Common conditions of the lower limb Flashcards
What is hip OA?
Degenerative condition that involves degeneration of the articular cartilage in the acetabulum and head of the femur
What demographic is hip OA?
After 40 years F
After 50 years M
What are the non-modifiable risk factors of hip OA?
Advanced age
Family history
History of acute joint injury &/or deformity
Labral tears, ligament laxity, fracture, cam deformity, joint dysplasia
What are the modifiable risk factors of hip OA?
Obesity
Biomechanical loading
Hormonal influences on inflammation
Repetitive joint overloading
Certain sports: high intensity, direct joint impact with other individuals
Occupational factors: physical labour
Occupation is non-modifiable for some patients
What are the pathophysiological factors of hip OA?
Biomechanical factors
Inflammatory factors
Enzymatic factors
What is the process of hip OA?
Cartilage develops small tears that grow larger with more stress > cartilage eventually fragments > chondrocytes attempt to keep up with cartilage loss but eventually cannot > underlying bone becomes exposed > bone rubs on bone resulting in reactive sclerosis and osteophyte formation
What are the clinical features of hip OA?
Gradual onset
May be bilateral
Pain is cardinal symptom
Aching and poorly located – groin, buttock, medial thigh, knee
Joint stiffness
Especially in morning (due to articular gelling)
Limited ROM
First movements lost are internal rotation and extension
+/- crepitus, visible deformity, signs of acute or subacute inflammation
+/- weakness, tenderness and spasm/contracture of gluteals, quadriceps; abnormal gait
What is the common aetiology of an SIJ dysfunction?
Degeneration
Mechanical disorders
Hyper or hypo mobility
Women following childbirth
Structural abnormalities
Post-traumatic
Severe trauma e.g. MVA, horse-riding accidents
Repetitive rotational stresses
What is the less common aetiology of SIJ dysfunction?
Inflammatory disorders e.g. ankylosing spondylitis
Infections
What are the factors that affect SIJ dysfunction?
Joint structure
Ligamentous support
Muscular influences
What are the clinical features of SIJ dysfunction?
Dull aching pain in buttock, groin or upper thigh
Can mimic pain from the lumbosacral spine or hip joint
+/- sensation of heaviness – usually no accompanying neuro symptoms
Can be unilateral or bilateral
Positive SIJ provocation tests
Imaging may demonstrate certain pathologies
How do hamstring injuries occur?
Hamstring injuries occur when they are exposed to large eccentric tensile forces during hip flexion and knee extension
They also play a role in foot and ankle biomechanics
What are the two classifications of hamstring injuries?
Type I: long head of biceps at musculotendinous junction
Type II: Semimembranosus occurring near ischial tuberosity
What are the risk factors of hamstring strain injuries?
Type I;
Sprinters (during eccentric activation in terminal swing phase)
Usually involve long head of biceps – often at musculotendinous junction
Type II;
Large amplitude, stretching movements
Involve the proximal free tendon of semimembranosus and occur close to ischial tuberosity
What are the risk factors for proximal hamstring tendinopathy?
Due to repetitive mechanical overload of tendon (long distance running, jumping, repeated hip flexion)
What are the clinical features of hamstring strains?
Type I and II: Sudden onset pain
Moderate to severe depending on grade
Disabling – difficulty walking, unable to run
Pain and weakness on active-resisted muscle testing
Reduced stretch
Marked focal tenderness with palpation
+/- local haematoma, bruising
Important to differentiate referred pain to hamstring region
What are the clinical features of proximal hamstring tendinopathy?
Insidious onset pain: lower gluteal region, posterior thigh
Aggravated through passive stretch, active resisted testing, direct palpation of ischial tuberosity
Lumbar flexion can also aggravate (causes compression of tendon against ischial tuberosity and ischiogluteal bursa)
What is greater trochanter pain syndrome?
A condition that encompasses the structures surrounding the greater trochanter of the hip: gluteus medius, gluteus minimus tendons, bursae: trochanteric, subgluteal, ITB
What are the risk factors for greater trochanter pain syndrome?
