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MSPT I > COMPS:HIP > Flashcards

COMPS:HIP Flashcards

1
Q

Pt Reported Outcomes:

Lower Extremity Functional Scale

LEFS

A
  • GENERAL LE measure—–activity based
    • ​**no s/s or impairments
  • scores range 0-80 w/ HIGHER SCORES==BETTER FUNCTION
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2
Q

Pt Reported Outcomes

Western Ontario and MacMaster Universities Osteoarthritis Index

WOMAC

A
  • commonly used in OA outcomes research and care
    • ​HIP and KNEE
  • Subscales
    • Pain 0-20
    • Stiffness 0-8
    • Phys Function 0-68
  • HIGHER scores on WOMAC === WORSE pain, stiff, functional limits
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3
Q

Pt Reported Outcomes

Hip Injury and OA Scale

HOOS

A
  • 5 Subscales:
    • Pain: P 0-40
      • Symptoms: S 0-20
      • Act limits Daily Living: ADL 0-68
      • Function in sport and rec.: SP 0-16
      • Hip related QOL: QoL 0-16
  • LOWER scores on HOOS === WORSE pain, stiff, functional limits
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4
Q

Pt Reported Outcomes:

Hip Outcome Score

HOS

A
  • ADL and Sports Scales
  • Scores range 0-100 w/ HIGHER SCORES ===BETTER function
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5
Q

Pt Reported Outcomes

Harris Hip Function Scale

A
  • popular
  • Good for pre/post op comparisons
  • Emphasizes Pain and Function
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6
Q

Minimal ROM req’s for Basic Function:

Gait, Sitting, Bed mobility, stairs

A
  • 90deg FLEX
    • Normal==120
  • 20deg ABD
    • Normal==45
  • 0deg IR
    • Normal==45
  • 20deg ER
    • Normal==45-60
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7
Q

Problem Solve:

  • Pt recently had hip spica cast removed as he was recovering from a femoral fx. Current ROM:
    • Flexion=105
    • ABD= 20
    • IR and ER= 5
      *
A
  • When performing PROM ex’s, which motion should be emphasized for your pt if the goal is to facilitate basic function???
    • ER
  • As long as FLEX reamins limtd to 105, what functional acts will be difficult?
    • compensation w/ trunk flexion
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8
Q

Unloading of Hip using ADs

A
  • Walker OR 2 Ax Crutches—-WB restrictions!!!
    • ​unloads up to 100% BW
    • GOOD/THE choice for NWB, TTWB, PWB up to 50% BW
  • One crutch unloads up to 50% of BW
    • GOOD choice for PWB IF cleared for 50% or more BW
  • Cane unloads up to 40% BW
    • GOOD choice for PWB if cleared for 60% or more BW
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9
Q

Pathomechanics of Hip Jt Injury

Motion Deficiency

What develops?

A
  • Femoral Acetabular Impinge. (FAI)
    • Cam
    • Pincer
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10
Q

Pathomechs of Hip Jt Injury

Excessive and Uncontrolled Motion

What develops?

A
  • Structural Instability
    • Dysplasia
    • Capsular Insuff.
      • ​Global
      • Acquired
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11
Q

Pathomechanics of Hip Jt Injury

Osseous Overloads

What develops?

A
  • Traumatic
  • Cumulative (ex. Stress Fx)
    • Predisposed
      • ​insufficiency
    • Microtrauma
      • ​overuse
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12
Q

MANY roads lead to…..

A

OA

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13
Q

Explain OA….

A
  • OA
    • End-pt for MANY hip patho’s
    • Emerging evidence for FAI
    • Better estab’d relationship to dysplastic hip
    • Fxs linked to EARLIER OA dev.
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14
Q

Hip Fx and Rule of Thirds

A

1/3 Recover

1/3 Recover BUT reduced mobility

1/3 Die

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15
Q

Hip Fx is one of leading causes of death in older adults.

Why?

A
  • Fx results in comorbid condition that results in Death.
  • Cycle:
    • ​Hip Fx–> Immob. & INC sedentary time–> PNA (or other med. comps)–> Death
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16
Q

Hip Fxs– Prox. Femur

Risk Factors for Falls in Elderly:

A
  • Slower walking speed (modifiable)
  • Hx of falls
  • Sarcopenia
  • Poor balance (modifiable)
  • Cognitive decline
  • Poor vision
  • Osteoporosis
  • Household obstacles such as rugs, power cords, clutter (modifiable)
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17
Q

Hip Fxs – Prox. Femur

Hip Hemiarthroplasty (1/2)

Indications:

A
  • Acute displaced INTRAcapsular prox. femur fx
    • frail elderly
  • Failed int. fixation of INTRAcapsular fx’s
    • osteonecrosis of femoral head
  • ALSO used for SEVERE DJD of femoral head w/ healthy acetabulum
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18
Q

Hip Fx’s – Prox. Femur

Hip Hemiarthroplasty

uni vs bipolar, Sx approach, Rehab

A
  • Unipolar
    • ​stem/head is 1 piece
  • Bipolar
    • ​SOME mvmt b/w stem and head components
  • Sx Approach
    • ​POSTEROLATERAL == MOST COMMON!!!
      • Cemented OR Non-cemented
  • Rehab???
    • ​mimics rehab for THA
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19
Q

Hip Fx’s – Prox Femur

ORIF

Indications???

