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MSK 1 > 10/18 - Hip Extra Articular Pathology > Flashcards

10/18 - Hip Extra Articular Pathology Flashcards

1
Q

what do you think when you see a past med history of corticosteroids

A

greater risk of AVN

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2
Q

what questions ab pain do we want to ask

A

relationship to movement
location
nature
severity

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3
Q

what does a c-sign for pain often indicate

A

path inside the hip joint
- ant hip / groin

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4
Q

what structures does ant pain of hip implicate

A

lower abs
hip flexors
prox ADDs

bone - fem neck, pubic rami

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5
Q

what structures does lat pain of hip implicate

A

trochanteric region muscular attachments

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6
Q

what structures do med pain of hip implicate

A

ADD
pubic symphysis
athletic pubalgia

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7
Q

why is athletic pubalgia a challenging population to treat

A

often have multiple contributing components

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8
Q

what structures does post hip pain impliate

A

gluteal & hamstring musculature
lumbar/SIJ referral

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9
Q

what should you consider if you hear of shooting/burning pain sx

A

paresthesia - consider lumbosacral spine

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10
Q

what should you consider if someone c/o stiffness in the morning

A

OA

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11
Q

how does OA and stiffness change throughout the day

A

stiff in morning
start moving around, start to feel a little better
then as do more throughout the day, get sx again

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12
Q

what should you consider if pt has mechanical sx of catching, clicking, snapping, locking

A

intra-articular path

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13
Q

what are the snaps and pops felt in mechanical sx often d/t

A

as articular surfaces move over each other

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14
Q

if pt is having sx w ADLs (ie amb, stairs, sitting, transfers) what do you start thinking the cause may be

A

these ADLs require SLS
- greater demand on musculature, esp glut med

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15
Q

what ms lengths are assessed in a modified thomas test

A

iliopsoas
rectus fem
TFL/ITB

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16
Q

what is a (+) modified thomas test

A

(+) thigh > horizontal
(+) knee flex <90
(+) hip ABD

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17
Q

what ms lengths are assessed in an ober test

A

TFL/ITB

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18
Q

what is a (+) ober test

A

(+) hip remains ABD

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19
Q

what ms length is assessed in a straight leg raise (SLR)

A

hamstrings

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20
Q

what is a consideration of the SLR ms length test that might lead you to choose to assess hamstrings in the popliteal angle instead

A

SLR can irritate sciatic n.
- 90-90 position of popliteal angle protects sciatic nerve

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21
Q

what is a (+) SLR

A

(+) <70deg
30-70deg = radiculopathy

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22
Q

what ms length is assessed in the popliteal angle

A

hamstrings

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23
Q

what is a (+) popliteal angle

A

(+) knee flex >20deg

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24
Q

what does ms length does hip ABD @0 and @90deg assess

A

ADDs

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25
Q

what is a (+) hip ABD @0 and @90

A

(+) <40deg ABD
- in both positions

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26
Q

what are 2 ways to test ms strength/endurance

A

dynamometry
plank positions

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27
Q

what are 2 functional tests often used

A

6MWT
30’’ STS (from chair) Test

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28
Q

what is a consideration in how you administer a 6MWT

A

walk behind pt (avoid pacing them)

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29
Q

what are 4 nonarthritic hip patient reported outcome measures

A
  1. Hip And Groin Outcome Scale (HAGOS)
  2. International Hip Outcome Tool (iHOT-33)
  3. International Hip Outcome Tool (iHOT-12)
  4. Hip Outcome Score (HOS)
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30
Q

what is the population and conditions the HAGOS is best suited for

A

pop - young to middle-aged, physically active
conditions - intra & extra-articular

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31
Q

what is a key domain of the HAGOS that is not in other patient reported outcome measures

A

sport/recreation

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32
Q

what populations are the nonarthritic hip outcome measures best suited for

A

young and active

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33
Q

what is a hip OA patient reported outcome measure

A

western ontario and mcmaster university arthritis index (WOMAC)

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34
Q

what populations and conditions are the WOMAC best suited for

A

pop - elderly pts
conditions - hip and knee OA

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35
Q

what are the 3 subscales assessed in the WOMAC and how does this differ from the nonarthritic patient reported outcome measures used

