5- Hip & Pelvis Flashcards
Name the muscles that attach to the ischial tuberosity.
- biceps femoris (long head)
- semimembranosus
- semitendinosus
- adductor magnusz
Name the muscles that originate off of the pubis.
- gracilis.
- adductor longus
- adductor magnus
- adductor brevis
Name the muscles attaching to the ASIS.
What are 4 physical exam maneuvers supportive of piriformis syndrome?
- FAIR maneuver (flexion, adduction, IR)
- Freiberg test: forceful internal rotation of the hip with the patient supine
- Pace test: reproduction of buttock pain with resisted hip abduction
- Beatty test: Reproduction of buttock pain with abduction of the thigh against gravity with patient in lateral decubitus position
28yo male running sprint then had sudden pain and discoloration. Initially he couldnβt walk, but he came to OPD walking. Diagnosis & Mechanism, Predisposing factors, Management. π
HAMSTRING STRAIN
- Hamstrings are placed under maximal stretch when the hip is forced into flexion and the knee into extension.
- Injuries typically occur during the eccentric phase of muscle contraction
- Myotendinous junction, most commonly in the lateral hamstrings.
- Commonly seen in track and gymnastics injuries
TRAINING ERRORS
- Exercise fatigue (Load Management)
- Muscle imbalance
- Poor flexibility (Hamstrings are placed under maximal stretch when the hip is forced into flexion and the knee into extension)
- Inadequate warm-up
- Poor conditioning
PRESENTATION & EXAMINATION
- Ecchymosis may descend to the thigh and present at the distal thigh or back of the knee or calf.
- Painful ROM
- Pain elicited in the ischial region with knee flexion
- Tenderness to palpation
IMAING
- X Ray avulsion fracture of the ischial tuberosity.
- Control risk factors: Training errors
- Protection: Activity restriction
- Optimal Loading:
- Gentle stretch
- ROM & aerobic exercises
- Concentric exercises initially
- Eccentric exercises when tolerated
- Neuromuscular control exercises
- Sport-specific exercises
- ICE & Modalities
HAMSTRING INJURY GRADING
Grade
- No damage
Grade I:
- Minimal to no loss of strength
- Strain only, rupture <5% of muscle length involved
Grade II:
- Moderate loss of hamstring strength
- Partial rupture 5%β50% of muscle length involved
Grade lll:
- Total loss of hamstring muscle function/strength, associated with large hematoma
- Complete hamstring muscle/tendon tear or avulsion fracture
- Often requires surgery
RETURN TO PLAY
Acute phase (1-5 Days) β Stretching
- Pain-free passive range of motion (PROM)
- Active assistive range of motion (AAROM)
Subacute phase (3-21+ Days ) β Aerobic & Iso
- Stationary bike
- Pain-free pool activities.
- Pain-free submaximal isometrics
Remodeling phase (1β6 weeks) β Loaded Mobility
- Prone eccentric exercises and apply moist heat
- Exercise prior to pelvic-tilt hamstring stretches.
Functional phase (2 weeks to 6 months) β Full Program
- Prone concentric exercises
- Eccentric hamstring exercises such as Nordic curls.
- Start pelvic-tilt hamstring stretching
- Sport-specific skills and drills (i.e. jog, sprint)
Return to play
- Pain fully resolves, there is full ROM, and full strength.
- 1-6 months just like any other sport injury.
Cuccurollo 4th Edition Chapter 4 MSK pg214-215
Lateral buttock, posterior hip, and proximal posterior thigh, as well as the SI region. Diagnosis, Mechanism, Management. π
PIRIFORMIS SYNDROME
- Piriformis muscle, an external hip rotator
CAUSES
- Poor body mechanics in a chronic condition
- Forceful hip internal rotation
PRESENTATION
- Pain exacerbated by walking up stairs
- Sciatica
- Tenderness
- FAIR test (Flexion, Adduction, and Internal Rotation)
IMAGING
- Rule out other pathologies
π‘ ER-POLICE-MS
- Education & Control Risk Factors: body mechanics
- Optimal loading: stretching
- Modalities: US
- Medications
- Oral NSAIDs
- Corticosteroid injections
Cuccurollo 4th Edition Chapter 4 MSK pg215-216
Groin pain after match. Diagnosis, Predisposing factors, Management. π
HIP ADDUCTOR STRAIN (GROIN STRAIN)
- Occurs during resisted forceful abduction of the hip during eccentric contraction.
