COMPS:HIP Flashcards
Pt Reported Outcomes:
Lower Extremity Functional Scale
LEFS
- GENERAL LE measure—–activity based
- **no s/s or impairments
- scores range 0-80 w/ HIGHER SCORES==BETTER FUNCTION
Pt Reported Outcomes
Western Ontario and MacMaster Universities Osteoarthritis Index
WOMAC
- 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
Pt Reported Outcomes
Hip Injury and OA Scale
HOOS
- 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
-
Pain: P 0-40
- LOWER scores on HOOS === WORSE pain, stiff, functional limits
Pt Reported Outcomes:
Hip Outcome Score
HOS
- ADL and Sports Scales
- Scores range 0-100 w/ HIGHER SCORES ===BETTER function
Pt Reported Outcomes
Harris Hip Function Scale
- popular
- Good for pre/post op comparisons
- Emphasizes Pain and Function
Minimal ROM req’s for Basic Function:
Gait, Sitting, Bed mobility, stairs
- 90deg FLEX
- Normal==120
- 20deg ABD
- Normal==45
- 0deg IR
- Normal==45
- 20deg ER
- Normal==45-60
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
*
- 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
Unloading of Hip using ADs
- 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
Pathomechanics of Hip Jt Injury
Motion Deficiency
What develops?
- Femoral Acetabular Impinge. (FAI)
- Cam
- Pincer
Pathomechs of Hip Jt Injury
Excessive and Uncontrolled Motion
What develops?
- Structural Instability
- Dysplasia
-
Capsular Insuff.
- Global
- Acquired
Pathomechanics of Hip Jt Injury
Osseous Overloads
What develops?
- Traumatic
- Cumulative (ex. Stress Fx)
-
Predisposed
- insufficiency
-
Microtrauma
- overuse
-
Predisposed
MANY roads lead to…..
OA
Explain OA….
- 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.
Hip Fx and Rule of Thirds
1/3 Recover
1/3 Recover BUT reduced mobility
1/3 Die
Hip Fx is one of leading causes of death in older adults.
Why?
- Fx results in comorbid condition that results in Death.
-
Cycle:
- Hip Fx–> Immob. & INC sedentary time–> PNA (or other med. comps)–> Death
Hip Fxs– Prox. Femur
Risk Factors for Falls in Elderly:
- 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)
Hip Fxs – Prox. Femur
Hip Hemiarthroplasty (1/2)
Indications:
- 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
Hip Fx’s – Prox. Femur
Hip Hemiarthroplasty
uni vs bipolar, Sx approach, Rehab
-
Unipolar
- stem/head is 1 piece
-
Bipolar
- SOME mvmt b/w stem and head components
-
Sx Approach
-
POSTEROLATERAL == MOST COMMON!!!
- Cemented OR Non-cemented
-
POSTEROLATERAL == MOST COMMON!!!
-
Rehab???
- mimics rehab for THA
Hip Fx’s – Prox Femur
ORIF
Indications???
- Displaced OR non-displaced INTRAcapsular fem. neck fx
- Fx w/ disloc’s of femoral head
- INTERtrochanteric fx’s
- SUBtrochanteric fx’s
Hip Fxs—Prox Femur
ORIF
Traction procedure
- Pin THRU distal femur + traction system IN hospital bed to provide traction to leg to help w/ reduction of fx
- typ followed by sx
Hip Fx’s—Prox Femur
ORIF
In Situ Fixation
- 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
Hip Fx’s —Prox Femur
ORIF
Dynamic (MVMT) extramedullary fixation w/ a sliding (compression) hip screw and lateral compression plate
- 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
Hip Fxs–Prox Femur
ORIF
Static (NO MVMT) interlocking intramedullary nail fixation OR sliding hip screw coupled w/ an intramedullary nail
For SUBtrochanteric fx *******
Hip Fx’s –Prox Femur
ORIF
Bone force and healing
- NO bone force
- UNLIKELY to heal
- Bone req’s FORCE to HEAL !!!
Hip Fx–Prox Femur
ORIF
Rehabilitation:
- EARLY mob. possible due to stability of fixation
- Fx healing typ takes 10-16wks
Hip Fxs–Prox Femur
ORIF
WB status
ALWAYS det’d by surgeon
Hip Fx’s –Prox Femur
ORIF
Procedures that usually allow for WBAT:
- 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”
Hip Fx–Prox Femur
ORIF
Factors in determining WB status:
- age
- bone quality
- density
- fx loc.
