A Systematic

Approach
To Adult Hip Pain,
Part 1
In this two-part article, adult hip pain will be reviewed from the
inside out. The first part will take a look at the anatomy and
biomechanics affecting the hip, as well as the approach to
evaluation hip pain. Next month in the second part, common
conditions that cause hip pain will be examined.

By Robert Wang, BSc, Mohit Bhandari, MD, MSc, and

Richard J. Lachowski, MD, FRCPC

A dult hip pain is a common problem,

affecting over 25% of people with
joint-related pain. The complex anatomy of
weight-bearing joint, the hip supports the
entire upper body. At the same time, how-
ever, it allows for a flexible degree of
the hip joint and surrounding soft tissues movement between the lower limbs and the
offers challenges to diagnosing and appro- upper body. Any pathology affecting the hip
priately treating a painful hip. Failure to is particularly debilitating because it com-
diagnose and appropriately manage injuries promises the patient’s ability to ambulate.
of the pelvis can result in prolonged patient Determining the cause of a painful hip
morbidity and, in some cases, mortality. A can be a major challenge to physicians. A
systematic approach to adult hip pain, careful history, physical examination and
including a careful clinical and radiograph- appropriate investigations can identify the
ic examination, will identify the majority of majority of hip ailments. The purpose of
all clinically important pathologies in this this review article is to provide a systemat-
region. ic approach in the evaluation of hip pain in
One of every 10 patients with joint pain the adult patient.
complain of a painful hip. As a major

The Canadian Journal of Diagnosis / April 2001 109

Adult Hip Pain

Anatomy and
degree of articulation between the femoral
Biomechanics head and acetabulum. The articular surface
Hip Anatomy of the acetabulum is horseshoe-shaped, sur-
The hip joint is the largest joint in the body, rounding a nonarticular central depression
and consists of the femoral head articulat- known as the acetabular fossa. An articular
ing with the acetabulum. This ball-and- fat pad occupies the fossa, and can become
socket configuration permits a wide range impinged in some patients. The femoral
of motion, however, the stability is main- head is covered with articular cartilage,
tained by several structures that encase the except at the fovea centralis, where the lig-
joint. Excessive range of motion, without amentum teres is attached. The thickest lay-
anatomic stability, results in subluxations or ers of both femoral and acetabular cartilage
dislocations. The acetabulum, the hip cap- are seen in apposition at the superior and
sule, and muscles stabilize the joint as it slightly anterior joint surfaces, correspond-
moves through a wide range of motion. ing to the area receiving the greatest
The acetabular labrum is a fibro- weight-bearing stress.1
cartilagenous structure. It functions to The hip joint is enclosed by a strong
deepen the socket, to provide a greater fibrous capsule, which is made of four liga-
ments: iliofemoral ligament, pubofemoral
ligament, ischiofemoral ligament and liga-
ment teres. Figure 1 illustrates the joint cap-
sule and its sites of attachment. The liga-
ments function to prevent extremes of
Dr. Wang is research
assistant, division of motion. They become taut, for example,
orthopedic surgery, during the limits of extension to prevent
department of surgery,
McMaster University, hyperextension.
Hamilton, Ontario. Muscles around the hip help to co-
ordinate its wide range of motion. Hip flexion
is performed by the iliopsoas and the quadri-

Dr. Bhandari is fellow of the

clinician scientist program,
Dr. Lachowski is associate
division of orthopedic
clinical professor, division of
surgery, department of
orthopedic surgery,
surgery, and department of
department of surgery,
clinical epidemiology and
McMaster University,
biostatistics, McMaster
Hamilton, Ontario.
University, Hamilton,
Ontario.

110 The Canadian Journal of Diagnosis / April 2001

 Adult Hip Pain

ceps, while hip extension is primarily the

function of the hamstrings. Other muscles
abduct, adduct, internally rotate and external-
ly rotate the hip. Bursae reduce friction in
areas where muscle slides over tendon or
bone. There are many bursae in the hip joint,
however, only the greater trochanteric,
Greater
iliopectineal and ischiogluteal bursae seem to trochanteric
have clinical significance (Figure 1).2 bursa
Iliopectineal bursa
Biomechanics and Gait
The hip is subject to considerable stress
over a lifetime from movement, weight
bearing and repetitive impact. Any derange-
ment in the smooth gliding of the joint sur-
faces can cause deterioration of cartilage
and, subsequently, of the joint. The hip Ischiogluteal bursa