- relative weakness and tightness of the adductor muscle groups
Presentation & Examination
- Pain in the adductors distal to their origin at the ramus or adductor tubercle
- Pain with resisted adduction and occasionally with hip flexion
Imaging
- Distinguish muscle strain from adductor avulsion fracture
Treatment
- Rest, ice, NSAIDs
- Stretching and strengthening (Copenhagen plank)
Cuccurollo 4th Edition Chapter 4 MSK pg217
Anterior superior hip pain. Diagnosis & Mechanism, Predisposing factors, Management.
HIP FLEXOR STRAIN
- Occur during flexion of fully extended hip such as in hurdling or kicking
- Eccentric overload of psoas muscle, just like hamstring and adductors
- Sprinting as well as in soccer, gymnastics, baseball, and football
Presentation
- Tenderness to palpation
- Pain with resisted hip flexion
- Pain with passive hip extension
Imaging
- Xray AP and frog leg lateral views are used to exclude bony injury
- Apophyseal avulsion fracture (ASIS, ischial tuberosity, AIIS, lesser trochanter, iliac crest)
Management
- Protected weight bearing, icing, and gentle active ROM as soon as possible
Return to Play
- Gait (aerobic) is nonantalgic and ROM is full and pain free (stretching)
- Closed kinetic chain β Open kinetic chain β Eccentric β Plyometric
Cuccurollo 4th Edition Chapter 4 MSK pg215
Anterior superior hip pain. Diagnosis, Complications and Management. π
ILIOPSOAS BURSITIS AND TENDONITIS
- Inflammation of the muscle tendon unit and bursa occur with overuse or trauma, causing muscle tightness and imbalance
Complication: internal snapping hip syndrome
Management:
- Xray rule out underlying bony pathology
- Stretching, and strengthening
- Ice
- NSAIDs
- Corticosteroid injection if conservative measures fail
List 3 Causes of internal hip snapping & Management. ππ Dr. Jamal & Dr. Abdulrazaq
INTERNAL SNAPPING
- Sports or activities that involve repeated hip flexion or external femoral rotation, such as ballet dancing, resistance training, squatting, rowing, running, soccer, and gymnastics.
Causes
- Iliopsoas tendonitis or bursitis: Overuse - trauma - muscle tightness or imbalance
- Cartilage Injury: Acetabular labral tear or loose body in the hip joint
- Bone ossification: Femoroacetabular impingement (FAI) Cam & Pincer
Examination
- Tenderness in anterior groin (iliopsoas, labral tear, or loose body)
- Extend, abduct, and externally rotate the affected hip (out hip circles)
ER - POLICE - MIS
- Control Risk Factors: Correction of biomechanics, Relative rest
- Optimal Loading
- Stretching
- ROM Exercises
- ICE
- Medications
- NSAIDs
- Injection
- Corticosteroid injection if conservative measures fail
Cuccurollo 4th Edition Chapter 4 MSK pg216-217
Braddom 6th Edition Chapter 36 LL Injuries pg730
Femoroacetabular impingement (FAI). How to manage? Complications? ππ Dr. Abdulrazaq
Impingement of the femoral head-neck junction against the acetabular rim.
Presentation
- Groin pain that is worse with activity.
- Worsen with hip flexion and internal rotation
- Pain with squatting or getting into a crouched position
- Positive (FADIR) impingement test β positive for acetabular labral tears
Complications
- Early hip OA
- Labral tears
Types
- Cam (asphericity of the femoral head)
- Pincer (increased coverage by the acetabulum)
ER - POLICE - MS
- Risk Factors / Protection: activity modification
- Optimal Loading
- Mobilization of the hip joint
- Improving soft tissue flexibility
- Strengthening of the hip muscles
- Improving proprioception
- Functional & dynamic control of the hip.