Compressive loading of lateral soft tissue
Repetitive adduction of hip
Unaccustomed or sustained weight-bearing
Menopause
Direct contusion injury to lateral hip
What is the pathophysiology of greater trochanter pain syndrome?
Abnormal hip biomechanics a key factor
Increased compressive forces between ITB and greater trochanter
Compression of underlying gluteal tendons and bursae
Tenocytes respond by secreting larger proteoglycans
Increased water content leads to thicker tendon
Appearance of cartilage-like cells change structure of tendon
Associated thickening of ITB and bursae
What are the clinical features of greater trochanter pain syndrome?
Diagnosis of exclusion
Must consider lumbar spine and hip joint pathology
Insidious onset that worsens
Pain and tenderness over greater trochanter
Aggravated by lying on affected side, single leg weight bearing
+/- pain and weakness with active-resisted testing
Trendelenburg: useful as a pain provocation test
FABER: often reproduces familiar pain but ROM is general preserved
Contrast this to hip OA: limited ROM with FABER
What is a labral tear?
A tear in the acetabulum of the hip
What are the demographics of a labral hip tear?
Any age
F>M 3:1
What does the fibrocartilaginous extension of the acetabular rim do?
Enhances hip joint stability
Shock absorption and pressure distribution
Assist with joint lubrication and chondral nutrition
What are the risk factors of hip labral tears?
Athletic populations
What is the aetiology of hip labral tears?
Trauma (usually compression with a degree of rotation; increased shear forces on outer joint margin)
FAI (esp cam impingement)
Capsular laxity/hypermobility
Degeneration
Developmental dysplasia of hip
What are the types of hip labral tears?
Type 1: detachment of the labrum from cartilage at acetabular rim
Type 2: tear within the labrum
What are the clinical features of a hip labral tear?
Deep pain (usually groin or anterior hip)
Some patients report pain in buttock
Can be sharp and catching on movement
+/- mechanical symptoms
Snapping clicking or locking
An unstable feeling in the hip like it is going to give way
What is femoroacetabular impingement?
Abnormal contact occurs between the femoral head and the acetabulum caused by deformities in the femoral head and/or acetabulum of the innominate
What does FAI predispose?
FAI is not itself a pathology but can predispose intra-articular damage (labral tears, hip OA, chondropathy)
What are the classifications of FAI?
CAM
PINCER
MIXED
What is a CAM lesion?
Extra bone at anterolateral femur
Leads to non-spherical femoral head
Motion (esp IR) forces cam lesion into acetabulum
More common in men
What is a PINCER lesion?
Abnormality of acetabulum, leading to over-coverage of femoral head
More common in women
What is a mixed lesion?
Presence of both cam and pincer
Most common
What is the aetiology of FAI?
Hip loading during adolescence (repetitive, torsional movements)
Causes over activity of epiphyseal plate between femoral head anc neck
Genetics
Slipped capital femoral epiphysis
What are the extrinsic factors causing FAI?
Types of sports played and movements involved
Volume of sport/activity
Footwear
Surface
What are the intrinsic factors causing FAI?
Reduced hip flexion, internal rotation, hip extension
Poor lumbopelvic control
Increased subtalar pronation
What are the symptoms of FAI?
Motion or position-related pain in hip or groin
Pain may also be felt in the back, buttock or thigh
+/- clicking, catching, locking, stiffness, restricted ROM or giving way
What are the clinical signs of FAI?
Positive FADIR: limited ROM +/- pain
What are the imaging processes of FAI?
Anterio-posterior radiographs of pelvis
Lateral femoral neck view of hip
What is groin pain?
Adductor
Iliopsoas
Inguinal
Pubic
Hip related
Other: orthopaedic, neurological, rheumatological, urological, gastrointestinal, dermatological, oncological and surgical
What sports are common for adductor pathologies?
AFL, soccer, callisthenics, ice hockey