Common Disorders of the Hip Flashcards
Avascular Necrosis
What is the avascular necrosis?
areas of dead trabecular bone and bone marrow
- this goes to the subcondral plate
Avascular Necrosis
What are the subjective findings?
- pain @ groin (radiate to lateral hip, knee or ass)
- “throbbing and deep”
- pain is intermittent with gradual onset
- antalgic shift
Avascular Necrosis
What are common risk factors?
- cumulative corticosteroid total dose
- alcohol abuse
- systemic lupus
- sickle cell
- trauma
- cancer
Avascular Necrosis
What is the objective findings?
- painful ROM (with forced IR)
- pain with SLR
- antalgic gait
Avascular Necrosis
What are the special tests?
based on:
- subjective
- physical
- imaging
Avascular Necrosis
What is indicated in imaging?
- AP view of pelvis
- AP frog lateral radiographs
Avascular Necrosis
What is the best intervention?
Surgery is the best result
Avascular Necrosis
What is the prognosis?
Success related to the stage when care was started
Avascular Necrosis
What are the complications?
incomplete fx and superimposed degenertative arthritis
What is Legg-Calve-Perthes disease?
An idiopathic osteonecrosis of the head aged 4-10
- formed with less blood
- unilateral in 90% of pt
Legg-Calve-Perthes Disease
What is the assumed cause?
localized manifestation of generalized disorder of the epiphyseal cartilage that happens in the proximal femur
Legg-Calve-Perthes Disease
What population is most affected?
4x more common in boys
Legg-Calve-Perthes Disease
What are the subjective findings?
- vague ache in the groin that goes to medial thigh and inner knee
- early stage muscle spasm
Legg-Calve-Perthes Disease
What are the objective findings?
- limp (slight dragging)
- atrophy of quads
- may be small for their age
- (+) trendelenburg
- out-toeing
- decreased abduction and IR
- hip flexion contracture (0-30 deg)
Legg-Calve-Perthes Disease
What is the medical/imaging studies?
- AP and frog-lateral radiographs of pelvis
- normal early on
- progress to fragmentation
- irregularity
- eventual collapse of head
Legg-Calve-Perthes Disease
What are the interventions?
Less than 6 y/o and min capital femoral epiphysis involvement and normal ROM = intermittent physicals and radiographs every 2 months
More severe = operative or non-op
What is slipped capital femoral epiphysis?
Displacement of head thru the physis
- usually occurs during adolescent growth spurt
Slipped Capital Femoral Epiphysis
What is the position of the femoral head?
It stays in the acetabulum while the femoral neck is displaced anteriorly from the capital femoral epiphysis
What is the most common disorder of the hip in adolescents?
Slipped capital femoral epiphysis
Slipped Capital Femoral Epiphysis
What is the subjective findings?
- pain with activity
- hx of groin pain or medial thigh pain
- around 45% report knee or lower thigh for intial sx
- pain is dull and aching
- may be mild weakness in the leg
- may be no hx of trauma (can be so bad that theres pain turning in bed)
Slipped Capital Femoral Epiphysis
What are the objective findings?
- antalgic gait with limp (ofteen ER of involved foot)
- decreased ROM hip
- PROM will show ER of hip
- LE is 1-3 cm shorter
affected ROM - IR, abd and flexion
Slipped Capital Femoral Epiphysis
What does it cause?
The only peds disorder that causes greater loss of IR when the hip is moved into flexion
Slipped Capital Femoral Epiphysis
What are the predisposing factors?
- obesity
- male gender
- greater involvement with sport activities
Slipped Capital Femoral Epiphysis
What are the special tests?
IR with hip flexed to 90 deg
Slipped Capital Femoral Epiphysis
What are the medical/imaging studies?
AP and frog-lateral radiographs of the pelvis
Slipped Capital Femoral Epiphysis
What are the interventions?