- fx displacement
- fixation proc’s
- post-op stability
GOAL of ORIF====>
- Restore mobility ASAP to MINIMIZE negative local and systemic results of immobilization
Hip Fx’s —Prox femur
ORIF
Special considerations for exercise and gait
- 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
Hip Fx–Prox Femur
ORIF Rehab
MAX PROTECTION PHASE
- 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!!!
Hip Fx–Prox Femur
ORIF
MODERATE–>MINIMAL PROTECTION PHASES
- 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
S/S of Failure of Int. Fixation following Hip Sx
see Box 20.8
Hip OA
Condition characteristics
- 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
Normal vs. OA Hip Joint
see pics
Clinical Present Hip OA
Cibulka et al, 2009
Exam Findings
- 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
-
EXCEPTIONS:
-
Progressive loss ROM—CAPSULAR PATTERN
- Notable IR (<15deg) THEN FLEX
- capsular pattern
- Notable IR (<15deg) THEN FLEX
- DECd jt mob or symptom relief w/ long-axis distraction
- related Loss of Strength
Clinical Present of Hip OA
Clinical Tests:
KNOW THESE!!!
FABER/Patrick
Scour
Typically….. symptomatic and functional changes related to HIP OA are_________
slow-developing
Prognosis of Hip OA ~ related to ___________
Extent of radiographic changes
Well-established option for end stage hip OA NOT responsive to non-op Tx
THA
Time of progression from initial Dx of OA to THA procedure is HIGHLY __________
Highly variable AND pt dependent
Clinical course and expected outcomes for Hip OA
current/developing interest in……
Hip preservation sx’s and use of biologics
DJD (OA) of Hip
KEY FINDINGS from Pt Hx
- 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)
DJD (OA) Hip
Observations
- Antalgic gait
- lean toward INVOLVED side in STANCE phase
- impaired balance
- SHORT STEP LENGTH on UNINVOLVED limb
- Posture–> hip flex contracture
DJD (OA) Hip
Typ. Exam Findings:
Impairments
- 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
-
LATER:
DJD (OA) Hip
Typ. Exam Findings:
Impairments
EARLY STAGES
Capsular laxity & pt reported instability
DJD (OA) Hip
Typ. Exam Findings:
Impairments
LATER STAGES
Cartilage breakdown
Capsular fibrosis
Osteophytes
Basically….STIFFNESS
DJD (OA) Hip
Selective Tests
- 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
-
FABER
DJD (OA) Hip
Non-Op Tx
Primary Goal——
RESOLVE IMPAIRMENTS!!!
DJD (OA) HIP—
Non-Op Tx
2 things to do:
- GET THEM MOVING!
* Stretch tight mm’s
* Jt Mobs—-if limtd mob.- LOW grade===pain relief
- HIGH grade + MWM (mob w/ mvmt)=== INC ROM
- GET THEM MOVING!
- Strengthening
* LOW impact TE- aquatics, swimming, stationary bike/recumbent
- PROGRESS to GREATER closed chain WB as tolerated
- Begin w/ LOW RESISTANCE & HIGH REPS
- Strengthening
DJD (OA) HIP
NON-OP Tx
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
DJD (OA) Hip
Non-Op Tx
- 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
2 most often situations for THA
- when guys can no longer play golf
- Women
DJD (OA) Hip
Sx Tx
THA
Indications?
- SEVERE hip pain w/ motion and WB that has been WORSENING over time
- Impaired function and reduced QoL
DJD (OA) HIP
Sx Tx
THA
Prosthetic Components
-
Acetabulum:
- high density plastic or ceramic
-
Femur:
- metal alloy
DJD (OA) HIP
Sx Tx
THA
CEMENTED Polymethylmethacrylate
Cemented PMMH
explain…
- 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
-
GREATER risk of loosening over time
- ADVANTAGES:
DJD (OA) HIP
Sx Tx
THA
UNCEMENTED
**Bone grows INTO prosthetic**
- 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
-
protected WB initially*
- ADVANTAGES:
DJD (OA) HIP
THA
Hybrid THA:
- LESS COMMON
- Cemented acetabulum
- Press-fit femoral component
DJD (OA) Hip
Sx Tx
THA
Various approaches to gain access to hip jt affect post-op rehab
see pics
Posterolat Approach THA
vs.
Anterior Approach THA
Advantages vs. Disadvantages
Ant Approach THA
vs.
