10/25 - Hip Intra Articular Pathology Flashcards
what are the 3 main intra-articular conditions seen
nonarthritic
- femoroacetabular impingement syndrome (FAIS)
- microinstability
osteoarthritis
what are the 3 roles of the labrum
- ext of acetabulum (enhanced joint stability)
- suction seal
- shock absorption
what is FAIS
misshapen joint leads to breakdown of intra-articular structures
what is a FAI-CAM lesion and what is another word for that
nonspherical femoral head (ie change in bone shape) rotating inside acetabulum
aka slipped capital femoral epiphysis
what population is FAI-CAM common in
peds
what is a slipped capital femoral epiphysis
aka FAI-CAM
extra bone growth at head/neck junction of femur
- can then impinge labrum there and then damage the labrum
what motion causes pain in CAM lesion and why
pain w deeper flexion or when leg crosses over body
- that’s when bony pathology engages w labrum
what is the alpha angle for a CAM deformity
> 60deg
what is FAI - PINCER
prominent anterolateral rim of acetabulum
- overgrowth of ant edge
- retroversion of acetabulum
describe the lateral center edge angle in normal hip vs dysplasia vs FAI Pincer
normal: 25-39deg
dysplasia <25deg
- under coverage
FAI pincer >40deg
- over coverage
what does a smaller lateral center edge angle indicate
smaller the angle, more shallow the acetabulum and greater risk of sublux/dislocation
what sign occurs when there is retroversion of the acetabulum
crossover sign
what is a crossover sign
there is extra coverage w ant portion of acetabulum crosses over posterior
normal: ant should be deeper, post have more coverage
what are 3 categories of FAIS pathomechanics which lead to symptomatic bony impingement
- abnormal bony morphology
- CAM, Pincer, mixed - susceptible populations and activities
- prior dysplasia, SCFE, LCP - abnormal hip/pelvic kinematics
- activity w inc hip flexion (squats, drop jumps)
what is a “C” sign indicative of
deep hip pain w intra-articular path
could also be microinstability (extra-articular)
what are 4 characteristics of pain in FAIS
- nonspecific groin pain can radiate to medial thigh
- “C” sign - deep inferior hip pain
- pain w twisting, pivoting (aka when hip in loaded position)
- pain w end-range flexion
what is a consideration of sx of FAIS
cumulative effect of abnormal wear
what are mechanical sx of FAIS
intermittent sharp pain
clicking, catching, locking
what is a common exam finding of FAIS
limited hip IR
- bilateral morphology
- motion may be symmetrical
if someone has a bony abnormality w FAIS, what will this likely look like upon examination
bilateral
- will usually have limitations w ROM (IR and possibly flex)
what ms weakness is common in FAIS
glut med and max weakness
what ms length may be limited in FAIS
hip flexor length
why would someone w FAIS have sx when hip flex is resisted
hip flex close to ant portion of capsule and labrum
- if damage/irritation to that portion of ant hip capsule, will have irritation w resisted hip flex
what are 4 intra-articular tests that are more provocative for FAIS
FABER***
Scour
FADIR
log roll
what are 3 intra-articular tests that test more micro-stability for FAIS
ABD-hyperext-ER (AB-HEER)
prone instability
HEER
what is the most specific special test for hip injuries? what is its sensitivity?
log roll
NOT sensitive
what does a log roll test assess
ant laxity of hip by amt of ER
what are 4 other reasons intra-articular tests may be positive other than FAIS
arthritis (ie OA)
synovitis
labral path
loose body
what is a good use of FADIR special test in terms of FAIS
screening tool
- sensitive but not specific
what are 3 possible locations of pain from a FABER test and what are their MOIs
- groin pain
- ms strain vs intra-articular (no sensitive to what intra path) - SIJ (PSIS region) pain
- sacroiliac disorder - post hip pain
- post hip impingement
what are 4 things that could cause the reproduced clicking in a scour test
psoas
labrum
arthritis
loose body
what does a resisted SLR test help differentiate between
hip flexor strength discomfort
vs
pain inside the joint (intra-articular)
why is the FADIR an appropriate test to use in FAIS
symptomatic position
why are intra-articular injections used
common dx use (intra vs extra)
- does it make sx better?