moves in a combination of three basic

planes: flexion and extension, abduction
and adduction (side-to-side), and external Figure 1. Commonly inflamed bursae in the hip.
and internal rotation. The muscles that hold
us erect and allow walking and stair climb- the affected hip. The gait will be character-
ing exert considerable forces across the hip ized as antalgic (painful). During the swing
in the range of three to six times body phase, the pelvis may not rotate normally
weight.3 Thus, a 25-pound weight gain may around the painful and stiff hip joint.
seem like 150 additional pounds to the hip. Reducing the overall load or increasing
The lower extremities are dedicated to the surface area over which the load acts
the important tasks of weight bearing and can decrease stress on the hip. Canes,
ambulation. A gait abnormality is usually a crutches and walkers decrease overall load
consequence of pain, weakness and/or a and, therefore, are a common part of the
difference in leg length. The hips play an nonsurgical treatment for arthritis of the
important role in normal walking and run- hip. Properly used, a cane will significantly
ning and, thus, gait is usually significantly improve walking distance and comfort.
affected by hip pathology.
There are two phases in the normal gait
cycle: the stance phase, when the foot is on
the ground; and the swing phase, when it is
The Approach to
moving forward. Most hip problems Evaluating Hip Pain
become apparent in the stance phase.1 The History
individual with hip pathology will typically Obtaining a good history is important in
shorten the stance phase and will lean over formulating a differential diagnosis. The

The Canadian Journal of Diagnosis / April 2001 111

Adult Hip Pain

Table 1
CAUSES OF HIP PAIN AS RELATED TO THE SITE OF THE PAIN

Anterior Hip or Lateral Hip or

Groin Pain Trochanteric Pain Posterior Hip Pain
Differential Rule out: hip fracture, Rule out: hip fracture, bone Rule out: sciatic nerve irritation,
Diagnosis septic joint, and tumor, referred pain from sacroiliitis due to
avascular necrosis lumbar disc herniation spondyloarthropathy, lumbar,
disc or facet disease
Other causes: OA, RA, Other causes: trochanteric Other causes: muscle strain
iliopectineal bursitis bursitis, OA, radiating from
lumbar disc or facet disease

history not only helps to focus on hip thigh? Although anterior hip pain may be
pathologies, but it may help differentiate due to any of the conditions outlined in
hip disease from other conditions, such as Table 1, groin and medial thigh pain can
“referred pain” from spinal stenosis. The simulate L4 nerve root pain. In such cir-
patient with hip pathology often presents cumstances, the back should be examined,
with a chief complaint of pain and, there- as it can be the source of referred hip pain.
fore, the characteristics of the pain should Snapping. Is there snapping in and
be explored in detail. The following ques- around the hip? Snapping of the hip, or
tions should be addressed: coxa saltans, is generally caused by move-
Age. Range of motion decreases with ment of one structure against another. Three
age and different conditions occur at vari- common conditions (referred to as “snap-
ous age groups. For example, elderly ping hip syndromes”) are:5
women are more prone to osteoporotic a. Mechanical abnormalities that can
femoral neck fractures and suffer more result in internal snapping. This occurs
commonly from osteoarthritis (OA). at approximately 45 degrees of flexion,
Onset. A gradual onset of pain may sug- when the hip is moving from flexion to
gest a degenerative arthritic process, such extension. The snap, which may be
as OA, whereas a sudden onset may indi- accompanied by pain, is palpated ante-
cate a traumatic etiology. riorly; for example, the iliopsoas tendon
Location. Hip pain can broadly be clas- can slip over the osseous ridge of the
sified as anterior, lateral or posterior.4 Table lesser trochanter or the anterior acetabu-
1 outlines possible conditions causing pain lum, causing a snap that is felt/heard
in different regions of the hip. Many serious during movement. The iliofemoral liga-
pathologies can present in any location and, ment riding over the femoral head can
therefore, Table 1 should be used as a guide be another cause of internal snapping.
—not as an independent means—to arrive b. External snapping is due to a tight ili-
at a definitive diagnosis. otibial band or gluteus maximus tendon
Radiation. Is the pain felt mostly in the riding over the greater tuberosity of the
groin and along the medial side of the femur. The snapping or popping occurs