Posterolateral Approach THA
Precautions
see pics
DJD (OA) HIP
THA
Posterolateral Approach
- ROM:
-
No FLEX >90deg, No IR beyond neutral, No ADD beyond midline
- DO NOT CROSS LEGS
-
No FLEX >90deg, No IR beyond neutral, No ADD beyond midline
- 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
- Transfers: lead w/ UNINVOLVED side
DJD (OA) HIP
THA
Anterior Approach
- 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
- Do NOT cross legs when sitting
THA
Post-Op Precautions
- 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”
-
bending to tie shoes – combine FLEX w/ ABD
-
still not good to combine Hip Flex and ADD
THA
Post-op Education or “Pre-Hab”
- educate pt on expected ROM precautions
- rehearse proper gait pattern w/ AD
- instruct pt in ex’s that will be done immed. post-op
DJD of HIP
Sx Tx THA
EARLY PROTECTION PHASE
1 Day to 2 Weeks Post-Op
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
DJD (OA) HIP
Sx Tx
THA
EARLY PROTECTION PHASE
1 Day to 2 Weeks Post-Op
continued
- 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
- single knee to chest but keeping it LESS than 90deg w/ involved side
-
Anterior Approach
- __Do NOT stretch into EXT
DJD OA of HIP
THA
MODERATE AND MIN. PROTECTION PHASES
1-12 WKS POST-OP
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
Other Hip Sx’s
LESS invasive/aggresive vs. THA
- Hemi-arthro
- Hip resurfacing
- prosthetic “cap” over femoral head
- Arthroscopic mgmt labral tears
- repair vs. resection
- Sx debridement of osteophytes for Ant Acetabular Impingement
Other Hip Sx’s
When THA Fails…
- REVISION of THA
-
Girdlestone Procedure
- saw off head of femur
Femoral and Pelvic Stress Fx’s
Describe
- Mech. induced fx of prox. femur or pelvis
Femoral and Pelvic Stress Fx
mech. induced fx of prox femur or pelvis as a result of what?
-
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
Femoral and Pelvic Stress Fx
Differential Dx
- Acetabular labral tear
- Hip flexor strain
- Hip ADD strain
- Iliopsoas bursitis
- Osteochondral lesion
- Hip OA
Femoral and Pelvic Stress Fx’s
FACTS
- 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
Femoral and Pelvic Stress Fx
Dx Imaging
Plain Radiography
AP, Frog-Lateral
R/O other conditions (OA, tumor, etc.)
Examine for Displacement
Femoral and Pelvic Stress Fx
Dx Imaging
Bone Scan
Demos INCd focal uptake of radiotracer @ site of fx aka “HOT SPOT”
MAY read NEG. for first 24hrs after fx dev.
Femoral and pelvic stress Fx
Dx Imaging
MRI
Idea in Sn and Sp
Yields info about surrounding tissue (Diff. Dx)
Femoral neck stress Fx and runners
account for 6.6% of stress Fxs in runners
2 Anatomical classifications of Femoral Neck Stress Fx
-
Compression sided (pinching down)
- INF region of femoral neck
- non-operative mgmt
-
Tension sided (stretched)
- SUP region femoral neck
- ORIF (if caught late)
Femoral Neck Stress Fx
Clinical Presentatin
PAIN
- 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
Femoral Neck Stress Fx
Clinical Present
FUNCTIONAL
- 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***
Pelvic Stress Fx
- 1.6% of stress fxs in distance runners
- Pubic Ramus
- Palpable rami pain
Femoral and Pelvic Stress Fx’s
If running… 2-3 miles in they can go thru diff dx’s
- 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!!!***
Osteitis Pubitis
What should you remember???
DIFF bone stress injury
Can LEAD TO stress fx
Osteitis Pubitis
Description + Causes
- Inflamm. of Pubic Symphysis thru several pot. mech’s
- REPETITIVE athletic act.
- Degen OR rheumatic causes
- Urological/gynecological procedures OR pregnancy (non-infectious)
Osteitis Pubitis
Differential Dx
- 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
Osteitis Pubitis
Clinical Presentation
ONSET
Acute
Gradual
Osteitis Pubitis
Clinical Presentation
PAIN DISTRIBUTION
- Central symphysis region
- Prox. ADD region
- stresses pubic symphysis
- Lower abdomen
- stresses pubic symphysis
- Genital region
Osteitis Pubitis
Clinical Presentation
FUNCTIONAL LIMITS.
- Gait
- Swing Phase
- Pivoting
- Sport Specific:
- cutting, jumping, kicking
Osteitis Pubitis
Clinical Present.
