10/18 - Hip Extra Articular Pathology Flashcards
what do you think when you see a past med history of corticosteroids
greater risk of AVN
what questions ab pain do we want to ask
relationship to movement
location
nature
severity
what does a c-sign for pain often indicate
path inside the hip joint
- ant hip / groin
what structures does ant pain of hip implicate
lower abs
hip flexors
prox ADDs
bone - fem neck, pubic rami
what structures does lat pain of hip implicate
trochanteric region muscular attachments
what structures do med pain of hip implicate
ADD
pubic symphysis
athletic pubalgia
why is athletic pubalgia a challenging population to treat
often have multiple contributing components
what structures does post hip pain impliate
gluteal & hamstring musculature
lumbar/SIJ referral
what should you consider if you hear of shooting/burning pain sx
paresthesia - consider lumbosacral spine
what should you consider if someone c/o stiffness in the morning
OA
how does OA and stiffness change throughout the day
stiff in morning
start moving around, start to feel a little better
then as do more throughout the day, get sx again
what should you consider if pt has mechanical sx of catching, clicking, snapping, locking
intra-articular path
what are the snaps and pops felt in mechanical sx often d/t
as articular surfaces move over each other
if pt is having sx w ADLs (ie amb, stairs, sitting, transfers) what do you start thinking the cause may be
these ADLs require SLS
- greater demand on musculature, esp glut med
what ms lengths are assessed in a modified thomas test
iliopsoas
rectus fem
TFL/ITB
what is a (+) modified thomas test
(+) thigh > horizontal
(+) knee flex <90
(+) hip ABD
what ms lengths are assessed in an ober test
TFL/ITB
what is a (+) ober test
(+) hip remains ABD
what ms length is assessed in a straight leg raise (SLR)
hamstrings
what is a consideration of the SLR ms length test that might lead you to choose to assess hamstrings in the popliteal angle instead
SLR can irritate sciatic n.
- 90-90 position of popliteal angle protects sciatic nerve
what is a (+) SLR
(+) <70deg
30-70deg = radiculopathy
what ms length is assessed in the popliteal angle
hamstrings
what is a (+) popliteal angle
(+) knee flex >20deg
what does ms length does hip ABD @0 and @90deg assess
ADDs
what is a (+) hip ABD @0 and @90
(+) <40deg ABD
- in both positions
what are 2 ways to test ms strength/endurance
dynamometry
plank positions
what are 2 functional tests often used
6MWT
30’’ STS (from chair) Test
what is a consideration in how you administer a 6MWT
walk behind pt (avoid pacing them)
what are 4 nonarthritic hip patient reported outcome measures
- Hip And Groin Outcome Scale (HAGOS)
- International Hip Outcome Tool (iHOT-33)
- International Hip Outcome Tool (iHOT-12)
- Hip Outcome Score (HOS)
what is the population and conditions the HAGOS is best suited for
pop - young to middle-aged, physically active
conditions - intra & extra-articular
what is a key domain of the HAGOS that is not in other patient reported outcome measures
sport/recreation
what populations are the nonarthritic hip outcome measures best suited for
young and active
what is a hip OA patient reported outcome measure
western ontario and mcmaster university arthritis index (WOMAC)
what populations and conditions are the WOMAC best suited for
pop - elderly pts
conditions - hip and knee OA
what are the 3 subscales assessed in the WOMAC and how does this differ from the nonarthritic patient reported outcome measures used
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
what is extra-articular hip path mostly associated with (in 1 word)
musculature
what are 4 types of hip tendinopathy that you can see
hip ABD
iliopsoas
glut med/min
hamstring
what are characteristics of the ADD ms that leads to path
poorly vascularized
richly innervated at transitional zone
very painful (nerves) but poor healing (vascularization)
where is the origin of the ADD fibers and what can this mean for path
medial fibers attach to symphyseal capsule, intra-articular disk
- can lead to osteitis pubis
what is the insertion of the ADD longus
mid 1/3 linea aspera
what is the insertion of the ADD magnus
ADD tubercle
what is the insertion of the gracilis
pes anserine
what is a common MOI for ADDs
eccentric load from hip ext to hip flex
- cutting and kicking
what sports are ADD injuries common in
soccer and ice hockey
what are 3 risk factors for ADD injuries
previous groin injury (2x)
lack of off-season conditioning
ms imbalance
what are 4 differential dx for ADD injuries
sports hernia / athletic pubalgia