A

subscales:
- pain
- stiffness
- physical function

more functional questions for elderly in WOMAC; in other measures - designed for younger pts w more Qs ab higher levels of activity

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36
Q

what is extra-articular hip path mostly associated with (in 1 word)

A

musculature

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37
Q

what are 4 types of hip tendinopathy that you can see

A

hip ABD
iliopsoas
glut med/min
hamstring

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38
Q

what are characteristics of the ADD ms that leads to path

A

poorly vascularized
richly innervated at transitional zone

very painful (nerves) but poor healing (vascularization)

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39
Q

where is the origin of the ADD fibers and what can this mean for path

A

medial fibers attach to symphyseal capsule, intra-articular disk
- can lead to osteitis pubis

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40
Q

what is the insertion of the ADD longus

A

mid 1/3 linea aspera

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41
Q

what is the insertion of the ADD magnus

A

ADD tubercle

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42
Q

what is the insertion of the gracilis

A

pes anserine

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43
Q

what is a common MOI for ADDs

A

eccentric load from hip ext to hip flex
- cutting and kicking

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44
Q

what sports are ADD injuries common in

A

soccer and ice hockey

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45
Q

what are 3 risk factors for ADD injuries

A

previous groin injury (2x)
lack of off-season conditioning
ms imbalance

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46
Q

what are 4 differential dx for ADD injuries

A

sports hernia / athletic pubalgia
osteitis pubis
inguinal hernia
referred pain from lumbar spine

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47
Q

what is a special test to test for ADD injury

A

ADD squeeze
- 0deg hip flex: in supine, have fist in between knees and squeeze (less reactive)

  • 45deg hip flex: in hooklying, have fist in between knees as they squeeze (should be more reactive)
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48
Q

what are 3 risk factors of ADD injuries that we manage

A

ADD to ABD strength imbalances
lower ab weakness
dec hip ROM

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49
Q

how is ADD and ABD strength imbalances a risk factor for ADD injuries

A

ADD strength <80% of ABD strength
- 17x more likely to sustain ADD injury

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50
Q

what are 2 concomitant injuries to consider with ADD injuries

A

FAIS
athletic pubalgia

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51
Q

what are interventions in the acute phase of ADD injury management (3)

A

gentle ROM (hip, knee)
lumbopelvic stabilization
AROM of adjacent / unaffected ms

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52
Q

what are 2 criteria to progress from acute to sub acute phase of ADD injury management

A
  1. tolerate ADLs w min sx
  2. tolerate PT activity w min sx
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53
Q

what are the general goals of each phase of ADD injury management

A

acute - protective
subacute - address impairments
late - progressive strength
return to sport

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54
Q

what are 3 interventions in the subacute phase of ADD injury management

A

flexibility of ADDs if low reactivity
joint mobs if capsular restriction
ADD/ABD strengthening

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55
Q

what is dec hip ROM correlated with

A

development of extra-articular groin pain

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56
Q

what is the goal of ADD/ABD strengthening in ADD injury management

A

add >80% of ABD

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57
Q

what are 5 interventions of the late phase of ADD injury management

A
  1. isometric -> concentric -> eccentric
  2. progress to full ROM in frontal plane
  3. include force (con/ecc) in ABD position
  4. lower ab exercises
  5. plank progressions/copenhagens
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58
Q

what are copenhagens exercises

A

plank position w focus on ABDs
- plank elevated up on a box

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59
Q

what are the pain parameters for returning to sport from a ADD injury

A

if >2/10 but <5/10, return w caution
if <2/10 ready to return
if >5/10 not ready for sport

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60
Q

what are 4 milestones to achieve to return to sport after an ADD injury

A

strength
endurance
motor control
sport-specific demands

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61
Q

what is the function of the iliopsoas

A

hip flex
erect posture
lumbar side bending

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62
Q

what is an associated structure w the iliopsoas which can get irritated

A

iliopsoas bursa

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63
Q

what are sx of an irritated iliopsoas

A

internal snapping hip
tenderness
“c sign”

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64
Q

what is a common MOI for iliopsoas irritation

A

overuse

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65
Q

what does iliopsoas irritation put you at risk for

A

labral tear

66
Q

what is important to be able to identify that it is the iliopsoas that is irritated

A

special testing
- helps to narrow down bc all these hip structures can get irritated