if helps - inflammation was in intra-articular joint, help to tolerate ADLs and PT
if does nothing - think extra-articular path
what are the 3 components of non-operative treatment of FAIS
- modify irritating positions and activity
- maximize mobility of joint
- hip/core/lumbopelvic strength
what are irritating positions/activities to modify in FAIS
limit ant pelvic tilt
- if tight hip flex and/or weak gluts
adjust seat hight to avoid inc hip flex
- deeper flex = more engagement
limit squat depth
limit incline or stair running
- inc hip flex
what directions should joint mobility be maximized in FAIS
into capsular restrictions post and inf
(if post capsular restriction, femur will shift away to ant)
how can PT prognosis change depending on how they present with FAIS
good PT prognosis:
- more capsular restriction, weakness, hip joint mobility limitations + bony abnormality
- modifiable factors w PT
poor PT prognosis:
- good strength, mobility + bony abnormality
- more likely to need surgery
what are 3 examples of interventions targetting hip / core / lumbopelvic strength in FAIS
hip ABD & rotator ms
plank variations
paloff press
hypermobility vs instability
hypermobility - greater than normal physiologic motion
instability - sx such as pain and/or apprehension are present
what is microinstability
capsuloligamentous laxity & clinical sx such as pain with/without apprehension
why is microinstability under-diagnosed
subtle
not as obvious as hip dysplasia or sublux
sx for microinstability are similar to hypomobility
what is location of most microinstability in the hip and why
usually anterior
- post portion of acetabulum has more bony congruence -> more susceptible ant dislocations
where and with what are hip microinstability sx present
sx w WBing ER and/or forceful ext
groin or deep joint pain “C-sign”
what are strength deficits seen in microinstability in hip and is this relevant
ABD and rotators
pretty much weak in everyone, isn’t helpful
what does ROM and ms lengths look like in hip microinstability
inc ER ROM
dec length of iliopsoas complex
- guarding to stabilize ant capsuloligamentous complex
what are 5 (+) special tests w hip microinstability
- log roll
- FABER
- AB-HEER
- prone instability
- HEER
if sx w hip flexion, what is it likely d/t and what is it likely not ? why?
hip flexors can be used to create dynamic stability
- likely d/t instability/microinstability
usually not d/t tendinitis
describe the use of AB-HEER in testing hip microinstability and why
provocative test
- basically putting head of femur as ant as possible to see if get sx
what are provocative tests looking to recreate sx of hip microinstability
AB-HEER
prone instability
HEER
describe hip microinstability cluster
95% chance of microinstability if 3 (+) tests:
- AB-HEER
- prone instability
- HEER
what are 4 interventions of microinstability in the hip
- education/activity modification
- exercises w mid-range initially
- exercise progressions
- caution w hip flexor stretching
what are activity modifications that should be made in microinstability
avoid end range ext & ER
avoid pivoting movements
modify running stride to dec ext
what are 2 interventions of initial exercises in mid-range for microinstability
prone manual resist IR/ER
- alternating isometrics
quadruped external perturbation
what is the goal of initial exercises in mid-range for microinstability
to create dynamic stability
how should mid-range exercises be progressed in microinstability
hip ABD and rotators
lumbopelvic stabilizers
why should there be caution w hip flexor stretching
spasm d/t overuse
avoid tension on ant capsuloligamentous structures
what may be a more preferred way to dec hip flexor irritation in microinstability other than stretching
create better strength w other ms
what is OA
disorder of synovial joint
- deterioration of articular cartilage & new bone formation
what are radiograph findings of OA
joint space narrowing
osteophyte formation
what are sx of hip OA
stiffness
pain
where will the pain be and what will cause the pain d/t hip OA
groin, ant, lat hip
inc w amb, stairs, squatting
is primary or secondary hip OA more common
secondary (80%)
primary vs secondary hip OA
primary
- no predisposing mechanical factor
secondary
- end result of dz process
what are 6 examples of secondary OA causes
osteonecrosis
legg-calve-perthes dz
dysplasia
slipped capital femoral epiphysis
congenital coxa vara / valga
hip fx
what is the general takehome for OA diagnostic cluster
stiffness in morning
stiffness gets better w movement
the more WB activity, sx get worse
capsular pattern of pain
what are the 2 main clinical presentations of hip OA
gluteal weakness
balance deficits
what are 2 functional tests for hip OA
6MWT
TUG
what are two components that interventions for hip OA are working to maximize and why
strength
- offload joint
- stabilizing structures can absorb force
mobility
- larger SA distribution
what are 6 interventions in management of hip OA
pt education
manual therapy
strengthening
flexibility
balance
aerobic exercise
what is included in the pt education for hip OA
avoid end-range positions, sitting cross-legged
what are 2 indications for manual therapy
low grade pain
high grade mobility restriction
what ms should be targeted for strengthening in hip OA and how
glut med
single leg tasks
- be cautious early on w WBing
what should be considered of aerobic exercises in hip OA
consider impact of forces & irritability
- dec pain
depending on severity of sx, think ab amt of WBing you want them to do (running vs biking)
what are balance progressions
DL -> SL
EO -> EC
static -> dynamic
what are 4 goals of PT management of hip OA
- maintain function
- relieve sx
- prevent deformity
- education (ie hip joint protection)
what are 6 treatment principles of hip OA
- inflammation (responsible for pain)
- joint alignment
- ROM
- ms length
- ms strength
- joint protection
what are 3 techniques to protect the hip joint from OA
- body wt reduction
- load carry modification
- AD use
what is an ideal way to modify the load carry in hip OA
posterior (backpack) better than a shoulder bag
- also balance sides out
THA cemented vs cementless
cemented - tolerate load right away
- potential for loosening d/t cement
cementless - WB restriction early on while bone heals
what is a precaution of trochanteric osteotomy if done during THA
no activve/resisted ABD
what are the 3 types of surgical approach to THA
ant
post
direct lateral
how are precautions related to the surgical approach of THA
avoiding motion that will load the area of the capsule that was cut
what are precautions of a post THA and why
avoid flex, ADD, IR
-> ERs divided
what is a complication from during a THA
femoral stem fx
what is the composition of a hybrid THA
acetabular component - cementless
femoral - cement
outcomes in cemented vs uncemented
no significant difference
what are precautions w an ant surgical approach and why
ext, ER
- minimal incision
what precautions are associated w a direct lateral surgical approach
none
low dislocation rate
ABD mechanism impacted
what are 3 early complications of THA
thromboembolic event (ie DVT)
infection
dislocation
what THA surgical approach is dislocation the most common in? when does this inc risk decline?