osteitis pubis
inguinal hernia
referred pain from lumbar spine
what is a special test to test for ADD injury
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)
what are 3 risk factors of ADD injuries that we manage
ADD to ABD strength imbalances
lower ab weakness
dec hip ROM
how is ADD and ABD strength imbalances a risk factor for ADD injuries
ADD strength <80% of ABD strength
- 17x more likely to sustain ADD injury
what are 2 concomitant injuries to consider with ADD injuries
FAIS
athletic pubalgia
what are interventions in the acute phase of ADD injury management (3)
gentle ROM (hip, knee)
lumbopelvic stabilization
AROM of adjacent / unaffected ms
what are 2 criteria to progress from acute to sub acute phase of ADD injury management
- tolerate ADLs w min sx
- tolerate PT activity w min sx
what are the general goals of each phase of ADD injury management
acute - protective
subacute - address impairments
late - progressive strength
return to sport
what are 3 interventions in the subacute phase of ADD injury management
flexibility of ADDs if low reactivity
joint mobs if capsular restriction
ADD/ABD strengthening
what is dec hip ROM correlated with
development of extra-articular groin pain
what is the goal of ADD/ABD strengthening in ADD injury management
add >80% of ABD
what are 5 interventions of the late phase of ADD injury management
- isometric -> concentric -> eccentric
- progress to full ROM in frontal plane
- include force (con/ecc) in ABD position
- lower ab exercises
- plank progressions/copenhagens
what are copenhagens exercises
plank position w focus on ABDs
- plank elevated up on a box
what are the pain parameters for returning to sport from a ADD injury
if >2/10 but <5/10, return w caution
if <2/10 ready to return
if >5/10 not ready for sport
what are 4 milestones to achieve to return to sport after an ADD injury
strength
endurance
motor control
sport-specific demands
what is the function of the iliopsoas
hip flex
erect posture
lumbar side bending
what is an associated structure w the iliopsoas which can get irritated
iliopsoas bursa
what are sx of an irritated iliopsoas
internal snapping hip
tenderness
“c sign”
what is a common MOI for iliopsoas irritation
overuse
what does iliopsoas irritation put you at risk for
labral tear
what is important to be able to identify that it is the iliopsoas that is irritated
special testing
- helps to narrow down bc all these hip structures can get irritated
what are reasons for a flexion contracture
ms restriction
- iliopsoas
- rectus fem
- TFL
ant capsuloligamentous contracture
what is the consequence of a flexion contracture
load shifted to a region w thinner hyaline cartilage (ie changes how femur loading inside the acetabulum)
-> ant tilt of pelvis
-> inc lumbar lordosis
what contracture can the Thomas assess
iliopsoas contracture
what are interventions for iliopsoas contracture (4)
- hip flexor stretching
- soft tissue mob
- lumbopelvic strength
- early phase, even if hip flexors reactive - short lever hip flexor strength
- supine > seated > standing
what is the challenge w greater trochanteric pain syndrome and why does this not really matter
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
what is located in the region that could be responsible for greater trochanteric pain syndrome
glut med tendon
glut min tendon
trochanteric bursa
prox ITB
how does trochanteric bursitis present
aching pain lateral aspect of hip
tenderness at greater troch
what is the pt pop and PMH that trochanteric bursitis more common in
40-60yo
hx of OA, RA
what is the treatment for trochanteric bursitis
modalities for inflammation
address underlying cause
- our focus
what are the underlying causes for trochanteric bursitis and what is most common
ITB
iliopsoas restriction
gluteal weakness
sees iliopsoas and gluteal a lot
- the glut weakness leads to the overuse component
what is the rough anatomy of hip joint
hip rotator cuff
4 facets
tendon attachments
3 bursa
what should be noted ab bursa vs tendon attachment anatomy and why is this significant
bursa tends to be bigger than tendon attachment
- larger area of pain = bursa
smaller area of pain = tendon attachments
what is the most prevalent LE tendinopathy
glut med and glut min tendinopathy
what pt pop is glut med and min tendionopathy really common in
women >40yo
what is the pain presentation of glut med and min tendinopathy
lat hip pain (greater troch)
sidelying (sleep)
SL loading tasks
- walking, stairs, running
why does a sidelying position cause pain for someone w glut min and med tendinopathy? how can we modify this?