- sx relief
- containment of femoral head
- ROM restoration
- surgical fixation
What is the description of stress fx on the femoral neck?
because of the accelerated bone remodeling from repeated stress
Stress fx
What is the population affeected with this?
In military recruits and athletes (runners especially)
Stress fx
In older populations, where is the fracture?
on the superior side of the neck
Stress fx
In younger populations, where is the fracture?
in the inferior side of the neck (compression-side fracture)
Stress fx
What is the subjective findings?
- suddeen hip pain (associated with revent changes in training or surface)
- pain the deep thigh (early sx)
- pain during WB or at extremes of hip motion = radiate to knees
- night pain happens with fx progression
Stress fx
What are the objective findings?
- physical exam is usually (-)
- may be empty end feel
- pain at extremities of hip ER or IR
- pain with resisted hip ER
Stress fx
What are the special tests?
Not one test
- resisted SLR = (+) pain @ thigh or groin
- patellar-pubic percussion tests can be +
- Flucrum test = (+) sharp pain and apprehension
Patellar-pubic
- sensitivity = 0.96
- specificity = 0.76
Stress fx
What are the medical/imaging studies?
- radiographs taken too soon only (+) in 20% of cases
- best dx/d with MRI
Stress fx
For tension side fractures, how are they treated?
treated surgically
Stress fx
If there is no fx line but sclerosis, what is the intervention?
modified best rest to NWB on crutches until no sx
- pain free = progress to wt-bearing
- significant PWB is pain free = cycling and swimming
- weekly radiograph until full w/o pain
Stress fx
If there is a fx but no displacement, what is the intervention?
intial period of best rest or complete NWB then WB as sx permit
What is a 2 joint hamstring strain?
the strain/rupture of 1 or more of the 3 hammies
- muscle tears are usually partial
- eccentric phase of the muscle usually are the time for tears
Hamstring Strain
What are the subjective findings?
- distinct MOI w/ pain right away during full stride running or while quick deceleration
- can hear a “pop”
- posterior thigh pain
- gets worse with knee flexion
Hamstring Strain
What is the objective findings?
- tenderness with PROM stretching of hammies
- tender to palpation
- Pain w/ resisted knee flexion (IR/ER to isolate)
Hamstring Strain
What is the medical studies needed?
Radiographs are rarely needed unless there is a question of a fracture or bony avulsion injury
Avulsion - tendon tear with bone
Hamstring Strain
What is grade 1 intervention?
continue with activities as much as possible
Hamstring strain
What is grade 2 intervention?
5-21 days of rehab or 3 weeks
Hamstring Strain
What is grade 3 intervention?
3-12 weeks of rehab
Hamstring Strain
What are the important components of hamstring interventions?
Be sure to emphasize eccentric loading of the hammies
be able to address any biomechanical factors:
- excessive anterior pelvic tilt
- SI or lumbar dysfunction
- leg length issues
- other factors
What is hip adductor tendinopathy?
most commonly proximal adductor pathology that comes from repetitive loading
Hip adductor tendinopathy
What are the muscles that are affected?
Gracilis
pectineus
adductor long / brev / magnus
Hip adductor tendinopathy
What is the most common muscle injured?
Adductor longus
Hip adductor tendinopathy
What is the primary movement that is associated with MOI?
Repetitive loading that has to do with twisting and turning
- possible muscle imbalance of the muscles stabilizing the hip joint and pubis
Hip adductor tendinopathy
What are the subjective findings?
- twinging or stabbing pain @ groin that starts and stops quickly
- edema or ecchymosis several days post injury
- sx are bad with running, directional changes, kicking, SL exercises, cutting and lunges
Hip adductor tendinopathy
What are the objective findings?
- pain w/ passive abduction
- manual resistance to hip adduction at different angles of hip flexion:
0 = gracilis
45 = add longus and brevis
90 = pectineus
Hip adductor tendinopathy
What are the interventions?