67
Q

what are reasons for a flexion contracture

A

ms restriction
- iliopsoas
- rectus fem
- TFL
ant capsuloligamentous contracture

68
Q

what is the consequence of a flexion contracture

A

load shifted to a region w thinner hyaline cartilage (ie changes how femur loading inside the acetabulum)

-> ant tilt of pelvis
-> inc lumbar lordosis

69
Q

what contracture can the Thomas assess

A

iliopsoas contracture

70
Q

what are interventions for iliopsoas contracture (4)

A
  1. hip flexor stretching
  2. soft tissue mob
  3. lumbopelvic strength
    - early phase, even if hip flexors reactive
  4. short lever hip flexor strength
    - supine > seated > standing
71
Q

what is the challenge w greater trochanteric pain syndrome and why does this not really matter

A

hard to determine w certainty the specific anatomic structure
- usually more global

might not matter what we do for treatment
- still addressing same ms imbalances

72
Q

what is located in the region that could be responsible for greater trochanteric pain syndrome

A

glut med tendon
glut min tendon
trochanteric bursa
prox ITB

73
Q

how does trochanteric bursitis present

A

aching pain lateral aspect of hip
tenderness at greater troch

74
Q

what is the pt pop and PMH that trochanteric bursitis more common in

A

40-60yo
hx of OA, RA

75
Q

what is the treatment for trochanteric bursitis

A

modalities for inflammation
address underlying cause
- our focus

76
Q

what are the underlying causes for trochanteric bursitis and what is most common

A

ITB
iliopsoas restriction
gluteal weakness

sees iliopsoas and gluteal a lot
- the glut weakness leads to the overuse component

77
Q

what is the rough anatomy of hip joint

A

hip rotator cuff
4 facets
tendon attachments
3 bursa

78
Q

what should be noted ab bursa vs tendon attachment anatomy and why is this significant

A

bursa tends to be bigger than tendon attachment
- larger area of pain = bursa

smaller area of pain = tendon attachments

79
Q

what is the most prevalent LE tendinopathy

A

glut med and glut min tendinopathy

80
Q

what pt pop is glut med and min tendionopathy really common in

A

women >40yo

81
Q

what is the pain presentation of glut med and min tendinopathy

A

lat hip pain (greater troch)
sidelying (sleep)
SL loading tasks
- walking, stairs, running

82
Q

why does a sidelying position cause pain for someone w glut min and med tendinopathy? how can we modify this?

A

ipsilateral side - loading joint
contralateral - putting top leg in ADD and stretching

add pillows b/w legs and lay on contralateral side

83
Q

what are 2 general terms for what lateral hip pain likely indicates

A

greater trochanteric pain syndrome
gluteal tendinopathy

84
Q

gluteal tendinopathy & inflammation?

A

limited inflammation

85
Q

what are irritating motions for gluteal tendinopathy

A

tensile load w/i Gmed/Gmin
- eccentric contractions

excessive compression
- positions of hip ADD
- lower neck angles (coxa vara)

high compression positions
- ADD (often shift wt in standing)

86
Q

what testing should be done for gluteal tendinopathy

A

tests that create tensile/compressive load across gluteal tendons
- assess ABD in ADD
- sustained SLS (pain provocation)

87
Q

what position should ADD be tested in

A

neutral or slight knee flex

88
Q

why can sustained SLS be a pain provocation test w gluteal tendinopathy

A

in SLS, slight ADD as body shifts so leg right underneath you

89
Q

what are special tests for greater trochanteric pain syndrome (extra-articular)

A

gluteal derotation
- take hip in flex and rotate to aggravate

SLS

90
Q

what are functional tests for greater trochanteric pain syndrome

A

pain over time
- SLS (low load)
- hopping (high load)

dynamic control - hip ADD
- walking
- step down
- SL squat
- hopping
- running

91
Q

what pt pop is a functional test looking at pain over time in SLS and hopping super appropriate for

A

runners and athletes

92
Q

what are interventions for greater trochanteric pain syndrome (5)

A

ther-ex
joint & soft tissue mobs
shockwave
corticosteroid injection
surgical procedures

93
Q

what are principles of exercises to implement w greater trochanteric pain syndrome

A

reduce compression (via dec ADD)
dec high tensile loads (relative rest)
graded tendon loading