A
  • Displaced OR non-displaced INTRAcapsular fem. neck fx
  • Fx w/ disloc’s of femoral head
  • INTERtrochanteric fx’s
  • SUBtrochanteric fx’s
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20
Q

Hip Fxs—Prox Femur

ORIF

Traction procedure

A
  • Pin THRU distal femur + traction system IN hospital bed to provide traction to leg to help w/ reduction of fx
    • typ followed by sx
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21
Q

Hip Fx’s—Prox Femur

ORIF
In Situ Fixation

A
  • Percutaneous nail thru skin from greater troch to femoral head—- NO cutting thru mm or capsule
    • ​Non-displaced fx’s
    • Impacted femoral neck fx’s
  • ***Fewer precautions vs. THA or Hemi-arthro
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22
Q

Hip Fx’s —Prox Femur

ORIF

Dynamic (MVMT) extramedullary fixation w/ a sliding (compression) hip screw and lateral compression plate

A
  • allows for sliding b/w plate and screw—> creates compression across fx w/ WB
  • mainly for stable intertrochanteric fx’s
  • MAY be combo’d w/ an osteotomy for comminuted fx’s
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23
Q

Hip Fxs–Prox Femur

ORIF

Static (NO MVMT) interlocking intramedullary nail fixation OR sliding hip screw coupled w/ an intramedullary nail

A

For SUBtrochanteric fx *******

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24
Q

Hip Fx’s –Prox Femur

ORIF

Bone force and healing

A
  • NO bone force
    • UNLIKELY to heal
  • Bone req’s FORCE to HEAL !!!
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25
Q

Hip Fx–Prox Femur

ORIF

Rehabilitation:

A
  • EARLY mob. possible due to stability of fixation
  • Fx healing typ takes 10-16wks
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26
Q

Hip Fxs–Prox Femur

ORIF
WB status

A

ALWAYS det’d by surgeon

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27
Q

Hip Fx’s –Prox Femur

ORIF

Procedures that usually allow for WBAT:

A
  • Non-displaced, rigidly fixed, OR impacted femoral neck fx’s w/ in-situ fixation
  • Stable (uncomminuted) INTERtrochanteric fx’s w/ dynamic hip screw and lateral side plate fixation
  • Stable SUBtrochanteric fx’s w/ interlocking intramedullary nailing and bone-bone fixation

NOTE: notice “non-displaced, stable, stable”

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28
Q

Hip Fx–Prox Femur

ORIF

Factors in determining WB status:

A
  • age
  • bone quality
    • density
  • fx loc.
  • fx displacement
  • fixation proc’s
  • post-op stability
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29
Q

GOAL of ORIF====>

A
  • Restore mobility ASAP to MINIMIZE negative local and systemic results of immobilization
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30
Q

Hip Fx’s —Prox femur

ORIF
Special considerations for exercise and gait

A
  • Soft tissue healing takes @ least 6 wks; BOTH injury (fx) AND sx procedure can impact local musculature
    • ​TRAUMA from Fx
    • INCISION from Sx
  • TFL usually cut during Sx and has to heal***
  • Return of ABD strength is BIG ISSUE—-slower if glute med cut during sx
    • ​IF glute med NOT cut—–start ABD ex’s sooner
  • INTRAcap Fx’s req. incision INTO capsule during sx—-pt MIGHT have post-op ROM PRECAUTIONS in order to AVOID DISLOCATION
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31
Q

Hip Fx–Prox Femur

ORIF Rehab

MAX PROTECTION PHASE

A
  • 90deg HIP FLEX ROM by 2-4wks
  • EASY ankle + knee ROM ex’s
  • UE ex.
  • LOW intensity mm performance ex:
    • submax iso’s (guide by pain)
    • progress to AAROM
  • NO bridging or SLR w/ involved side early on
  • Be careful NOT to violate WB precautions!!!
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32
Q

Hip Fx–Prox Femur

ORIF

MODERATE–>MINIMAL PROTECTION PHASES

A
  • Progress to PWB; eventually FWB
  • Stretch any Tight mm’s
  • Expand ADL training
  • Aerobic ex.
  • Add resistance for hip ex’s
  • Add balance ex’s
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33
Q

S/S of Failure of Int. Fixation following Hip Sx

A

see Box 20.8

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34
Q

Hip OA

Condition characteristics

A
  • GLOBAL cart. loss and loss of jt space
  • wide-spread loss of normal jt structure and related loss of function
  • often cumulative result of an earlier injury pattern progressing over time:
    • ​Prev injury
    • Acetabular labral tear
    • Dysplasia (early onset OA)
    • Avascular Necrosis
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35
Q

Normal vs. OA Hip Joint

A

see pics

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36
Q

Clinical Present Hip OA

Cibulka et al, 2009

Exam Findings

A
  • MODERATE Ant and/or Lat. pain
    • ​MOST OFTEN PROMINENT DURING WB
  • Pain often prominent in morning
    • ​subsides in <1hr
  • Typ >50yo
    • EXCEPTIONS:
      • ​Prev injury
      • dysplasia hx
      • med-induced AVN
  • Progressive loss ROM—CAPSULAR PATTERN
    • Notable IR (<15deg) THEN FLEX
      • capsular pattern
  • DECd jt mob or symptom relief w/ long-axis distraction
  • related Loss of Strength
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37
Q

Clinical Present of Hip OA

Clinical Tests:

KNOW THESE!!!