MUSCLE IMBALANCES
**remember location!!!
-
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
Osteitis Pubitis
Clinical EXAM
- 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
- Multiposition ADD. Squeeze
- Often not apparent UNTIL pt does not respond to non-op tx
-
IMAGIING
-
Plain Radiography
- looking for surf. irregs and degen.
- MRI
- Edema
-
Plain Radiography
Athletic Pubalgia & Sports Hernia
what should you remember???
Pubic “pain” —> NOT ACTUALLY A HERNIA
There is NO hernia!!!!
Athletic Pubalgia
“Sports Hernia”
- 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.
Athletic Pubalgia
Involved Structures
- 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****
Athletic Pubalgia and ROM loss
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)
Athletic Pubalgia
Mech. of Onset
- 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
Athletic Pubalgia
Clinical Present.
S/S
- 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***
Athletic Pubalgia
Diff. Dx
- 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
Athletic Pubalgia
Cluster Approach Summary
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
-
NEGATIVE: FABER, FADDIR, SCOUR
- R/O Lumbosacral & SIJ involve
- LQS as approp.
Athletic Pubalgia
Prognosis and Tx Implications
Proper dx is imperative and syndrome class. necessitates an effective screening process for mult. regions
Athletic Pubalgia
Prognosis and Tx Implications
Trial of Non-Op Tx typ. indicated…
- impairment-based interventions
- Rest
- NSAIDs
- Corticosteroid injections
- Biological agents considered
Athletic Pubalgia
Prognosis and Tx. implications
Various Sx proc’s …
- Laparoscopic
- Open vs. “Mini” Open
Athletic Pubalgia
Prognosis and Tx Implications
Outcomes???
- 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
Meralgia Parasthetica
*Painful parasthesias
What is it and who is @ risk???
- 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
Meralgia Parasthetica
How to Test:
- 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
-
IF this relieves pt’s symptoms of lateral thigh burning, pain, parasthesia
Meralgia Parasthetica
Intervention:
- 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
Femoral Acetabular Impinge. or FAI
occurs when?
Occurs when there is DECd joint clearance b/w femur and acetabulum
FAI
3 types:
- CAM
* Femoral deformity- bony overgrowth
- CAM
- Pincer
* Acetabular deformity- acetabular overgrowth
- Pincer
- MIXED
FAI
CAM
aka “Pistol Grip” Deformity
Excessive bone @ head-neck junction
**bone grows OUT
CAM FAI
Delamination
separation b/w layers in the acetabulum
Pincer FAI
Cross-Over Sign
Acetabular RETROversion
Acetabulum covers TOO MUCH of femoral head
- 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
Cam vs. Pincer
https://www.youtube.com/watch?v=ENjq5Is94PE
FAI and Acetabular Labral Tears
- 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
Clinical Course and Outcomes for FAI
- 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)
Clinical Course and Outcomes for FAI
Sx Options
- 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)
-
Osteoplasty (prox femur OR acetabular rim)
- Open osteoplasty correction of FAI
-
Arthroscopy
FAI Progress to Early Arthritis???
EXPLAIN…
- 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
Spectrum of FAI-related Jt. Patho
**one pot. mechanism only**
- FAI==> altered jt mechs==> labral lesions==> chondral damage==> OA
The FURTHER a labral tear goes ___________, the LESS _______ it is
Labral tear further INTO JOINT== LESS REPAIRABLE
HIP LABRAL TEAR
SEE PICS
Acetabular Labral Tears
Pt Reported Symptoms
- Hx of hyperEXT or pivoting/twisting or fall
- pain, click, locking and/or catching
- may feel unstable (“giving way”)
Acetabular Labral Tears
MOI
most are in Ant/Sup region of labrum
Acetabular Labral Tears
Typ. Exam Findings
Imaging
-
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***
-
+ FABER (opp of FADDIR)
-
Imaging
- MRI or MRA (angiography)
Acetabular Labral Tears
Interventions
- 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
Structural Instability
vs.
Hypermobility
- Structural instability
- what the pt reports
**These two are NOT always EQUAL!!!
Components of Jt Stability
3
- Neural (proprioceptive/sequencing)
* Rehab Focus
- Neural (proprioceptive/sequencing)
- Active (muscular)
* Rehab Focus
- Active (muscular)
- Passive (ligamentous/boney)
* Sx Focus
- Passive (ligamentous/boney)
The Structurally Unstable Patient
*know underlying cause*
- 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!!!