- RICE @ acute stage
- hip add isometrics and gentle stretching @ subacute
- Graded resistive with concentric/eccentric and PNF
Hip adductor tendinopathy
What is the typical prognosis?
Most recover fully or have min pain with high intensity activity only
OA
What are the subjective findings?
- insidious pain @ ass, groin, thigh or knee
- pain is dull ache to sharp
- gets worse with activity
- limping happens
- activity will increase pain that last hours
- hard time with stairs, putting on socks
OA
What are the objective findings?
- early signs: IR and abd or flexion
- pain @ end range
- pain with resisted hip flexion and adduction
OA
What are the special tests?
Scour (Rel = 0.87)
Faber (Sn = .41-.99 / Sp = .71-1.00)
OA
What are some interventions?
It’s a goddamn lot just be careful
- relieve sx
- decrease disability
- reduce progression
- education (modifications)
- modalities
- decreased WB activities (swimming or cycling)
- BW reduction
- walking stick (?)
- manual techniques
- passive stretches
- strengthening of hip and trunk stabilizers
OA
How is the hip unloaded with a walking stick?
Possibly reduce the hip load by 20-30%
What is a snapping hip?
snapping or popping sensation that happens when the tendons around the hip move over bony prominences
Snapping Hip
What is the internal etiology?
the iliopsoas is snapping over structures just deep to it
= stenosing tenosynovitis of the muscle insertion
What’s deep: femoral head, proximal lesser trochanter
Snapping hip
What is the external etiology?
snapping of the ITB or glute max over the greater trochanter
Snapping hip
What is the external etiology most common in?
in females with wide pelvis and prominent trochanters
Snapping hip
What is the intra-articular etiology?
- synovial chondromatosis
- loose bodies
- fracture fragments
- labral tears
Snapping hip
What are the subjective findings?
- feeling that snapping or poppping @ greater trochanter areea and happens when walking
- snapping from sublux of iliopsoas tendon = pain @ groin when hip extended from a flexed position (sit to stand)
- pain with snapping if trochanteric bursa is inflamed
Snapping hip
What are the objective findings?
- IT band sublux can be felt during standing with hip rotation while holding an adducted position
- snapping of iliopsoas tendon while hip extension from flexed position
Snapping hip
What are the special tests?
Ober and thomas
Snapping hip
If there is an imbalance of the TFL or iliopsoas is causing sx, what is the intervention focused on?
reconditioning and prevention thru:
- muscle length improvement
- correcting imbalances
Snapping hip
What is the typical prognosis?
If responding well to conservative management = no surgery (rarity)
What is the most common cause of lateral hip pain?
Trochanteric bursitis while OA is most common
Trochanteric bursitis
What are the subjective findings?
pain @ thigh, groin and glute
- especially when lying on the involved side
- pain could radiate down
- pain is bad when rising from a seat or recumbent position
- gets better after a few steps
- reoccurs after walking for an hour or so
Trochanteric bursitis
What are the objective findings?
- pain with palpation or with stretching of ITB
- resisted abd, extension or ER of hip = pain
- hip adductor tightness
Trochanteric bursitis
What are the special tests?
obers in general (both modified or normal)
Modified - knee straight
Trochanteric bursitis
What is the overall prognosis?
responds well to conservative measures
- possibly injection of a local anesthetic and corticosteroid prep into the greater trochanter
Trochanteric bursitis
What are the interventions?
- stretching the soft tissues of lateral thigh
- flexibility of ER, quads and hip flexors
- stronger hip abduction
- establishing muscular balance between hip adductors and abductors
- possibly orthotics if because of biomechanical fault
What is the etiology of labral tears?
- trauma
- FAI
- capsular laxity/hip hypermobility
- dysplasia
- degeneration
often goes undiagnosed during an extended time period
Labral tears
What are the subjective findings?