ipsilateral side - loading joint
contralateral - putting top leg in ADD and stretching
add pillows b/w legs and lay on contralateral side
what are 2 general terms for what lateral hip pain likely indicates
greater trochanteric pain syndrome
gluteal tendinopathy
gluteal tendinopathy & inflammation?
limited inflammation
what are irritating motions for gluteal tendinopathy
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)
what testing should be done for gluteal tendinopathy
tests that create tensile/compressive load across gluteal tendons
- assess ABD in ADD
- sustained SLS (pain provocation)
what position should ADD be tested in
neutral or slight knee flex
why can sustained SLS be a pain provocation test w gluteal tendinopathy
in SLS, slight ADD as body shifts so leg right underneath you
what are special tests for greater trochanteric pain syndrome (extra-articular)
gluteal derotation
- take hip in flex and rotate to aggravate
SLS
what are functional tests for greater trochanteric pain syndrome
pain over time
- SLS (low load)
- hopping (high load)
dynamic control - hip ADD
- walking
- step down
- SL squat
- hopping
- running
what pt pop is a functional test looking at pain over time in SLS and hopping super appropriate for
runners and athletes
what are interventions for greater trochanteric pain syndrome (5)
ther-ex
joint & soft tissue mobs
shockwave
corticosteroid injection
surgical procedures
what are principles of exercises to implement w greater trochanteric pain syndrome
reduce compression (via dec ADD)
dec high tensile loads (relative rest)
graded tendon loading
how should graded tendon loading be introduced for greater trochanteric pain syndrome management
isometrics
- analgesic effect
- dec pain by calming tendon down w repeated loading
low velocity high load
dynamic movement training
what is a key ms group to be strengthening when managing greater trochanteric pain syndrome and why
hip ABD
stability of pelvis in frontal plane
dec contribution of ITB
- pelvic drop inc tension/load thru TFL/ITB & and inc activation
how should hip ABD strengthening be introduced in managing greater trochanteric pain syndrome
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)
when should joint /soft tissue mobs be introduced in greater trochanteric pain syndrome management
as determined by assessment
- tightness doesn’t mean joint mobs
what is a consideration if using corticosteroid injection for greater trochanteric pain syndrome management
inflammatory vs degenerative process
why are surgical procedures not as common w greater trochanteric pain syndrome management
pain is more degenerative in nature, not really a rupture you can go back in and fix
what surgical procedures are options for greater trochanteric pain syndrome
gluteal tendon repair
ITB release/lengthening
trochanteric osteomy
what is the biggest thing to avoid w lateral hip pain
loaded hip ADD activity
- component of relative rest
why is gradual loading an effective intervention for greater trochanteric pain syndrome
inc load to remodel tissue
- disorganized tissue
- loading helps to reorganize fibers and have tissue start to do its job again
-itis vs -osis
itis = inflammatory management and/or injeciton
osis = chronic degenerative, no inflammatory
in all likelihood, lateral hip pain is likely what type of pathology
-osis than -itis
when do hamstrings compensate
if main hip ext (glut max) is weak
what is a key characteristic of the hamstrings which contributes to its function
crosses both hip and knee joint
- can help w hip ext and knee flex
what are the ms that make up the hamstring
biceps femoris
semitendinosus
semimembranosus
what are characteristics of the biceps femoris that are important to consider with tendinopathy (3)
extensive distal insertion
dual innervation
MTJ spans entire length
what sports/athletes are hamstring injuries common in and why
high speed sports:
- track
- football
- rugby
extreme stretch to region
- dancers
- soccer
how are hamstring tendinopathies classified?