94
Q

how should graded tendon loading be introduced for greater trochanteric pain syndrome management

A

isometrics
- analgesic effect
- dec pain by calming tendon down w repeated loading

low velocity high load

dynamic movement training

95
Q

what is a key ms group to be strengthening when managing greater trochanteric pain syndrome and why

A

hip ABD

stability of pelvis in frontal plane
dec contribution of ITB
- pelvic drop inc tension/load thru TFL/ITB & and inc activation

96
Q

how should hip ABD strengthening be introduced in managing greater trochanteric pain syndrome

A

phased approach
- OKC - low load from neutral to mid-range ABD (ie SL clamshell)
- OKC in positions of ADD (ie SL ABD)
- CKC w frontal plane motor control focus (ex: DL squat -> SL balance -> SL step down/squat)

97
Q

when should joint /soft tissue mobs be introduced in greater trochanteric pain syndrome management

A

as determined by assessment
- tightness doesn’t mean joint mobs

98
Q

what is a consideration if using corticosteroid injection for greater trochanteric pain syndrome management

A

inflammatory vs degenerative process

99
Q

why are surgical procedures not as common w greater trochanteric pain syndrome management

A

pain is more degenerative in nature, not really a rupture you can go back in and fix

100
Q

what surgical procedures are options for greater trochanteric pain syndrome

A

gluteal tendon repair
ITB release/lengthening
trochanteric osteomy

101
Q

what is the biggest thing to avoid w lateral hip pain

A

loaded hip ADD activity
- component of relative rest

102
Q

why is gradual loading an effective intervention for greater trochanteric pain syndrome

A

inc load to remodel tissue
- disorganized tissue
- loading helps to reorganize fibers and have tissue start to do its job again

103
Q

-itis vs -osis

A

itis = inflammatory management and/or injeciton

osis = chronic degenerative, no inflammatory

104
Q

in all likelihood, lateral hip pain is likely what type of pathology

A

-osis than -itis

105
Q

when do hamstrings compensate

A

if main hip ext (glut max) is weak

106
Q

what is a key characteristic of the hamstrings which contributes to its function

A

crosses both hip and knee joint
- can help w hip ext and knee flex

107
Q

what are the ms that make up the hamstring

A

biceps femoris
semitendinosus
semimembranosus

108
Q

what are characteristics of the biceps femoris that are important to consider with tendinopathy (3)

A

extensive distal insertion
dual innervation
MTJ spans entire length

109
Q

what sports/athletes are hamstring injuries common in and why

A

high speed sports:
- track
- football
- rugby

extreme stretch to region
- dancers
- soccer

110
Q

how are hamstring tendinopathies classified?

A

grade 1 - mild injury w most fibers intact
grade 2 - partial disruption
grade 3 - complete tear or avulsion

111
Q

describe the mechanisms of injury for a hamstring tendinopathy

A

sprinting/terminal swing
- preparing for contact
—» hamstrings are lengthening & decelerating the limb
—» greatest stretch at biceps femoris
- eccentric ability is critical for prevention/rehab

position of extreme stretch
- hip flex w knee ext (ie soccer, dancers)
- semimembranosus & prox free tendon

112
Q

list 6 potential differential dx for hamstring tendinopathy

A
  1. sciatic nerve irritation ***
  2. ischiofemoral impingement
  3. apophysitis or avulsion (adolescents)
  4. deep gluteal ms tear
  5. post pubic / ischial ramus stress fx
  6. rupture of prox hamstring tendon
113
Q

what dx is commonly associated w hamstring pathology and why

A

sciatic n. - will usually see irritation if hamstring pathology

sciatic nerve is close to hamstring attachment

114
Q

what is a likely differential dx for adolescents/younger pts presenting w hamstring path and why

A

apophysitis or avulsion
- in younger pts, ms often stronger than bones -> so avulse bone rather than tearing the ms

115
Q

how can the location of hamstring tendinopathy be determined and what is the relevance of location

A

location of max pain

the more prox to ischial tub = longer recovery
- more prox pain = more likely tendon involvement -> dec vascularization at that spot

length of area direct relationship w RTS

116
Q

re-injurying a previous sprain/strain is likely d/t what

A

under-doing rehab initially

117
Q

what are 6 intrinsic risk factors for hamstring tendinopathy

A

hx of prior strain
inc age
prior knee injury/surgery
strength deficits (hip & pelvis)
dec ms length - (+) quad, HS inconsistent evidence
limb stiffness