- anterior hip or groin pain
- feeling clicking, locking and giving away
Labral tears
What are the objective findings/special tests?
hip impingement test
Labral tears
What are the interventions?
Be able to trial conservative management and PT
- we want to limit pivoting motions
- strengthen inhibited muscles
- assess foot motion
Arthroscopic debridgement of tear
PT around 10-12 weeks
Labral tears
Why is it important to limit pivoting motions?
increase forces across the labrum
With manual treatments, what can we do?
- restore mobility and function
- decrease pain
- avoid surgery
What is FAI a precursor of?
For OA changes in the hip
- strongly associated with labral tears
FAI
What is the % growth rate of hip arthroscopy?
15% per year
FAI
What population is FAI prevelant in?
- more common in 20-40 y.o
- athletes make up 15%
FAI
What is the common MOI?
Repetitive end-range hyperextension or hyperflexion w/ abduction
Idiopathic tears from slipping and twisting injury
The sport will place the athlete at an increased risk for tears
What is FAI?
- the contact between femoral head-neck junction and the acetabular rim
- happens with combined movements
FAI
What is the combined movements that causes impingement?
Flexion and extension with adduction and either ER or IR
FAI
What does prolonged impingement lead to?
damage to the labrum and subchondral bone
FAI
What is it often misdiagnosed?
Snapping hip or psoas strain
What are the 2 primary causes of labral tears?
hip dysplasia and FAI
FAI
What is a clinical pearl?
if pt doesn’t complain of clicking, locking or catching is the best
- helps rule OUT labral tears compared to other hip pathology
FAI
What are the two type of impingements?
CAM and pincer
FAI
What is causes of CAM?
- aspherical femoral head
- bony prominence at anterolateral head-neck junction
- impinges @ rim of labrum
- leads to superior OA
FAI CAM
What are the provocative tests?
FADDIR
FAI
What are the causes of pincer impingement?
- over coverage of fem head by the acetabulum
- acetabulum impinges neck of femur
- leads to posterior-inferior or central OA
FAI CAM
Most prevalent population for CAM?
Young athletic males
FAI Pincer
Most prevalent population for pincer?
Middle aged women
FAI Pincer
What is the provocative test?
hip extension and ER
86% of FAI has what kind of impingement?
both CAM and Pincer
Limited in:
- IR and ER rotation
- flexion and adduction
Gradual and progressively become more limited
FAI
What are the common sx?
- C sign
- dull and achy pain
- pain is worse with long term sitting
- sometimes sharp catching pain with activity
- increased sx with hip flex, add and IR
- can limp
FAI
When the sx start, what does indicate?
damage to the cartilage or labrum
= disease progression with pain @ anterior groin area
FAI
What is the Warwick Agreement?
Answer is a picture
FAI
What is the most common complaint regarding activity?
- Heavy work (push/pull, climbing, carrying)
- Twisting
- squatting
- heavy-duty housework
- walking 15 min or more
…..
least common complaint: walking down steep hills
FAI
What are activities that should be avoided?
- end ranges
- treadmill running or narrow straight trail
- upright cycling
- sitting with hips flexed and neutral spine for long periods of time
FAI
What is the end range stretching position?
Flexion
adduction
internal rotation
OR FADDIR
FAI
What does running a straight line “encourage”?
internal rotation of LE
FAI
Why avoid upright cycling?
involves flexion and combination with hip IR
FAI
What are the non-surgical treatments?
- activity changes
- non-steroidal anti-inflammatory meds
- PT
FAI
What are the medications used for non-surgical treatment?
ibuprofen to help reduce pain and inflammation
FAI
What are the PT treatments?
exercises to improve ROM in the hip and strengthen the muscles around the joint
= stress relief on injured labrum or cartilage
FAI
What are the surgical treatments?
- will repair or clean out any damage to labrum and articular cartilage
- FAI = trimming of bony rim of acetabulum and shaving down the bump on the head
- severe cases = need open operation with bigger incisions