grade 1 - mild injury w most fibers intact
grade 2 - partial disruption
grade 3 - complete tear or avulsion
describe the mechanisms of injury for a hamstring tendinopathy
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
list 6 potential differential dx for hamstring tendinopathy
- sciatic nerve irritation ***
- ischiofemoral impingement
- apophysitis or avulsion (adolescents)
- deep gluteal ms tear
- post pubic / ischial ramus stress fx
- rupture of prox hamstring tendon
what dx is commonly associated w hamstring pathology and why
sciatic n. - will usually see irritation if hamstring pathology
sciatic nerve is close to hamstring attachment
what is a likely differential dx for adolescents/younger pts presenting w hamstring path and why
apophysitis or avulsion
- in younger pts, ms often stronger than bones -> so avulse bone rather than tearing the ms
how can the location of hamstring tendinopathy be determined and what is the relevance of location
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
re-injurying a previous sprain/strain is likely d/t what
under-doing rehab initially
what are 6 intrinsic risk factors for hamstring tendinopathy
hx of prior strain
inc age
prior knee injury/surgery
strength deficits (hip & pelvis)
dec ms length - (+) quad, HS inconsistent evidence
limb stiffness
what strength deficits are related to an inc risk of hamstring tendinopathy
glut max (synergistic function)
imbalance >20% b/w eccentric HS and concentric quads
what position is a good position to MMT hamstrings, why and what population is this esp important in
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
what are 3 extrinsic risk factors for hamstring tendinopathy and what is the significance of them
- environmental (rainfall & temp)
- not significant - sport-specific off-season training program
- likely addressing intrinsic factors - warm-up & stretching
- ineffective at reducing injuries (may even inc injury)
what is the traditional rehab program for hamstring tendinopathy? what is a better alternative to that program?
isolated hamstring strengthening and stretching
progressive agility and trunk stabilization
what was the problem w the traditional rehab program for hamstring tendinopathies
very sagittal plane
- see recurrent strains and problems
why is an agility and trunk stabilization rehab program for hamstring tendinopathies preferred over isolated strengthening/stretching and why
more prox stabilization bc more frontal and transverse plane motion
- just bc problem happened at hamstring, not necessarily causing the problem
what is an example of an exercise that can be modified/progressed several different ways that is great for hamstring tendinopathies
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
return to sport for hamstring tendinopathies after traditional (isolated strengthening/stretching) vs progressive agility/trunk stability rehab
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
what are 4 things to reduce/avoid in the acute/protective phase of rehab for hamstring tendinopathies
- reduce pain/edema
- reduce load to injured tissue
- avoid crutches w NWB/TTWB
- avoid excessive stretching
how long should load be reduced on injured tissue for hamstring tendinopathies
<5 days of relative immobilization
why should you avoid crutches w NWB/TTWB in hamstring tendinopathies
flexed knee inc tensile load on hamstrings
- puts hamstrings in constant contracted position
why should excessive stretching be avoided in the acute/protective phase in hamstring tendinopathies
may promote scar tissue and delay healing
what are 3 exercises to use in the acute/protective phase of hamstring tendinopathies
hip/knee A-PROM in pain-free range
submax HS isometrics
low level lumbopelvic exercises (ie TrA)
what are 3 mile stones to progress from the acute phase to subacute phase in hamstring tendinopathies
normal gait pattern
full hip and knee AROM/PROM
pain-free submax isometric HS
what are 5 components for the subacute rehab phase in hamstring tendinopathies
restore strength, ms length
progress NM control
progress lumbopelvic strength/endurance
cardiovascular
eccentric focus (>/=50% of opposite HS strength)
what are exercises to help restore strength and ms length in subacute phase of hamstring tendinopathies
mid range -> end ranges
isolated: hip ext; knee flex
multi joint: squat, STS, leg press
how should cardiovascular interventions be implemented in the subacute phase of hamstring tendinopathies