112 The Canadian Journal of Diagnosis / April 2001

 Adult Hip Pain

during hip flexion and extension, espe- range of motion, muscle strength and spe-
cially if the hip is held in medial rota- cial tests.
tion. This condition is exacerbated by Inspection. Much of the patient’s hip
trochanteric bursitis. problem can be assessed from observing
c. Acetabular labral tears or loose bodies gait, curvature of the back, pelvic symmetry
cause intra-articular snapping. In this and leg length. The following areas should
case, the patient complains of a sharp be noted on inspection:
pain into the groin and anterior thigh, • Deformity. With the patient standing,
especially during pivoting movements. inspect from the front and from behind
Passively, clicking may be felt and for any pelvic tilting or rotational defor-
heard when the extended hip is adduct- mity. While observing the patient from
ed and laterally rotated. behind, look for presence of scoliosis;
Mechanism. Did the patient fall on the from the side, note if lumbar lordosis is
outside/lateral aspect of his/her hip? A fall increased, which may indicate a fixed
on the lateral aspect of the hip could indicate flexion deformity.
a fracture or something more benign, such • Gait. Common abnormal gait patterns
as trochanteric bursitis. Did they land on associated with hip disease are antalgic
their knees? Landing on the knee and jarring and Trendelenburg. To apply the
the hip may result in a subluxation and/or Trendelenburg test, ask the patient to
labral tear. Were they involved in a repeti- stand on one leg. The hemi-pelvis on
tious type of work? Repetitive loading activ- the opposite side should remain elevat-
ities can result in a femoral stress fracture. ed, indicating func-
Progression. To gauge the progression of tioning adductors
Canes, crutches
the pain, the level of functional impairment on the weight bear- and walkers are a
should be noted. How many blocks could ing leg. If the common part of
the patient walk prior to the onset of their hemi-pelvis falls,
hip pain? How many blocks can they now this is a positive
the nonsurgical
walk? Also, ask if the patient is taking any test, which can be treatment for
medication(s) for the pain. The type of caused by gluteal arthritis of
medication, dosage and frequency will sug- muscle weakness,
gest the severity of the pain. inhibition from
the hip.
Exacerbation. What type of activity exac- pain or a hip deformity.
erbates the pain? For example, trochanteric • Leg length. Measure each leg from the
bursitis often results from abnormal running anterior superior iliac spine to the medi-
mechanics with the feet crossing midline al malleolus. Leg-length discrepancies
(increased adduction), wide pelvis and genu indicate hip pathology on the shortened
valgum, or running on bankless tracks. side.
Palpation. Because the hip joint is a
Physical Examination deep interior structure, careful palpation is
When examining the hip, the following necessary to localize the pain and to deter-
sequence is useful: inspection, palpation, mine whether the pain radiates elsewhere.

The Canadian Journal of Diagnosis / April 2001 113

 Adult Hip Pain

Palpation is usually performed with the pathology. Normal internal rotation is 35

patient supine. Palpate for crepitations by degrees and external rotation is 45
placing fingers over the femoral head, just degrees. The normal range for abduction is
lateral to the femoral artery 45 degrees to 50 degrees.
Routine blood below the inguinal liga- Manual Muscle Testing. Look for asym-
work helps ment. Roll the relaxed leg metry in muscle strength. The affected hip

determine the medially and laterally

(internal and external rota-
may be weaker. Test the following: flexors
(iliopsoas and rectus femoris), extensors (glu-
presence of a tion at zero degrees) to teus maximus and hamstrings), abductors
systemic detect any crepitations. (gluteus medius and gluteus minimus) and
Ask the patient to lie on adductors (adductor longus, magnus and bre-
illness that his/her side and palpate the vis, pectineus and gracilis).
may be greater trochanter and the Special Tests. These include the Thomas
underlying the trochanteric bursa. test, Ober’s test and the piriformis test.
Range of Motion. The • Thomas test. With the patient supine,
hip pain. normal range of motion place your hands under the lumbar
generally decreases with increasing age. spine. Obliterate the lumbar lordosis by
The following range of motion tests are either passively flexing one hip fully, or
useful in determining the presence of hip ask the patient to actively flex the hip