- Medications
- Oral: NSAIDs
- Intra-articular hip injections
- Surgery
- Advanced OA of the joint is a relative contraindication to hip preservation surgery, as preexisting advanced OA is the strongest predictor of poor outcome following FAI surgery
Braddom 6th Edition Chapter 36 LL Injuries pg730
List 2 Causes of external hip snapping & Management. ππ Dr. Jamal & Dr. Abdulrazaq
EXTERNAL HIP SNAPPING
Causes
- ITB or gluteus maximus snapping over the greater trochanter in any ROM
- Greater trochanter bursitis
Examination
- Tenderness over tensor fascia lata/ITB or gluteus maximus
- Internally and externally rotate the hip passively in the lateral decubitus position
Imaging
- Ultrasound
π‘ ER - POLICE - MS
- Control Risk Factors: Correction of biomechanics
- Optimal Loading
- Stretching
- ROM Exercises
- Relative rest
- ICE
- Medications
- NSAIDs
- Corticosteroid injection if conservative measures fail
Cuccurollo 4th Edition Chapter 4 MSK pg216-217
Braddom 6th Edition Chapter 36 LL Injuries pg730
Patients report night pain and are unable to lie on the affected side.
Diagnosis, Risk Factors and Management.π
GREATER TROCHANTERIC HIP BURSITIS
- Inflammation of the bursa located over the greater trochanter
- Located deep to the gluteus medius and gluteus minimus and TFL
- Causes external snapping hip syndrome.
Presentation
- Night pain and are unable to lie on the affected side
- Tenderness over the greater trochanter on palpation
- Snap may be palpable over the greater tubercle
- Pain during movement from full extension to flexion (rising from bed or chair)
- Aggravation of pain during ambulation, and an antalgic gait.
- Radiate down the lateral aspect of the leg and into the buttock (mimics sciatica)
Risk factors
- Hip OA
- Obesity
- Leg length discrepancy
- Direct trauma
- Overuse
- Herniated lumbar disc
- Hemiparesis.
Biomechanical Causes
- Altered gait mechanics
- Muscle imbalance
- Reduced flexibility
Imaging
- Xray to rule out bony pathology
Management
- Cane may be needed for support and stability
- ITB stretching
- Strengthening of the hip abductor muscles
- NSAIDs.
- Local corticosteroid injection for resistant cases
Cuccurollo 4th Edition Chapter 4 MSK pg217-218
PMR Secrets 3rd Edition Chapter 46 Hip pg368-369
What are the indications for hip arthroscopy? π
- Removal of loose bodies
- Repair of torn labrum
- Synovitis (the synovial lining of the hip joint is inflamed, causing disabling pain that may be relieved by a synovectomy)
- Palliative treatment to buy time for a future hip arthroplasty
PMR Secrets 3rd Edition Chapter 46 Hip pg369
OA Hip, risk factors, presentation & x-ray findings
Why should a patient with unilateral hip osteoarthritis carry a cane on the unaffected side? ππ
HIP OSTEOARTHRITIS
- Progressive breakdown of articular cartilage
- Proteoglycan degradation
- Disruption of the collagen network
- Joint destruction and loss of function
Risk Factors
- Sudden impact
- Direct trauma
- Overuse or repetitive motion injuries
- AVN corticosteroids
- Obesity and ligamentous injury
- Joint hypermobility and instability
- Abnormal distribution of weight
- Increased stress on the articular surfaces of the joint
- Cartilage injury and joint degeneration
Presentation
- Hip pain and stiffness
- Difficulty flexing forward to don/doff footware
- Hip pain with transferring from sit to stand
- Walking often increases the pain
- Loss of internal rotation > flexion & extension > contracture
- Antalgic gait and abductor lurch
Xray
- Joint space narrowing
- Marginal osteophytosis
- Subchondral sclerosis
- Subchondral cyst formation
Treatment
- Activity modification, physical therap
- NSAIDs
- Intraarticular injections with local anesthetic with or without corticosteroids
- Hip replacement surgery
Cane Opposite Side
- Limit pelvic drop on the side of the cane.
- Decrease the load on the affected hip
- Lower the load on gluteus medius-minimus
Braddom 6th Edition Chapter 36 LL Injuries pg731-732
PMR Secrets 3rd Edition Chapter 46 Hip pg368
Hip Dislocation: Direction & Mechanism, Complications & When can he bear weight. ππ
Posterior Hip Dislocation
- Most common (90%): Head of the femur is covered posteriorly by the capsule and not by bone.
- Mechanism: RTA when the hip is flexed, adducted, and medially rotated.
- Presentation
- Flexed, adducted, and internally rotated
- Leg appears shorter
- Inability to abduct the affected hip.
Anterior Hip Dislocation
- Mechanism: Forceful abduction with external rotation of the thigh
- Presentation: Flexed hip and knee, externally rotated
- Complication: Femoral nerve injury
Complications
- Sciatic nerve injury
- Posttraumatic OA
- Avascular Necrosis of head of femur
Orthopedic Emergency
- Nonβweight bearing is advised for 3 to 4 weeks
- Protected weight bearing for an additional 3 weeks.