bike -> elliptical -> slow jog**
** control stride length
what are 4 milestones to progress from subacute to late phase in hamstring tendinopathies
- symmetrical HS flexibility
- 5/5 MMT; HHD involved HS >/= 90%
- (-) balance deficits - maintain SLS
- symmetrical jogging w/o sx
what are 6 interventions in the late phase of hamstring tendinopathies
- progress demands needed for sport/work activity
- eccentric hamstring load in lengthened positions (ex: Nordic HS exercise)
- lumbopelvic stabilization in multiple planes
- agility
- plyometrics
- progress running speed
what are 3 milestones for return to sport for hamstring tendinopathies and what is a consideration of these milestones
- normal/symmetrical ROM
- full/pain-free strength
- short (90deg knee flex) & lengthened (15deg knee flex) positions - no sx w plyometrics/agility (before, during, and after)
what is the benefit to an eccentric focus in subacute phase of hamstring tendinopathies
ability of ms to resist length (eccentric contraction) beneficial to avoiding strain injuries
what are 4 considerations for interventions of hamstring tendinopathies
- consider sport specific demands
- consider ROM the ms group is functioning
- program should facilitate strength throughout entire ROM - ms activation inc energy required to strain ms to failure
- focus on eccentric strength at end ranges of motion (most dangerous positions for the hamstrings)
what are 4 clinical features of piriformis syndrome
buttock pain
pain w sitting (more prox)
tenderness near greater sciatic notch
pain w maneuvers that tension piriformis
where should be palpated for piriformis syndrome
midway b/w sacrum & greater trochanter
what is a functional test for piriformis syndrome and why
step down to assess pelvic stability
piriformis is ABD as hip moves into flex
- aggravated w up and down stairs
what is a compensation made when doing a step down functional test for piriformis syndrome and why
excessive femoral ADD / IR
-common presentation w prox weakness -> then overloading other tissues -> piriformis pays the price for other ms not doing their job
what are positions to avoid if someone has piriformis syndrome
crossed legged sitting
sidelying w top leg crossing midline
sitting on wallet
what is a consideration of stretching and piriformis syndrome
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
what are 5 interventions for piriformis syndrome
education
stretching if indicated by ms length
strengthening of glut med and max
lumbopelvic strength and endurance
corticosteroid and/or botox injections
when are corticosteroids and botox each used in piriformis syndrome
corticosteroid - for piriformis if sciatic n. irritation
botox - w hypertonicity that doesn’t change w treatment
why is lumbopelvic strength and endurance an intervention w piriformis syndrome
common concurrent presentation
how does piriformis compensate for other weak ms
function as ABD and ext when glut med and max are tight
what might make you think the piriformis is tight when it isn’t
overuse leads to hypertonicity
- makes you think its tight
what is the ischiofemoral space, and how can this lead to impingement
<20mm b/w lesser trochanter and lateral ischium
- quadratus fem sits there
how does ischiofemoral impingement pain present
deep buttock/gluteal pain
inc pain w hip ext
what is getting compressed or irritated in ischiofemoral impingement
quadratus femoris
where should you palpate if you suspect ischiofemoral impingement
the QF - between piriformis and hamstrings
what are 2 special tests for ischiofemoral impingement
long stride test
sidelying IFI test
what position creates the smallest ischiofemoral space
long stride (for back leg)
what are 2 tests that assess both the piriformis and the sciatic nerve
active piriformis test
sitting piriformis test
combined
what are 5 interventions for ischiofemoral impingement
- strengthening hip ABDs and ERs
- ms length
- soft tissue mobs
- joint mobs
- cortisone injection
what is the goal of strengthening hip ABDs and ERs in ischiofemoral impingement and what are progressions
control valvus in CKC (position may dec speed)
DL squat -> SLS -> single leg squat -> multiplanar movement -> sport-specific activity
what ms length is being assessed in IFI
ADDs - tightness may dec space
stretch in ext bias
- position lesser troch engages ischium
what soft tissue should be mob in IFI
quad fem
what joint mobs are done for IFI
promote hip ABD
- med/inferior w hip in ABD