inc risk w post approach
pseudocapsule formed at 6mo
what is a late complication of THA
implant loosening
- or if person falls and damages the construct
what is involved in joint resurfacing and how is this different from THA
acetabular component replaced
cap over fem head
fem neck/shaft spared
when is joint resurfacing indicated over THA
joint resurfacing if arthritis only on one surface
replacing both if arthritis on both surfaces
when is joint resurfacing indicated over THA
joint resurfacing if arthritis only on one surface
replacing both if arthritis on both surfaces
what are determining factors of whether hip fx will be treated as ORIFs or closed
- location
- displacement
inc displacement -> inc likelihood to have ORIF
why is there an inc mortality risk with hip fx
d/t sequelae of care afterwards
- pressure sores
- wounds
- infections
- poor mobility post
what surgery is indicated fro a displaced femoral neck fx
hemiarthroplasty
what are 5 things examined in an acute care setting s/p hip fx
- DVT risk
- bed mobility
- WB status **
- transfer ability
- gait safety
what are 4 acute care interventions s/p hip fx
- ankle pumps, quad and glut sets
- plan room for transfers and gait
- appropriate assistance w gait
- AD choice
what makes basic LE isometrics important as an acute care intervention s/p hip fx
prevent DVTs
goals in acute care (3) vs sub acute (5) vs chronic (4) s/p hip fx
ACUTE
1. OOB
2. safe gait
3. d/c planning
SUB ACUTE
1. gait
2. transfer ability
3. endurance
4. ADL adaptations
5. plan to return home (if possible)
CHRONIC
1. strength
2. gait
3. balance
4. ADL issue
why is hip ABD strengthening a post-acute phase goal in s/p hip fx repair
depending on what was cut w surgery
what are 2 ms groups targeted w strength interventions s/p hip fx
knee ext
hip ABD (post-acute phase)
what is a test used to monitor fall risk in s/p hip fx
TUG
what are 3 physical performance tests used in s/p hip fx
- gait speed
- 30’’ STS test (post-acute)
- 6MWT (post-acute)
what are 2 factors that inc mortality and poorer outcomes w hip fx
inc age (>75yo)
co-morbidities (DM, chronic illness)
what does inc age (>75yo) inc the risk of s/p hip fx (3)
inc mortality & poorer outcome
inc time to dc
inc risk of subsequent fall
what is legg-calve-perthes disease
blood supply to head of femur disrupted
- subsequent fx w poor healing
what population is LCPD most common in
4-10yo boys (not exclusively)
what is the cause of LCPD
unknown
what does recovery look like in LCPD
recovery may take 2 yrs
- bone remodeling
how does LCPD present (2)
gradual onset of pain
short leg
why is it important to get imaging if suspicious of either LCPD or SCFE
sequelae of either of these are bad
- catching it is the biggest piece
- kids will heal easily and well
what is the population that slipped capital femoral epiphysis (SCFE) is most common in
adolescent males (8-15yo)
what inc the risk of SCFE
obesity
how does SCFE present (3)
knee or groin pain
short limb
may be bilateral
what is the main thing to look at to determine how likely hip dysplasia is
how shallow the depth of the acetabulum is
what are 3 factors that have an inc likelihood of developmental hip dysplasia
female > male
(+) family history
womb position (breech = inc risk)
what is the cause of developmental hip dysplasia
unknown
what is the typical age of dx for developmental hip dysplasia
variable age of dx