A

FABER/Patrick

Scour

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38
Q

Typically….. symptomatic and functional changes related to HIP OA are_________

A

slow-developing

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39
Q

Prognosis of Hip OA ~ related to ___________

A

Extent of radiographic changes

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40
Q

Well-established option for end stage hip OA NOT responsive to non-op Tx

A

THA

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41
Q

Time of progression from initial Dx of OA to THA procedure is HIGHLY __________

A

Highly variable AND pt dependent

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42
Q

Clinical course and expected outcomes for Hip OA

current/developing interest in……

A

Hip preservation sx’s and use of biologics

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43
Q

DJD (OA) of Hip

KEY FINDINGS from Pt Hx

A
  • older age
  • hx trauma, rep stress, hip develop. disorders/disease
  • stiff in AM upon waking OR after rest
  • Pain in groin, hip, buttock, ant thigh and/or knee
  • Pain WORSE w/ WB or @ end of day
  • Pain WORSE w/ squatting
  • Limtd functional acts: esp WB
    • ​inc diff overtime w/ ambulation, stairs, bathing, dressing (don/doff socks, shoes)
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44
Q

DJD (OA) Hip

Observations

A
  • Antalgic gait
    • lean toward INVOLVED side in STANCE phase
    • impaired balance
    • SHORT STEP LENGTH on UNINVOLVED limb
  • Posture–> hip flex contracture
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45
Q

DJD (OA) Hip

Typ. Exam Findings:

Impairments

A
  • limtd mm extensibility/flex
    • hip flexors, TFL/ITB, glute max
  • MM weakness
    • ABD’s, EXT’s, ER’s
  • Painful ACTIVE hip flex
  • Painful + Limtd hip PROM
    • firm capsular end feel
  • ROM–> limtd IR initially
    • ​LATER:
      • ​ABD, EXT, ER also limtd
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46
Q

DJD (OA) Hip

Typ. Exam Findings:

Impairments

EARLY STAGES

A

Capsular laxity & pt reported instability

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47
Q

DJD (OA) Hip

Typ. Exam Findings:

Impairments

LATER STAGES

A

Cartilage breakdown

Capsular fibrosis

Osteophytes

Basically….STIFFNESS

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48
Q

DJD (OA) Hip

Selective Tests

A
  • POSITIVE Scour Test
  • MAYBE POSITIVE
    • ​FABER
      • ​pain in Hip or Groin w/ OA
      • maybe limtd ROM also
    • FADDIR (Flex, ADD, IR)
      • ​Ant. Labral Tear Test
    • POSITIVE Labral Tests
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49
Q

DJD (OA) Hip

Non-Op Tx

Primary Goal——

A

RESOLVE IMPAIRMENTS!!!

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50
Q

DJD (OA) HIP—

Non-Op Tx

2 things to do:

A
    1. GET THEM MOVING!
      * Stretch tight mm’s
      * Jt Mobs—-if limtd mob.
      • ​LOW grade===pain relief
      • HIGH grade + MWM (mob w/ mvmt)=== INC ROM
    1. Strengthening
      * LOW impact TE
      • ​aquatics, swimming, stationary bike/recumbent
      • PROGRESS to GREATER closed chain WB as tolerated
      • Begin w/ LOW RESISTANCE & HIGH REPS
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51
Q

DJD (OA) HIP

NON-OP Tx

A

MUST PROGRESS TO HIGHER LOADS

(assuming does NOT inc symptoms)

  • do NOT stick w/ easy things
    • more benefits in pushing them
  • Overcome inhibition== INC strength
  • Strengthening INCs capacity== raises ceiling
    • ​Stronger you are==LESS effort needed for basic tasks
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52
Q

DJD (OA) Hip

Non-Op Tx

A
  • PRIMARY GOAL:
    • Resolve impairments
  • Biomech. Interventions:
    • ​Unloading (single pt cane)
    • Heel lift OR orthotic if LLD
    • Elevated seats IF flex limtd + painful
  • Improve aerobic capacity
  • Balance ex’s
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53
Q

2 most often situations for THA

A
  1. when guys can no longer play golf
  2. Women
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54
Q

DJD (OA) Hip

Sx Tx

THA

Indications?

A
  • SEVERE hip pain w/ motion and WB that has been WORSENING over time
  • Impaired function and reduced QoL
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55
Q

DJD (OA) HIP
Sx Tx

THA

Prosthetic Components

A
  • Acetabulum:
    • high density plastic or ceramic
  • Femur:
    • ​metal alloy
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56
Q

DJD (OA) HIP

Sx Tx

THA

CEMENTED Polymethylmethacrylate

Cemented PMMH

explain…

A
  • good for older pts
  • those not able to follow WB precautions
  • OK to WBAT RIGHT AWAY
    • ​ADVANTAGES:
      • ​earlier WB
      • shorter + faster rehab
    • DISADVANTAGES:
      • ​GREATER risk of loosening over time
        • ​cement degrades
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57
Q

DJD (OA) HIP

Sx Tx

THA

UNCEMENTED

**Bone grows INTO prosthetic**

A
  • better for younger & more active pts
    • ​ADVANTAGES:
      • ​LESS chance prosthetic loosening over time
    • DISADVANTAGES:
      • ​protected WB initially*
        • ​historically up to 6 wks TTWB, recently more of a trend for faster progression of WB
      • LONGER course of rehab
        • slower bc waiting for bone to grow into prosthetic
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58
Q

DJD (OA) HIP

THA

Hybrid THA:

A
  • LESS COMMON
  • Cemented acetabulum
  • Press-fit femoral component
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59
Q

DJD (OA) Hip

Sx Tx

THA

A

Various approaches to gain access to hip jt affect post-op rehab

see pics

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60
Q

Posterolat Approach THA

vs.

Anterior Approach THA

A

Advantages vs. Disadvantages

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61
Q

Ant Approach THA

vs.