Prevacid is indicated for short-term treatment of reflux esophagitis and maintenance therapy of healed reflux esophagitis.
Most common side effects ( > 3%) in short-term studies are headache and diarrhea.
Doses higher than 30 mg per day should not be administered to patients with impaired hepatic function and the elderly.
*After the first day of therapy, significantly more patients (p < 0.05) on Prevacid 30 mg (n = 402) compared to omeprazole © Abbott Laboratories, Limited
Saint-Laurent, Québec H4S 1Z1
20 mg (n = 418) reported no daytime heartburn (48.7% vs. 37.6%) and nighttime heartburn (62% vs. 52%) in an 8-week Product Monograph available on request.
randomized, double-blind study in patients with endoscopically diagnosed reflux esophagitis.1
Consult Product Monograph for dosage recommendations.
 Adult Hip Pain

Table 2
SYNOVIAL FLUID ANALYSIS

Non-
Normal Inflammatory Inflammatory Infectious Hemorrhagic
Color Clear Clear Opaque Opaque Sanguinous
Viscosity High (due to High Low Low Variable
hyaluronate)
WBC/mm3 < 200 < 2000 > 2000 > 50,000 Variable
% PMN < 25% < 25% > 25% > 50% Variable
Examples Traumatic, OA, Seropositives, Septic arthritis Trauma
neuropathic, seronegatives, hemophilia
hypertrophic crystal
arthropathy arthropathies

and hold the leg firmly against the • Ober’s test. This test assesses the tensor
abdomen. Elevation of the opposite faciae latae (iliotibial band [IT]) for
thigh suggests a loss of extension in contracture. Lay the patient on his/her
that hip—a fixed flexion deformity. side with the lower leg flexed at the hip
Adult Hip Pain

Table 3
INTERPRETING PLAIN RADIOGRAPHS OF THE HIP

Bone Articular
Alignment Mineralization Cartilage Soft Tissue
What to • Fracture • Osteoporosis • Joint-space narrowing • Signs of effusion
look for
• Dislocation • Osteopenia • Osteophytes
• Angle of inclination • Avascular necrosis • Subchondral sclerosis
• Acetabular index • Subchondral cysts
• Femoral offset and • Subluxations
abductor lever arm
• The inter-teardrop line
• Teardrop sign
• Bryant's triangle and
Nelaton's line
• Shenton line

and knee for stability. Then passively experienced by the patient. In about
abduct and extend the patient’s upper 15% of the population, the sciatic
leg, with the knee straight or flexed to nerve, all or in part, passes through the
90 degrees. Slowly lower the upper piriformis muscle rather than below it.
limb; if a contracture is present, the leg It is these people who are more likely to
will remain abducted and not fall to the suffer from piriformis syndrome.5
table. It is important to extend the hip
slightly so that the IT Laboratory Investigations
band passes over the Not all lab investigations need to be done
Radiography is
greater trochanter. with every case of adult hip pain. Certain
the primary • Piriformis test. tests, such as rheumatoid factor and anti-
imaging tool for The patient is in the nuclear antibodies, are critical in diagnos-
side lying position. ing systemic autoimmune diseases. The
disease of the
The patient flexes the general lab work that can be done as part of
adult hip. test hip to 60 hip pain assessment includes blood work
degrees, with the and synovial fluid analysis.
knee flexed. The examiner stabilizes the Routine blood work helps in determining
hip with one hand and applies a down- the presence of a systemic illness that may be
ward pressure to the knee. If the piri- underlying the hip pain. More commonly, the
formis muscle is tight, pain is elicited in clinician looks for elevated white count for
that muscle. If the piriformis muscle is signs of infection; for example, in a septic
pinching the sciatic nerve, pain results hip. It also is useful to look for auto-antibod-
in the buttock, and sciatica may be ies if an autoimmune disease is suspected.

