 2010, Happy Farmer, viewed 23rd September 2015, https://www.flickr.com/photos/kkoshy/5156445007/in/photolist-8RE8sg-waqg4-ndeCxA-t3H9A-5kWf96-5mmMAe-6uHz7S-5J1Jcj-8EfDG7-B1FV4-Pshj8-ekhdMj-9UpFEx-MRr2s-pARJed-7rKz5M-nWTAJ9-b7oCrH-4ZCk3N-iiQPYB-8vBWnB-6enoYv-bv1H5g-7sad16-969bRP-6mCxRA-qjZvWs-7rSixD-q36A-rCRKro-xsApBR-6ehXeA-jNFb5r-7z2gzm-5gr521-fy2XiC-51U2Ep-qC9Npe-9jwJY3-rHcbJR-d3KLx-brqnPk-7QaJYd-5NRnYF-pncqQ6-94GknR-35Rt6q-7R7Ej6-vZvL6-5LUhPG
8. Reaves, W, Bong, C, 2009, The Acupuncture Handbook of Sports Injuries & Pain: A Four Step Approach to Treatment Hidden Needle Press Boulder Colorado
9. Cooper, Kahn & Zucker, T 2009. Acupuncture for musculoskeletal medicine, Lippincott Williams & Wilkins, Philadelphia.
References
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