Posterolateral Approach THA

Precautions

A

see pics

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62
Q

DJD (OA) HIP

THA

Posterolateral Approach

A
  • ROM:
    • ​No FLEX >90deg, No IR beyond neutral, No ADD beyond midline
      • ​​DO NOT CROSS LEGS
  • ADLs
    • Transfers: lead w/ UNINVOLVED side
      • ​bed–> chair or chair–> bed
    • keep knees LOWER than hips when sitting
    • RAISE toilet seat, bed, chair
      • <90deg hip flex
    • Avoid bending trunk over legs when rising or lowering to chair or dressing
      • shower chair
    • Stairs
      • UP w/ GOOD, DOWN w/ BAD
    • Pivot on sound extremity w/ walker, turn AWAY from involved side when pivoting
    • Avoid IR toward INVOLVED extremity when standing
    • Sleep Supine w/ ABD pillow
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63
Q

DJD (OA) HIP

THA

Anterior Approach

A
  • ROM: Avoid Hip EXT, ADD, ER past neutral
    • ​also avoid combo of ER w/ Flex and ABD
    • avoid excess. FLEX
    • IF glute med disrupted OR trochanteric osteotomy done—-> do NOT perform anti-gravity hip ABD for 6-8 wks OR until approved by surgeon
  • ADLs
    • Do NOT cross legs when sitting
      • avoid ADD, avoid ER
    • Early ambulation: step-to rather than step-thru op’d side
    • Avoid rotating AWAY from op’d side when standing
      • ​ex. turn TOWARD op’d side so as to avoid ER of op’d side
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64
Q

THA

Post-Op Precautions

A
  • Typ no “hard stop” end date for ROM precautions
  • Typ after few mo’s ==== pt begins violating or forgetting about precautions and is OK
  • BUT even down the road…..
    • still not good to combine Hip Flex and ADD
      • ​bending to tie shoes – combine FLEX w/ ABD
        • ​”Froggy Style”
65
Q

THA

Post-op Education or “Pre-Hab”

A
  • educate pt on expected ROM precautions
  • rehearse proper gait pattern w/ AD
  • instruct pt in ex’s that will be done immed. post-op
66
Q

DJD of HIP

Sx Tx THA
EARLY PROTECTION PHASE

1 Day to 2 Weeks Post-Op

A

We want them as mobile as possible!!!

No complications + More Mobile==Go Home

  • Prevent pulm./vascular complications
    • ​ANKLE PUMPS
    • DEEP BREATHING
  • Prevent dislocation or subluxation
    • ​Educate pt and caregivers about precautions
    • ABD pillow
    • higher chairs; commodes
    • monitor s/s
  • Achieve independent functional mobility
    • ​bed mob + transfer training
    • ambulate w/ AD
      • rolling walker==most common
67
Q

DJD (OA) HIP

Sx Tx

THA

EARLY PROTECTION PHASE

1 Day to 2 Weeks Post-Op

continued

A
  • Maint strength + function UEs and UNoperated LE
  • Prevent reflex inhibition and atrophy of the operated LE
  • Regain active mobility and control of the operated LE
    • ​In Bed–> AAROM for hip, assist. heel slides, assist ABD/ADD
    • In Sitting–> Knee Flex/Ext, emphasis on TKE
    • In Standing–> NWB hip AROM w/ knee FLEXED (easier) & EXT (harder)
    • ​In Standing–> B/L squats, heel raises
      • ***Delay in UNCEMENTED***
  • Prevent Flex contracture of the operated hip
    • ​AVOID use of pillow under knee of operated hip
    • Posterolateral Approach
      • lying prone when permit’d
      • Thomas Stretch of the UNoperated side
        • single knee to chest but keeping it LESS than 90deg w/ involved side
          • *if abso. necessary
    • Anterior Approach
      • _​_Do NOT stretch into EXT
68
Q

DJD OA of HIP

THA

MODERATE AND MIN. PROTECTION PHASES

1-12 WKS POST-OP

A

NO PROGRESS. TO END RANGES

  • Regain strength and endurance ALL extremities
    • ​ESP hip ABD and EXT
  • improve aerobic endurance–LOW IMPACT
  • Restore functional ROM of operated hip
    • ​Do NOT exceed ROM precautions/restrictions
  • Prepare for full return to functional acts.
    • ​ Carrying stuff— carry on OPERATED side

**NOTE: younger pts will return to sport w/in 1 year

69
Q

Other Hip Sx’s

LESS invasive/aggresive vs. THA

A
  • Hemi-arthro
  • Hip resurfacing
    • prosthetic “cap” over femoral head
  • Arthroscopic mgmt labral tears
    • repair vs. resection
  • Sx debridement of osteophytes for Ant Acetabular Impingement
70
Q

Other Hip Sx’s

When THA Fails…

A
  • REVISION of THA
  • Girdlestone Procedure
    • ​saw off head of femur
71
Q

Femoral and Pelvic Stress Fx’s

Describe

A
  • Mech. induced fx of prox. femur or pelvis
72
Q

Femoral and Pelvic Stress Fx

mech. induced fx of prox femur or pelvis as a result of what?