Dysplasia
Labrum does MORE work
Bone does LESS work
- 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***
Capsulo-ligamentous Laxity
aka Ligamentous Laxity
- MAY be noted in conjuction w/ OR instead of boney abnorms
Capsulo-ligamentous Laxity
aka Ligamentous Laxity
2 Categories:
-
Generalized
* connect. tissue disorders- Ehler’s-Danlos
- Marfan’s
- etc..
-
Generalized
-
Focal
* iliofemoral ligament attenuation/damage
-
Focal
How do we measure Generalized/Universal Laxity?
Beighton’s Scale
Repetitive Micro-Trauma & Acquired Capsulo-ligamentous Laxity
- Abnorm forces thru hip transmit forces to iliofemoral ligament AND labrum
-
Results:
- Focal, rotational instability
- Elongated capsule
- Associated labral tear
Repetitive Micro-Trauma & Acquired Capsulo-ligamentous Laxity
MOI
- 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
Hypermobility Prognosis & Tx Implications
**if clinical presentation leads to impression of HYPERmobility—–NON-op tx measures recommended
- 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
-
Radiographs
Sidenote:
Hip Dysplasia
- 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
Structural hypermobility OR laxity DOES NOT ALWAYS result in______________
Clinical Instability!!!
Extra Articular Hip Injuries
What is KEY to effective Tx?
Accurate Dx
Extra-articular hip injuries
Multi-structural involvement
-
Co-existence w/ INTRA-articular involve.
- FAI
- labral tears
- Lumbopelvic component
-
Syndromes
- COMBINED core and hip musculotendinous structure involve.
Extra-articular Hip injuries
“Outliers”
Pelvic floor
Nerve entrap. syndromes
Extra-articular Hip injuries
Give some examples…
- 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)
Greater Trochanteric Pain Syndrome
GTPS
- labeled trochanteric bursitis in past
- Trochanteric inflamm IS POSSIBLE BUT….
-
Other structures often involved…..
-
Glute Med.
- tendinopathy
- tear
- Glute Min.
- tendinopathy
- tear
-
Glute Med.
-
Other structures often involved…..
Gluteal Tendinopathy
FACTS
MORE common in FEMALES
40-65yo
Gluteal Tendinopathy
Functional Diff’s
- Pain variable w/ walking, S/L, sitting
- Fatigue and possible gait disturbance
Gluteal Tendinopathy
Clinical Findings:
- 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
Trochanteric Bursitis
Pt Report
PAIN loc’d over lateral hip w/ referral to lateral thigh to knee
Trochanteric Bursitis
Mech. of Patho.
- Aggravated by ITB rubbing over trochanter
Trochanteric Bursitis
Risk Factors:
- Risk on “downhill leg” if running on banked road
Trochanteric Bursitis
Aggravating Acts:
- lying on affected side, standing asymmetrically w/ hip in ADD., walking/running on uneven surf. (crested road)
Iliopectineal Bursitis
Pt Report
Pain loc’d in inguinal region referring to the ANT thigh as far as knee
Iliopectineal Bursitis
Mech. of Patho
- bursa lies DEEP to iliopsoas tendon as it crosses hip joint
- CLOSELY assoc’d w/ hip jt patho
- DJD
- RA
- etc..
Iliopectineal Buritis
Aggravating Factors
- Rep’d hip flexion, rising to stand after prolonged sitting, prolonged walking
- Pts report pain w/ crossing legs OR ADD affected LE
Iliopectineal Bursitis
Interventions
- Focus on stretching iliopsoas
- hip mobs
- soft tissue mobs
- therapeutic modalities
Ischiogluteal or Ischial Tuberosity Bursitis
“Weaver’s Bottom”
Pt Report
- Pain over ischial tubs–esp in sitting
- MAY spread to sciatic distribution due to swelling
Ischiogluteal or Ischial Tuberosity Bursitis
“Weaver’s Bottom”
Mech. of Patho
- Sedentary indiv’s OR direct trauma to region
- bursa lies DEEP to glute max over isch. tubs.
Ischiogluteal or Ischial Tuberosity Bursitis
“Weaver’s Bottom”
Aggravating Acts
- Resisted hip EXT and HS’s painful
Ischiogluteal or Ischial Tuberosity Bursitis
“Weaver’s Bottom”
Diff. Dx
referral from LS or referral from hip may cause pain in same area
Ischiogluteal or Ischial Tuberosity Bursitis
“Weaver’s Bottom”
Specific Intervention
- Using a doughnut pad to relieve pressure while sitting
Hip/Pelvis Bursitis
Interventions
- 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