118
Q

what strength deficits are related to an inc risk of hamstring tendinopathy

A

glut max (synergistic function)
imbalance >20% b/w eccentric HS and concentric quads

119
Q

what position is a good position to MMT hamstrings, why and what population is this esp important in

A

15deg knee flex in prone
- hamstrings at greatest risk w hip flex almost knee ext, testing strength at vulnerable position

esp important in younger patients

120
Q

what are 3 extrinsic risk factors for hamstring tendinopathy and what is the significance of them

A
  1. environmental (rainfall & temp)
    - not significant
  2. sport-specific off-season training program
    - likely addressing intrinsic factors
  3. warm-up & stretching
    - ineffective at reducing injuries (may even inc injury)
121
Q

what is the traditional rehab program for hamstring tendinopathy? what is a better alternative to that program?

A

isolated hamstring strengthening and stretching

progressive agility and trunk stabilization

122
Q

what was the problem w the traditional rehab program for hamstring tendinopathies

A

very sagittal plane
- see recurrent strains and problems

123
Q

why is an agility and trunk stabilization rehab program for hamstring tendinopathies preferred over isolated strengthening/stretching and why

A

more prox stabilization bc more frontal and transverse plane motion
- just bc problem happened at hamstring, not necessarily causing the problem

124
Q

what is an example of an exercise that can be modified/progressed several different ways that is great for hamstring tendinopathies

A

bridges
- greater hamstring activation in 90deg knee flex
- can add progression of moving ball across body (internal perturbations) and maintain level pelvis w trunk stabilization

125
Q

return to sport for hamstring tendinopathies after traditional (isolated strengthening/stretching) vs progressive agility/trunk stability rehab

A

no statistical difference

progressive - quicker return to sport
- while not statistically significant, probably clinically significant
- also had significantly less re-strains/re-tears than the traditional group

126
Q

what are 4 things to reduce/avoid in the acute/protective phase of rehab for hamstring tendinopathies

A
  1. reduce pain/edema
  2. reduce load to injured tissue
  3. avoid crutches w NWB/TTWB
  4. avoid excessive stretching
127
Q

how long should load be reduced on injured tissue for hamstring tendinopathies

A

<5 days of relative immobilization

128
Q

why should you avoid crutches w NWB/TTWB in hamstring tendinopathies

A

flexed knee inc tensile load on hamstrings
- puts hamstrings in constant contracted position

129
Q

why should excessive stretching be avoided in the acute/protective phase in hamstring tendinopathies

A

may promote scar tissue and delay healing

130
Q

what are 3 exercises to use in the acute/protective phase of hamstring tendinopathies

A

hip/knee A-PROM in pain-free range
submax HS isometrics
low level lumbopelvic exercises (ie TrA)

131
Q

what are 3 mile stones to progress from the acute phase to subacute phase in hamstring tendinopathies

A

normal gait pattern
full hip and knee AROM/PROM
pain-free submax isometric HS

132
Q

what are 5 components for the subacute rehab phase in hamstring tendinopathies

A

restore strength, ms length
progress NM control
progress lumbopelvic strength/endurance
cardiovascular
eccentric focus (>/=50% of opposite HS strength)

133
Q

what are exercises to help restore strength and ms length in subacute phase of hamstring tendinopathies

A

mid range -> end ranges
isolated: hip ext; knee flex
multi joint: squat, STS, leg press

134
Q

how should cardiovascular interventions be implemented in the subacute phase of hamstring tendinopathies

A

bike -> elliptical -> slow jog**

** control stride length

135
Q

what are 4 milestones to progress from subacute to late phase in hamstring tendinopathies

A
  1. symmetrical HS flexibility
  2. 5/5 MMT; HHD involved HS >/= 90%
  3. (-) balance deficits - maintain SLS
  4. symmetrical jogging w/o sx
136
Q

what are 6 interventions in the late phase of hamstring tendinopathies

A
  1. progress demands needed for sport/work activity
  2. eccentric hamstring load in lengthened positions (ex: Nordic HS exercise)
  3. lumbopelvic stabilization in multiple planes
  4. agility
  5. plyometrics
  6. progress running speed
137
Q

what are 3 milestones for return to sport for hamstring tendinopathies and what is a consideration of these milestones

