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Hip Flashcards

1
Q

Differential For Groin Pain

A
  1. Pelvic avulsion fractures (more common at ASIS and AIIS and in skeletal immature)
  2. Pubic apophysitis (pubic symphysis is last part of human skeleton to mature so can be into early 20’s)
  3. Pelvic ring stress fracture
  4. SCPE (adolescents)
  5. Legg-Calve-Perthes Disease (adolescents)
  6. Acetabular dysplasia
  7. Hip OA
  8. Muscle strain (particularly adductor longus, rectus femoris, iliopsoas)
  9. Avascular necrosis
  10. Femoral fracture (neck fracture or shaft stress fracture)
  11. Lumbar spine referral
  12. SI referral
  13. Inguinal-related pain
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2
Q

Ruling out avascular necrosis

A

Limited research but suggested that normal hip ROM rules this out

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3
Q

Ruling out femoral fracture or stress fracture in clinic

A

The patella-pubic percussion test (sensitivity, 95%; negative likelihood ratio = 0.07) and fulcrum test (Negative likelihood ratio = 0.09 and another study 0.92) provide good to limited clinical utility to help rule out femoral neck fractures and femoral shaft stress fractures.

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4
Q

Femoral Neck Stress Fracture and Imaging

A

Radiographs often won’t be able to pick these up, especially early on, and cannot rule these out. MRI is a better option for this.

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5
Q

How to rule out avulsion fractures

A

Radiograph

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6
Q

How to rule out avascular necrosis

A

Radiographs

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7
Q

How to rule out lumbar spine pathology

A

A lack of peripheralization or centralization (sensitivity, 92%; negative likelihood ratio = 0.12) of the athlete’s symptoms with repeated lumbar spine ROM testing and negative straight leg raise (sensitivity, 97%; negative like- lihood ratio = 0.05) and slump testing (sensitivity, 83%; negative likelihood ratio = 0.32) assist with ruling out the potential existence of discogenic/radiculopathy pathology. Facet joint pathology is best ruled out with a negative extension- rotation test (sensitivity, 100%; negative likelihood ratio = 0.00).

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8
Q

How to rule out SI joint

A

The thigh thrust test has good clinical utility to rule out (sensitivity, 88%; negative likelihood ratio = 0.18) potential sacroiliac joint pathology.

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9
Q

Adductor-Related Groin Pain

A
  1. TTP with palpation
  2. Pain with resisted adduction
  3. Pain with stretching
  4. Pain may radiate down to knee

Ruling out if not reproducing pain with palpation (>90% accuracy). Can use ultrasound or MRI.

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10
Q

Iliopsoas-Related Groin Pain

A
  1. Pain may radiate to anterior part of proximal thigh
  2. Pain with palpation
  3. Pain with resisted hip flexion
  4. Pain with hip flexor stretching

Ruling out if not reproducing pain with palpation (>90% accuracy). MRI or US may be helpful.

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11
Q

Inguinal-Related Pain

A

Pain in the inguinal canal and inguinal canal tenderness, or pain with Valsalva maneuver, coughing, and/or sneezing. No palpable inguinal hernia found, including on invagination of the scrotum to palpate the inguinal canal. Pain with resisted abdominal muscle testing.

One proposed etiology of inguinal-related pain is that posterior abdominal wall weakness leads to bulging of abdominal structures that compresses the genital branch of the genitofemoral nerve.

Laparoscopic surgery for hernia repair has been shown to have a higher return to play than non-surgical rehab but conservative rehab is recommended first.

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12
Q

Pubic-related groin pain

A

Will have local tenderness of the pubic symphysis and adjacent bone. No specific resistance test but more likely if there is pain with BOTH resisted testing of the abdominals and the adductors.

Imaging can often show findings in asymptotic populations but higher grades of pubic bone marrow edema and a protrusion of the symphyseal joint disc can be associated with pain.

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13
Q

Hip-Related Groin Pain

A

Clinical tests work well as screening tests but positive tests only indicate the need for further testing (diagnostic imaging).

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14
Q

FAI Syndrome

A

Motion- or position-related pain in the hip or groin. Pain may also be felt in the back, buttock, or thigh. Patients may also describe clicking, catching, locking, stiffness, restricted range of motion, or giving way. CAM or PINCER morphology must be present on imaging. Limited range of hip motion, typically restricted internal rotation, and evidence of labral and/or chondral damage on imaging

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15
Q

Ruling out apophysytis

A

MRI best to look at this but clinically recommended diagnosing based on age, location of pain near pubic insertion, and worsening of symptoms with adductor related exercise.