A
  • Repetitive overload that overcomes normal structural properties
    • EX. overtraining
  • Loading that overcomes compromised structural properties (something already compromised and you make it worse by loading it)
    • Fx occuring w/ osteopenia
73
Q

Femoral and Pelvic Stress Fx

Differential Dx

A
  • Acetabular labral tear
  • Hip flexor strain
  • Hip ADD strain
  • Iliopsoas bursitis
  • Osteochondral lesion
  • Hip OA
74
Q

Femoral and Pelvic Stress Fx’s

FACTS

A
  • MANY cases w/ delayed dx—–avg 14wks
  • NO reliable clinical tests to diff. TYPE of stress fx
    • ​imaging will tell you
    • if suspected==> immed. referral
75
Q

Femoral and Pelvic Stress Fx

Dx Imaging

Plain Radiography

AP, Frog-Lateral

A

R/O other conditions (OA, tumor, etc.)

Examine for Displacement

76
Q

Femoral and Pelvic Stress Fx

Dx Imaging

Bone Scan

A

Demos INCd focal uptake of radiotracer @ site of fx aka “HOT SPOT”

MAY read NEG. for first 24hrs after fx dev.

77
Q

Femoral and pelvic stress Fx

Dx Imaging

MRI

A

Idea in Sn and Sp

Yields info about surrounding tissue (Diff. Dx)

78
Q

Femoral neck stress Fx and runners

A

account for 6.6% of stress Fxs in runners

79
Q

2 Anatomical classifications of Femoral Neck Stress Fx

A
  • Compression sided (pinching down)
    • ​INF region of femoral neck
    • non-operative mgmt
  • Tension sided (stretched)
    • ​SUP region femoral neck
    • ORIF (if caught late)
80
Q

Femoral Neck Stress Fx

Clinical Presentatin

PAIN

A
  • Groin + Ant. thigh
  • Potentially Lat. thigh
    • ​RARELY in glute region
  • Potentially MED. knee pain
  • OFTEN reproducible w/ END RANGE IR + OVERPRESSURE
    • ​MAYBE reproducible w/ SLR or MMT for FLEX and/or ABD
81
Q

Femoral Neck Stress Fx

Clinical Present

FUNCTIONAL

A
  • INITIALLY pain during OR after strenuous act.
    • ​ex. running
  • PROGRESSES to affect lower lvl act.
    • ​ex. walking
  • In Acute stages……
    • ​painful OR restful @ night

**** takes time to get stress on bone***

82
Q

Pelvic Stress Fx

A
  • 1.6% of stress fxs in distance runners
  • Pubic Ramus
  • Palpable rami pain
83
Q

Femoral and Pelvic Stress Fx’s

If running… 2-3 miles in they can go thru diff dx’s

A
  • BOTH stress fx’s present closely to number of diff. dx’s
  • Thoroughy discuss act. lvl + med. hx
  • Missed dx can be SEVERE——referral when unsure
  • Appropriate dx + follow-up—-majority of hip + pelvic stress fx’s resolve
  • TENSION SIDE (sup. side) neck stress fx’s are MORE LIKELY to req. ORIF

***Prev. stress fx===MORE likely to have stress fx’s

***CATCH THEM EARLY!!!***

84
Q

Osteitis Pubitis

What should you remember???

A

DIFF bone stress injury

Can LEAD TO stress fx

85
Q

Osteitis Pubitis

Description + Causes

A
  • Inflamm. of Pubic Symphysis thru several pot. mech’s
    • ​REPETITIVE athletic act.
    • Degen OR rheumatic causes
    • Urological/gynecological procedures OR pregnancy (non-infectious)
86
Q

Osteitis Pubitis

Differential Dx

A
  • Athletic Pubalgia
    • extra-articular component
  • Adductor strain
    • bc SO close to insertion
  • Lower abdominal strain
  • Pubic ramus stress fx
  • Pelvic floor dysf.
  • Infectious pubic inflamm.
    • Osteomyelitis
87
Q

Osteitis Pubitis

Clinical Presentation

ONSET

A

Acute

Gradual

88
Q

Osteitis Pubitis

Clinical Presentation

PAIN DISTRIBUTION

A
  • Central symphysis region
  • Prox. ADD region
    • stresses pubic symphysis
  • Lower abdomen
    • stresses pubic symphysis
  • Genital region
89
Q

Osteitis Pubitis

Clinical Presentation

FUNCTIONAL LIMITS.

A
  • Gait
    • Swing Phase
  • Pivoting
  • Sport Specific:
    • cutting, jumping, kicking

​

90
Q

Osteitis Pubitis

Clinical Present.

MUSCLE IMBALANCES

**remember location!!!

A
  • TIGHTNESS
    • Rectus abdominus*
    • ADD
    • Iliopsoas
    • Rec Fem
  • STRENGTH ASYMMETRIES
    • ​Adductors****

*NOTE: Rectus abdominus + ADD’s=== Antagonistic imbalance==Asymmetrical pull

*NOTE: mm’s attach in proximity to ea. other and can create antagonistic imbalance

91
Q

Osteitis Pubitis

Clinical EXAM

A
  • Hx is imperative
  • R/O other structures
    • Hip—do clinical tests
    • Extra-art.—do MMT, length-tests, palpate*
  • Clinical Tests: min description
    • ​Multiposition ADD. Squeeze
      • ​try to recreate pain
    • No sig. data on testing methodology
  • Often not apparent UNTIL pt does not respond to non-op tx
  • IMAGIING
    • ​Plain Radiography
      • looking for surf. irregs and degen.
    • MRI
      • Edema
92
Q

Athletic Pubalgia & Sports Hernia

what should you remember???

A

Pubic “pain” —> NOT ACTUALLY A HERNIA

There is NO hernia!!!!