A
  1. normal/symmetrical ROM
  2. full/pain-free strength
    - short (90deg knee flex) & lengthened (15deg knee flex) positions
  3. no sx w plyometrics/agility (before, during, and after)
138
Q

what is the benefit to an eccentric focus in subacute phase of hamstring tendinopathies

A

ability of ms to resist length (eccentric contraction) beneficial to avoiding strain injuries

139
Q

what are 4 considerations for interventions of hamstring tendinopathies

A
  1. consider sport specific demands
  2. consider ROM the ms group is functioning
    - program should facilitate strength throughout entire ROM
  3. ms activation inc energy required to strain ms to failure
  4. focus on eccentric strength at end ranges of motion (most dangerous positions for the hamstrings)
140
Q

what are 4 clinical features of piriformis syndrome

A

buttock pain
pain w sitting (more prox)
tenderness near greater sciatic notch
pain w maneuvers that tension piriformis

141
Q

where should be palpated for piriformis syndrome

A

midway b/w sacrum & greater trochanter

142
Q

what is a functional test for piriformis syndrome and why

A

step down to assess pelvic stability

piriformis is ABD as hip moves into flex
- aggravated w up and down stairs

143
Q

what is a compensation made when doing a step down functional test for piriformis syndrome and why

A

excessive femoral ADD / IR
-common presentation w prox weakness -> then overloading other tissues -> piriformis pays the price for other ms not doing their job

144
Q

what are positions to avoid if someone has piriformis syndrome

A

crossed legged sitting
sidelying w top leg crossing midline
sitting on wallet

145
Q

what is a consideration of stretching and piriformis syndrome

A

assess ms length first to avoid any aggressive stretching

pain doesn’t necessarily mean it needs to be stretched - bc doesn’t mean that it is tight

146
Q

what are 5 interventions for piriformis syndrome

A

education
stretching if indicated by ms length
strengthening of glut med and max
lumbopelvic strength and endurance
corticosteroid and/or botox injections

147
Q

when are corticosteroids and botox each used in piriformis syndrome

A

corticosteroid - for piriformis if sciatic n. irritation
botox - w hypertonicity that doesn’t change w treatment

148
Q

why is lumbopelvic strength and endurance an intervention w piriformis syndrome

A

common concurrent presentation

149
Q

how does piriformis compensate for other weak ms

A

function as ABD and ext when glut med and max are tight

150
Q

what might make you think the piriformis is tight when it isn’t

A

overuse leads to hypertonicity
- makes you think its tight

151
Q

what is the ischiofemoral space, and how can this lead to impingement

A

<20mm b/w lesser trochanter and lateral ischium
- quadratus fem sits there

152
Q

how does ischiofemoral impingement pain present

A

deep buttock/gluteal pain
inc pain w hip ext

153
Q

what is getting compressed or irritated in ischiofemoral impingement

A

quadratus femoris

154
Q

where should you palpate if you suspect ischiofemoral impingement

A

the QF - between piriformis and hamstrings

155
Q

what are 2 special tests for ischiofemoral impingement

A

long stride test
sidelying IFI test

156
Q

what position creates the smallest ischiofemoral space

A

long stride (for back leg)

157
Q

what are 2 tests that assess both the piriformis and the sciatic nerve

A

active piriformis test
sitting piriformis test
combined

158
Q

what are 5 interventions for ischiofemoral impingement

A
  1. strengthening hip ABDs and ERs
  2. ms length
  3. soft tissue mobs
  4. joint mobs
  5. cortisone injection
159
Q

what is the goal of strengthening hip ABDs and ERs in ischiofemoral impingement and what are progressions

A

control valvus in CKC (position may dec speed)

DL squat -> SLS -> single leg squat -> multiplanar movement -> sport-specific activity

160
Q

what ms length is being assessed in IFI

A

ADDs - tightness may dec space

stretch in ext bias
- position lesser troch engages ischium

161
Q

what soft tissue should be mob in IFI

A

quad fem

162
Q

what joint mobs are done for IFI

A

promote hip ABD
- med/inferior w hip in ABD

MSK 1 (31 decks)

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