116 The Canadian Journal of Diagnosis / April 2001

 Adult Hip Pain

4
a
5
c 3
v
1
h 6

Figure 3. Bryant’s triangle (top) and Nelaton’s line (bottom).

a = The line that crosses the lateral and medial margins of the base of the
acetabulum.
c = Center of the hip.
h = Horizontal position of the hip center. This distance is from the distal concentration. The three most important
tip of the teardrop to a perpendicular line dropped from the hip center.
v = The vertical position of the hip center. This is the distance from the aspects of synovial fluid analysis are:
inter-teardrop line to the hip center.
1 = The inter-teardrop line. This is the horizontal line that joins the right 1) cell count and differential; 2) crystal
and left distal margins of the teardrop. The angle formed by line a inter- examination; and 3) culture and gram stain.
secting line 1 is is the angle of acetabular inclination.
2 = Midline. Table 2 illustrates the characteristic features
3 = Abductor lever arm.
4 = The approximate length of abductor muscles. of synovial fluid in various hip conditions.
5 = The body weight lever arm.
6 = Proximal femur length. This is the distance from the inter-teardrop
line to the lesser trochanter. Imaging of the Hip
There are many imaging modalities used to
Figure 2. Alignment measurements of the hip. view the hip. Frequently used imaging tools
include plain radiographs, bone scans, com-
puted tomography and magnetic resonance
The presence of rheumatoid factor (RF) can imaging (MRI). An approach to plain films
confirm a diagnosis of rheumatoid arthritis. will be discussed in detail and indications
Positive RF and anti-nuclear auto-antibodies for the other imaging tools will be
can also indicate the presence of lupus. addressed below.
Synovial fluid analysis provides a defin- Radiography is the primary imaging
itive diagnosis for infections and crystal tool for disease of the adult hip. Routine
arthropathies. Normally, the fluid is color- hip views on x-ray are anteroposterior (AP)
less (or straw-colored), with a protein con- of the pelvis, AP of the hip and lateral
centration that is one-third plasma protein films. Specialized views provide clearer

The Canadian Journal of Diagnosis / April 2001 117

Adult Hip Pain

Table 4
SELECTING IMAGING TOOLS FOR SPECIFIC HIP CONDITIONS

Arteriography
Condition Ultra-sound X-ray Bone Scan Tomography MRI CT & Venography
Fracture --- * * * * * ---
(stress) (stress) (pelvic) (pelvic)
Trauma --- * --- --- * * ---
Avascular --- * * --- * * *
Necrosis
Degenerative --- * --- --- --- --- ---
Arthritis
Tumors --- * * --- * * *
Soft Tissue * * --- --- --- * ---
Injury
Osteoporosis --- * * --- * --- ---

* = used for this hip condition

--- = not often used for this hip condition

images of certain aspects of the joint; for the AP pelvis that are important.
example, the frog-leg lateral gives better Abnormalities in these measurements would
view of the anterolateral femoral head and indicate fracture/dislocations that would not
is useful in suspected avascular necrosis have been identified on a gross examination
(AVN). Forty degrees cephalad AP is use- of the x-ray (Figure 2).3 An “absent
ful for subtle femoral neck fractures and teardrop” on x-ray is suspicious for metasta-
pubic fractures. tic disease, as with an absent (nonvisualized)
Generally, four pedicle on lumbar radiographs. Bryant’s tri-
MRI is the most areas need to be con- angle and Nelaton’s line are measurements
sensitive and sidered when viewing that can be applied to a true lateral x-ray of
specific modality a plain radiograph: the hip. A positive finding in each case is
alignment, bone min- suggestive of a dislocated hip (Figure 3).2
for detecting AVN eralization, articular Shenton’s line is a curved line that can
of the hip. cartilage and soft tis- be drawn on an AP pelvis radiograph from
sue. Table 3 indicates the medial edge of the femur, arcing
specific characteristics to look for when smoothly upwards and then down to meet
interpreting plain films of the hip. the inferior edge of the pubis. If this line is
Alignment. It is important to compare the discontinuous, a dislocation or fracture-
alignment of both sides. Asymmetry may dislocation exists.
suggest a fracture dislocation on the affected Bony Mineralization. Conditions that
side. There are alignment measurements on can be detected as changes in bony miner-