93
Q

Athletic Pubalgia

“Sports Hernia”

A
  • NOT hernia in trad. sense
  • Disruption of Post. Inguinal Wall OR Ant. Pubic attach’s
  • General term describing chronic pubic/inguinal pain that is NOT INTRA-ART.
  • Syndrome: mult. causes poss.
  • 1980’s—-more recognized today
  • Diff Dx is imperative and imaging interp. can be diff.
94
Q

Athletic Pubalgia

Involved Structures

A
  • Pubic Symphysis AND….
  • Musculotendinous insertions in proximity:
    • ​abdominals
    • hip flexors
    • hip ADD’s
  • most often function to CONTROL some combo of excess. EXT or ROT. of the abdomen and excess. ABD of thigh****
95
Q

Athletic Pubalgia and ROM loss

A

ROM stopped due to pain=== empty end feel (meaning they stop you before you get to ANY end range so NO END FEEL==EMPTY END FEEL)

96
Q

Athletic Pubalgia

Mech. of Onset

A
  • More common in males vs. females
  • Repetitive forces to pubic symphysis OR tendinous insertions of adductors and rectus abdominis
  • “High energy twisting activities and thigh hyperABD in athletes w/ strong ADD mm’s over-powering lower abdominals
    • ​ex. football, hockey, soccer
97
Q

Athletic Pubalgia

Clinical Present.

S/S

A
  • Chronic pain—> often only during exertion
  • Sharp, burning pain local to lower abdomen & inguinal region
    • ​***later will radiate to the ADD region and pot. testicular region***
98
Q

Athletic Pubalgia

Diff. Dx

A
  • Pain and/or weakness w/ strength testing
  • Tightness and/or weakness w/ flex. testing
  • Pot. pain w/ palpation of specific suspected structures
    • ​***NEGATIVE TESTS FOR INTRA-ARTICULAR INVOLVEMENT
99
Q

Athletic Pubalgia

Cluster Approach Summary

A

Confirming Regional Involvement and Dx

  • ​Symptoms:
    • deep groin, lower abs (unilateral) W/ ACTIVITY OR EXERTION
  • Lower abdomen:
    • leg lowering
    • resisted sit-ups
    • pubic tub. palpation
  • Thigh:
    • Flex. tests: iliopsoas, ADD’s, abs, rec fem
    • MMT: hip flexors, ADD’s, glute med
    • ADD. origin palpation
  • R/O primary hip involve.
    • ​NEGATIVE: FABER, FADDIR, SCOUR
      • ​***FAI has shown assoc. w/ athletic pubalgia
  • R/O Lumbosacral & SIJ involve
    • LQS as approp.
100
Q

Athletic Pubalgia

Prognosis and Tx Implications

A

Proper dx is imperative and syndrome class. necessitates an effective screening process for mult. regions

101
Q

Athletic Pubalgia

Prognosis and Tx Implications

Trial of Non-Op Tx typ. indicated…

A
  • impairment-based interventions
  • Rest
  • NSAIDs
  • Corticosteroid injections
  • Biological agents considered
102
Q

Athletic Pubalgia

Prognosis and Tx. implications

Various Sx proc’s …

A
  • Laparoscopic
  • Open vs. “Mini” Open
103
Q

Athletic Pubalgia

Prognosis and Tx Implications

Outcomes???

A
  • Non-consistent outcome reporting BUT post-sx studies report >80% “return to sport”
  • Further outcome studies req’d for both non-sx and sx tx
104
Q

Meralgia Parasthetica

*Painful parasthesias

What is it and who is @ risk???

A
  • Irritation or entrapment of Lateral Femoral Cutaneous Nerve in the area of the anteroLAT. hip
    • ​~1cm medial to ASIS
  • @ Risk:
    • ​baseball catchers
    • English-style equestrians
    • obese indiv’s
    • pregnant women
      • bc in hip flex. all the time
105
Q

Meralgia Parasthetica

How to Test:

A
  • Push down w/ thumb INTO abdomen and UP towards umbillicus @ lvl just prox. to and 1” medial to ASIS
    • ​IF this relieves pt’s symptoms of lateral thigh burning, pain, parasthesia
      • ​== suggests Meralgia Parasthetica
106
Q

Meralgia Parasthetica

Intervention:

A
  • Apply same pressure to nerve w/ pt in SIDELYING—while you simultaneously passively EXT hip
    • ​push POST and SUP on the nerve (and surrounding tissue) as you EXT hip, then move back and forth
107
Q

Femoral Acetabular Impinge. or FAI

occurs when?

A

Occurs when there is DECd joint clearance b/w femur and acetabulum

108
Q

FAI

3 types:

A
    1. CAM
      * Femoral deformity
      • ​bony overgrowth
    1. Pincer
      * Acetabular deformity
      • ​acetabular overgrowth
    1. MIXED
109
Q

FAI

CAM

aka “Pistol Grip” Deformity

A

Excessive bone @ head-neck junction

**bone grows OUT

110
Q

CAM FAI

A

Delamination

separation b/w layers in the acetabulum

111
Q

Pincer FAI

Cross-Over Sign

Acetabular RETROversion

Acetabulum covers TOO MUCH of femoral head

A
  • Presentation of Focal anterior over-coverage of hip
  • Acetabular Retroversion== ant. wall (AW) being more lateral that post wall (PW)
  • In normal hip
    • ​AW lies more medially
  • Cranial acetabular retroversion described also as Fig. 8 Configuration
112
Q

Cam vs. Pincer

A

https://www.youtube.com/watch?v=ENjq5Is94PE

113
Q

FAI and Acetabular Labral Tears

A
  • Most often FAI is NOT initial dx of interest
  • Pt symptoms MOST LIKELY result from 2* labral tear, chondral damage, or degen changes IN labrum
  • Changes result in pain+functional limitation==SYNDROME
    • ​FAI (mechanical) + Clinical Findings (pain, function limits) ==> SYNDROME
114
Q