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16
Q

Hip OA

A

In older athletes, hip OA should always be considered and is clinically indicated by hip flexion of 115° or less and hip internal rotation less than 15°, and radiographically verified as joint space narrowing or presence of femoral or acetabular osteophytes.

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17
Q

Research on ROM and Strength Deficits For Those With Groin Pain

A

Research not clear on if there are ROM deficits compared to controls. All adductor/pubic related groin pain, hip pain, FAI, and after scopes show strength deficits, often in multiple planes. The adductors have been shown to be weak for those with groin pain. Also, athletes with adductor and pubic related groin pain have been shown to have weak abductors and abdominals.

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18
Q

Suggested Management For Adductor Related Groin Pain

A

Regular rehab is first choice but for recalcitrant cases can do a partial adductor longus tenotomy.

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19
Q

Relevance of CAM morphology with pain?

A

If adductor related pain and imaging reveals this they have good prognosis with regular rehab compared to hip related pain.

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20
Q

Angles for femoral head in relation to shaft?

A

In frontal plane, the angle of inclination is normally 120° to 125° in the adult population. In the transverse plane, the proximal femur is oriented anterior to the distal femoral condyles as a result of a medial torsion of the femur, with a normal range between 14° and 18° of anteversion.

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21
Q

What is the functional role of the gluteus medius?

A

Primary frontal plane stabilizer of the hip

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22
Q

Difference between CAM and pincer impingements?

A

Cam impingement is the result of asphericity of the femoral head, which is often related to a slipped capital femoral epiphysis or other epiphyseal injury or protrusion of the head-neck junction occurring at the proximal femur. Pincer impingement is the result of acetabular abnormalities, such as general (protrusia) and localized anterosuperior acetabular overcoverage of the femur (acetabular retroversion). Excessive acetabular coverage anteriorly may result in premature abutment of the femoral neck on the anterior acetabular rim. Impingement may be more pronounced when relative femoral retroversion and anteversion are, respectively, combined with acetabular retroversion and anteversion. The third category is a combination of the cam and pincer impingement, which is likely the most common category.

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23
Q

Can torn labrum cause pain?

A

It has free nerve endings and can be a source of nociception.

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24
Q

Common Findings With Impingement?

A
  1. Pain in groin or lateral hip/trochanter
  2. Pain with sitting
  3. Pain described as sharp or aching
  4. Pain produced with FADIR
  5. IR at 90 limited to 20 or less
  6. Radiographic findings of CAM or pincer impingements
  7. Hip flexion and abduction also limited
  8. Clicking, popping, catching noted
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25
Q

Symptoms seen with structural instability?

A
  1. Groin, lateral hip, or generalized pain
  2. Pain with FADIR or FABER
  3. Popping, locking, or snapping are present
  4. Greater than 30 degrees IR in 90 flexion
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26
Q

Symptoms/diagnosis of intra-articular pathology (labral tear, loose bodies, chondral defect)

A
  1. Groin pain or generalized hip pain
  2. Snapping, popping, clicking present
  3. FABER or FADIR painful
  4. MRA findings (3T MRI equal to 1.5T MRA)
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27
Q

Physical Impairments to Measure For Non-Arthritic Hip Pain?

A
  1. Trendelenburg Sign (Have them hike and hold 30 seconds; can have light support if needed)
  2. FABER (Support the opposite ilium; can add OP if no pain)
  3. FADIR (Flex to 90 and then do full IR and add)
  4. Log Roll (Make sure knee and ankle stay still)
  5. Passive IR and ER (prone and sitting)
  6. Passive hip flex and abd (both supine)
  7. Hip Abd MMT
  8. Hip IR MMT (sitting and supine with leg off EOB)
  9. Hip ER MMT (sitting and supine with leg off EOB)
  10. Hip Flex Strength Test (sitting, stabilize anterior shoulder and hip all the way flexed)
28
Q

Education for Impingement

A

Avoid positions that consistently place the hip in positions of impingement

29
Q

Strengthening for Hip Pain

A
  1. With excessive external rotation there is likely decreased IR strength
  2. With excessive internal rotation there is likely decreased ER strength
  3. For instability you likely need abduction and rotational strength
30
Q

Osseous ROM Limitations (impingement and version’s)

A

These will be hard end feels and should not be treated with flexibility.

31
Q

What is a sports hernia?

A

Activity-related groin or lower abdominal pain that involves abnormal tension in the inguinal region or tissue disruption (most commonly the posterior wall of inguinal canal at transversalis fascia). Pain usually brought on with palpation of pubic ramus, resisted hip flexion, hip adduction, and trunk flexion.