118 The Canadian Journal of Diagnosis / April 2001

 Adult Hip Pain

alization about the hip include inflamma- is one of the four cardinal features of OA
tory synovitis, osteoporosis and AVN. A on plain radiograph. The others are pres-
loss of the sharp cortical line of the epiph- ence of osteophytes, subchondral sclerosis
ysis is indicative of inflammatory synovi- and subchondral bone cysts.
tis, which is associated with rheumatic dis- Soft Tissues. Joint effusions at the hip
eases. In osteoporosis, there is a thinning of are difficult to diagnose due to the deeply
the cortex and loss of trabeculae. The term situated nature of the hip capsule and its
osteopenia describes local x-ray findings in relative nondistensibility. Three different
the absence of widespread bone density radiographic signs indicate fluid in the hip
changes. Note that osteopenia is not recog- joint:2
nizable on plain films until there has been 1. Lateral dislocation of the femoral
a 40% loss in bone mineral density.6 head. This is common in juvenile RA.
Plain film indicators of AVN are scat- It takes a large effusion to subluxate or
tered lucencies and areas of sclerosis. On dislocate the femoral head out of the
the frog-leg view, there can be breaks in acetabulum.
the cortex and the characteristic rim sign 2. Absence of a vacuum effect. This tech-
(a subcortical black lucent line). At a later nique can detect small effusions, and is
stage, collapse of the femoral head is accomplished by providing manual
observed. Although x-ray can show signs traction to the hip while the x-ray is
of AVN, MRI is the most sensitive tool in being taken. In a normal hip, traction
diagnosing this condition. creates a negative pressure in the joint
Cartilage. Articular cartilage is normal- and is observed as a radiolucent cres-
ly radiolucent and, therefore, an x-ray of a cent between the joint surfaces. This
normal hip joint shows a clear area of joint phenomenon does not occur when
space. Changes that show narrowed joint there is extra fluid in the joint.
space are indicative of a loss of articular 3. Demineralization of subchondral bone.
cartilage. Narrowed or loss of joint space Fading of the sharp subchondral white
Adult Hip Pain

line of the femoral head is indicative ing injuries.3,8 CT also is useful in charac-
of an inflammatory synovitis. The terizing calcifications seen by plain radi-
radiographic abnormality is caused by ography. This may include tumor matrix
demineralization, which results in a within bone or characterizing soft tissue
fuzzy, ill-defined outline and apparent calcification or ossification.
joint-space widening.
Calcification within soft tissue, on x- Magnetic Resonance Imaging
ray, also indicates abnormality in the hip MRI is the most sensitive and specific
joint. It may be seen in muscle, around the modality for detecting AVN of the hip.
joint capsule, and in bursa and tendons MRI is useful in detecting soft-tissue
(calcific bursitis or tendinitis). The find- lesions (including tumors), transient
ing of calcification is fairly nonspecific, osteoporosis, synovial pit, bone cysts and
but can suggest an underlying process like stress fractures. Compared to CT scan,
rheumatoid arthritis, systemic lupus ery- MRI is better for imaging medullary bone
thematosus, heterotropic ossification or a and soft tissues, and CT is better for imag-
response to past trauma. ing cortical bone.7
Of the various imaging tools, the plain
Nuclear Imaging (Bone Scan) radiograph is generally first used. If high-
In clinical situations where the physical er resolution scans are required, a CT scan
exam and x-ray do not help localize the is usually ordered before an MRI. There is
source of pain, bone scans are a useful no universal algorithm for how to select
guide in locating the probable area of imaging modalities. Table 4, however,
pathology. Nuclear imaging indicates outlines some clinical scenarios where
regions of increased metabolic activity certain images are more advantageous
(“hot spots”) by an increased uptake of a than others. Dx
radioactive tracer. It is useful in detecting
bony metastatic disease, AVN, arthritis References
and Paget’s disease. 1. Balderston R, Rothman R, Booth R, et al: The Hip. Lea &
Febiger, Philadelphia, 1992, pp. 234-6.
2. Fagerson T: The Hip Handbook. Butterworth-
Heinemann, Boston, 1998, pp. 119-24.
Computed Tomography 3. Callaghan JJ, Rosenberg AG, Rubash HE: The Adult Hip.
The most common use of computed Volume 1. Lippincott-Raven, Philadelphia, 1998, pp. 456-
67.
tomography (CT) is to image the hip joint 4. Roberts N, Williams R: Hip pain: Systematic approach to
diagnosis. Primary Care 1988;15:783-93.
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6. Hayes WC, Myers ER, Robinovitch SN, et al: Etiology and
and intra-articular osseous fragments are prevention of age-related hip fractures. Bone 1996;
80:77s-86s.
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120 The Canadian Journal of Diagnosis / August 2000