Clinical Course and Outcomes for FAI

A
  • if clinical present leads you to FAI—-non op tx recommended
    • outcome studies still early in dev.
  • If pt unresponsive to non-op tx—–ADD. IMAGING
    • ​Radiographs (FAI)
    • MRA (labral tear)
      • ​A=arthrogram-local dye leaks if tear
    • Dx Injection (confirms source of sx’s)
115
Q

Clinical Course and Outcomes for FAI

Sx Options

A
  • Sx avail. for pts w/ ongoing pain and function limits related to INTRA-art. patho of FAI
    • Arthroscopy
      • ​Osteoplasty (prox femur OR acetabular rim)
        • remove the bone
      • ​Labral debridement, repair (usually most restricted after), or reconstruction (putting something else in like bone- can do mvmt earlier w/ reconstruction)
    • Open osteoplasty correction of FAI
116
Q

FAI Progress to Early Arthritis???

EXPLAIN…

A
  • Bedi et al—> examined cart. degradation markers in athletes w/ FAI
  • Compared to controls, found elevated lvls of:
    • ​Inflamm C-reactive PRO
    • Cart. oligomeric matrix PRO
    • Basically….. cartilage breakdown even if looks GOOD on imaging
  • These changes indicate cartilage turnover and stemic inflamm. assoc’d w/ OA
117
Q

Spectrum of FAI-related Jt. Patho

**one pot. mechanism only**

A
  • FAI==> altered jt mechs==> labral lesions==> chondral damage==> OA
118
Q

The FURTHER a labral tear goes ___________, the LESS _______ it is

A

Labral tear further INTO JOINT== LESS REPAIRABLE

119
Q

HIP LABRAL TEAR

A

SEE PICS

120
Q

Acetabular Labral Tears

Pt Reported Symptoms

A
  • Hx of hyperEXT or pivoting/twisting or fall
  • pain, click, locking and/or catching
  • may feel unstable (“giving way”)
121
Q

Acetabular Labral Tears

MOI

A

most are in Ant/Sup region of labrum

122
Q

Acetabular Labral Tears

Typ. Exam Findings

Imaging

A
  • Typical Exam Findings/+ Tests
    • + FABER (opp of FADDIR)
      • pulls labrum
    • + FADDIR—ant labrum test (opp of FABER)
      • pinches labrum
    • + SCOUR test
    • + Labral tests
    • **Pain w/ resist. SLR —
      • ​compensated hip flexors***
  • Imaging
    • MRI or MRA (angiography)
123
Q

Acetabular Labral Tears

Interventions

A
  • Ex’s for hip stability and strength
  • Core stabilization ex’s
  • AVOID pos’s or tx that would further stress labrum:
    • ​HyperEXT
    • End-range OVERpressure
    • HIGH GRADE ant. glides
  • AVOID sheering, pivoting, extreme EXT
  • MAY need arthroscopic repair OR resection
124
Q

Structural Instability

vs.

Hypermobility

A
  • Structural instability
    • what the pt reports

**These two are NOT always EQUAL!!!

125
Q

Components of Jt Stability

3

A
    1. Neural (proprioceptive/sequencing)
      * ​Rehab Focus
    1. Active (muscular)
      * ​Rehab Focus
    1. Passive (ligamentous/boney)
      * ​Sx Focus
126
Q

The Structurally Unstable Patient

*know underlying cause*

A
  • boney architecture
  • Femoral deformities
    • ​Coxa valga, INCd femoral version
  • Mis-shaped femoral head
  • Shallow acetabulum
  • Anteverted acetabulum
  • Primary Capsulo-labral Compromise
    • ​ligament/capsule tear in hip
  • Universal laxity
  • Focal laxity
  • Ligamentum Teres deficiency
    • the “head ligament” —– blood supply!!!
127
Q

Dysplasia

Labrum does MORE work

Bone does LESS work

A
  • SHALLOW acetabulum
  • Predisposes hip to sublux. AND abnorm contact stresses on femoral head
  • Assoc’d w/ hyperplastic labrum AND degen
  • Dysplastic hip can LOAD labrum up to 5x above normal
  • ***Cannot treat underlying bony patho arthroscopically***
128
Q

Capsulo-ligamentous Laxity

aka Ligamentous Laxity

A
  • MAY be noted in conjuction w/ OR instead of boney abnorms
129
Q

Capsulo-ligamentous Laxity

aka Ligamentous Laxity

2 Categories:

A
    1. Generalized
      * ​connect. tissue disorders
      • Ehler’s-Danlos
      • Marfan’s
      • etc..
    1. Focal
      * ​iliofemoral ligament attenuation/damage
130
Q

How do we measure Generalized/Universal Laxity?