- Progressive rehabilitation as tolerated 4-8 weeks
Cuccurollo 4th Edition Chapter 4 MSK pg218
Braddom 6th Edition Chapter 36 LL Injuries pg730-731
Management for intercarpsular or femoral neck fracture
Garden Classification of femoral neck fractures ππ
Positional advice for post op ππ EXAM & MOCK
How long should a patient maintain total hip precautions? π
What are some significant complications after total hip replacement ππ
Complications of surgical operation for hip fractures
π‘ Approximately 50% of patients return to their premorbid level of functioning
- Venous thrombosis
- Pulmonary embolism
- Heterotopic ossification (>50%)
Approaches
- Posterior THA Ω
Ψ§ ΩΩΨΉΨ― Ψ±ΩΩ ΨΉΩΩ Ψ±ΩΩ
- Higher risk for dislocation
- Avoid hip flexion over 90 degrees, hip adduction past midline, and extreme hip internal rotation
- High chair height is preferred in order to reduce hip flexion
- Anterior THA
- Lower risk for dislocation
- Avoidance of hip extension and external rotation
- Opposite of posterior THA precautions
Total Hip Precautions
- From 10-12 weeks (Allow pseudocapsule to form and soft tissue to heal)
- Can use abduction pillow for 6-12 weeks
- Crutch or walker for 6 weeks then cane (opposite side of the affected hip) for 6 weeks
- Monitor for neuropathy
- Incidence of dislocation is reduced by greater than 95% after 12 weeks.
Cuccurollo 4th Edition Chapter 4 MSK pg220
PMR Secrets 3rd Edition Chapter 46 Hip pg373
Intertrochanteric hip fracture. Presentation & Management
Intertrochanteric hip fracture
Complication
- Leg length discrepancy
- Nondisplaced, displaced two-part fractures, or unstable three-part fractures.
Management
- Compression screw
- Angle nail plate
Cuccurollo 4th Edition Chapter 4 MSK pg221-222
Subtrochenteric hip fracture. Presentation & Management
π‘ Hip pain with externally rotated and shortened limb
Subtrochanteric Hip Fracture
Challenges
- Very high mechanical stresses
- Most difficult to stabilize surgically
Management
- Blade plate and screws
- Intramedullary (IM) rod
Cuccurollo 4th Edition Chapter 4 MSK pg221-222
Endurance athletes with groin pain that is made worse with ADLs.
Spot diagnosis & Management. When can he return to play?
FEMORAL-NECK STRESS FRACTURES
π‘ Bone scans may be positive 2 to 8 days after onset of symptoms
Compression-type ΩΨ§ΩΩ Ω ΩΨ§ΩΩ
- Inferior to neck of femur
- More common & more stable
- Treated with bedrest & weight bearing as tolerated
- 6 to 8 weeks for a stress fracture to heal
- If compression-type fractures progress, they may require internal fixation
Transverse-type ΩΨͺΨΨ±Ω ΩΩ ΩΩ ΩΨ³Ψ§Ψ±
- Superior to neck of femur
- Unstable βtension side fracturesβ
- Treated with ORIF due to the high risk of displacement
- 10 to 12 weeks for healing
- Muscle strength and mobility take much longer.
Cuccurollo 4th Edition Chapter 4 MSK pg222
Conditions associated with gluteus medius weakness / positive Trendelenburg test ππ
- Radiculopathies
- Poliomyelitis
- Meningomyelocele
- Deconditioning
- Fractures of the greater trochanter
- Slipped capital femoral epiphysis (SCFE)
- Congenital hip dislocation
Cuccurollo 4th Edition Chapter 4 MSK pg212
Mention the 3 steps to measure Leg Length Discrepancy ππ Dr. Jamal
-
True Leg Length Discrepancy
- Anterior superior iliac spine (ASIS) to the medial malleolus.
-
Apparent Leg Length Discrepancy
- Pelvic obliquities or flexion or adduction deformity of the hip
- C knee is higher β tibia is longer
- D knee is further anterior β femur is longer
- Determine if the discrepancy is in the femur or the tibia
Cuccurollo 4th Edition Chapter 4 MSK pg213-214
Define degrees of weight-bearing ππ
PMR Secrets 3rd Edition Chapter 46 Hip pg371