A

Beighton’s Scale

131
Q

Repetitive Micro-Trauma & Acquired Capsulo-ligamentous Laxity

A
  • Abnorm forces thru hip transmit forces to iliofemoral ligament AND labrum
  • Results:
    • ​Focal, rotational instability
    • Elongated capsule
    • Associated labral tear
132
Q

Repetitive Micro-Trauma & Acquired Capsulo-ligamentous Laxity

MOI

A
  • Repetitive ER on a loaded limb ==>
  • Weakening/disruption of anterior structures ==>
    • ​iliofemoral lig.
    • capsule
    • labrum
  • INCd load thru soft tissues
    • ​labral tearing–stress
    • irritation of ABDs and hip flexors
      • as they work to stabilize
133
Q

Hypermobility Prognosis & Tx Implications

**if clinical presentation leads to impression of HYPERmobility—–NON-op tx measures recommended

A
  • IF pt unresponsive to NON-op Tx—- add. imaging warranted:
    • ​Radiographs
      • ID of dysplasia
    • MRA—dye into tear if tear
      • labral pathology
    • Dx Injection
      • confirms source of sx’s
134
Q

Sidenote:

Hip Dysplasia

A
  • Medical term for a hip socket that does NOT fully cover the ball portion of the proximal femur.
    • allows hip jt to become partially or completely dislocated
    • mostly congenital
135
Q

Structural hypermobility OR laxity DOES NOT ALWAYS result in______________

A

Clinical Instability!!!

136
Q

Extra Articular Hip Injuries

What is KEY to effective Tx?

A

Accurate Dx

137
Q

Extra-articular hip injuries

Multi-structural involvement

A
  • Co-existence w/ INTRA-articular involve.
    • ​FAI
    • labral tears
  • Lumbopelvic component
  • Syndromes
    • ​COMBINED core and hip musculotendinous structure involve.
138
Q

Extra-articular Hip injuries

“Outliers”

A

Pelvic floor

Nerve entrap. syndromes

139
Q

Extra-articular Hip injuries

Give some examples…

A
  • Greater troch pain syndrome
  • ADD-related groin injuries
  • Prox. HS injuries
  • Hip flexor injuries
    • iliopsoas
  • Assoc’d core patho/Athletic pubalgia (sports hernia not really a hernia)
140
Q

Greater Trochanteric Pain Syndrome

GTPS

A
  • labeled trochanteric bursitis in past
  • Trochanteric inflamm IS POSSIBLE BUT….
    • Other structures often involved…..
      • ​Glute Med.
        • tendinopathy
        • tear
      • Glute Min.
        • tendinopathy
        • tear
141
Q

Gluteal Tendinopathy

FACTS

A

MORE common in FEMALES

40-65yo

142
Q

Gluteal Tendinopathy

Functional Diff’s

A
  • Pain variable w/ walking, S/L, sitting
  • Fatigue and possible gait disturbance
143
Q

Gluteal Tendinopathy

Clinical Findings:

A
  • R/O intra-articular involve as 1* source
  • Palpable tendon attach. pain
    • POST/SUP trochanter== glute med.
    • ANT == glute min.
  • Pain w/ resisted ABD
  • + De-rotational test
  • Pain w/ 30s SLS
144
Q

Trochanteric Bursitis

Pt Report

A

PAIN loc’d over lateral hip w/ referral to lateral thigh to knee

145
Q

Trochanteric Bursitis

Mech. of Patho.

A
  • Aggravated by ITB rubbing over trochanter
146
Q

Trochanteric Bursitis

Risk Factors:

A
  • Risk on “downhill leg” if running on banked road
147
Q

Trochanteric Bursitis

Aggravating Acts:

A
  • lying on affected side, standing asymmetrically w/ hip in ADD., walking/running on uneven surf. (crested road)
148
Q

Iliopectineal Bursitis

Pt Report

A

Pain loc’d in inguinal region referring to the ANT thigh as far as knee

149
Q

Iliopectineal Bursitis

Mech. of Patho

A
  • bursa lies DEEP to iliopsoas tendon as it crosses hip joint
  • CLOSELY assoc’d w/ hip jt patho
    • ​DJD
    • RA
    • etc..
150
Q

Iliopectineal Buritis

Aggravating Factors

A
  • Rep’d hip flexion, rising to stand after prolonged sitting, prolonged walking
  • ​Pts report pain w/ crossing legs OR ADD affected LE
151
Q

Iliopectineal Bursitis

Interventions

A
  • Focus on stretching iliopsoas
  • hip mobs
  • soft tissue mobs
  • therapeutic modalities
152
Q

Ischiogluteal or Ischial Tuberosity Bursitis

“Weaver’s Bottom”

Pt Report

A
  • Pain over ischial tubs–esp in sitting
    • ​MAY spread to sciatic distribution due to swelling
153
Q

Ischiogluteal or Ischial Tuberosity Bursitis

“Weaver’s Bottom”

Mech. of Patho

A
  • Sedentary indiv’s OR direct trauma to region
    • bursa lies DEEP to glute max over isch. tubs.

​

154
Q

Ischiogluteal or Ischial Tuberosity Bursitis

“Weaver’s Bottom”

Aggravating Acts

A
  • Resisted hip EXT and HS’s painful
155
Q

Ischiogluteal or Ischial Tuberosity Bursitis

“Weaver’s Bottom”

Diff. Dx

A

referral from LS or referral from hip may cause pain in same area

156
Q

Ischiogluteal or Ischial Tuberosity Bursitis

“Weaver’s Bottom”

Specific Intervention

A
  • Using a doughnut pad to relieve pressure while sitting
157
Q

Hip/Pelvis Bursitis

Interventions

A
  • STRETCH tight structures around hip
    • ITB/TFL, Glutes, HS’s
  • MOBILIZE tight hip/lumbar spine/pelvis structures
  • Foam rolling over ITB and other structures
    • ​don’t care WHY it works as long as it WORKS!
  • Therapeutic Modal’s MAY enhance pain relief and better tolerance to mvmt—-implement if they allow MORE EXERCISE!!!
    • US
    • heat
    • e-stim
158
Q
A

MSPT I (10 decks)

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