32
Q

Presentation of sports hernia?

A
  1. More common in males
  2. Usually unilateral but as symptoms progress you may feel things on both sides
  3. Pain usually above the inguinal ligament (below inguinal ligament more likely hip or adductors) but can be in pubic region, groin, and sometimes medial thigh
  4. Palpation tenderness in abdominals
  5. No bulge present
  6. Pain with exertion or abdominal activation
  7. Likely pain with resisted adduction
33
Q

British hernia society’s position statement on diagnosis of sports hernia

A

3 of the 5 must be present:

–Pinpoint tenderness over the pubic tubercle at the point of insertion of the conjoint tendon
–Palpable tenderness over the deep inguinal ring
–Pain and/or dilation of the external ring with no obvious hernia evident
–Pain at the origin of the adductor longus tendon
–Dull, diffused pain in the groin that often radiates to the perineum and inner thigh or across the midline

34
Q

Pathology seen with sports hernia

A

About 85% of people with this have weakening of the posterior wall of inguinal ring. In some athletes there was also disruption of the external oblique aponeurosis. May also have micro tears of transverse abdominis fascia; disruption of tendons or rectus abdominis or external oblique at pubic bone.

35
Q

Anatomy of the inguinal canal

A

Floor = inguinal ligament
Anterior Wall = external oblique aponeurosis
Posterior Wall = Transversalis fascia
Roof = Combined fibers of internal oblique and transversus abdominis muscle and aponeurosis including conjoint tendon

36
Q

Hip joint pathology seen with sports hernia

A

There is a subset of athletes who present with symptomatic intraarticular hip disorders in conjunction with sports hernia. It is hypothesized that femoroacetabular impingement can increase compensatory stresses that contribute to development of sports hernia.

37
Q

Prognosis with sports hernia

A

Conservative treatment rarely resolves symptoms. Surgery indicated for recalcitrant cases and is very successful. Sometimes may need to do both hip and sports hernia surgery if the impingement led to the sports hernia.

38
Q

Sports hernia clinical exam

A
  1. Palpate obliques, TA, conjoined tendon (IO/TA)/rectus abdominis
  2. Perform crunch with palpation of distal/lateral rectus abdominis
  3. Palpate pubic tubercle and pubic symphysis
  4. Palpate adductors
  5. Adductor MMT
  6. Valsalva/cough
  7. Palpate superficial/deep inguinal ring
  8. Examine hip joint ROM
39
Q

Osteitis Pubis

A

Inflammatory process of pubic symphysis and surrounding structures. Usually produces pain in groin or pelvic region with pain during adduction and activity. Can use radiographs or MRI to help diagnose. Early cases radiographs may be normal, MRI can differentiate between acute and chronic cases. Conservative treatment is most recommended and may take up to 3 months.

40
Q

Acetabular Fracture

A

Usually happens from axial load to the femur with athletes. If greater than 3 mm displacement will usually recommend surgery. If surgery, start with PROM and move into AROM/NWB exercises and then begin PWB about 6 weeks with full WB at about 10 weeks.

41
Q

Imaging for sports hernia?

A

MRI is most appropriate

42
Q

Where do hamstring strains most often occur?

A

Intramuscular tendon of biceps femoris is most commonly injured with running injuries (terminal swing). The proximal free tendon of the semimembranosus is more commonly injured during kicking/dancing injuries (hip flex/knee ext) and usually take more time to heal.

43
Q

Risk factors for hamstring injuries

A

Previous injury, lack of flexibility, hamstring weakness, hamstring/quad strength imbalance, pelvic/trunk strength/coordination deficits.

44
Q

Physical Exam for Hamstring Strains

A
  1. Hip extension and knee flexion strength
  2. ROM (hamstring flexibility and knee ext ROM)
  3. Palpation
  4. Rule on adductor strain
  5. Look for signs of neural tension
45
Q

Best imaging for hamstring strains?

A

US and MRI

46
Q

Factors that will likely increase rehab time for hamstring injury

A
  1. Involvement of proximal, free tendon
  2. If it’s closer to ischial tuberosity
  3. Increased length and cross-section of injury
47
Q

Factors that lead to high risk of re-injury for hamstring strains

A
  1. Persistent weakness of muscle
  2. Reduced extensibility
  3. Adaptive bio mechanical changes
48
Q

Best/Least Supported hamstring strain treatments?

A

Best:
1. Eccentric strengthening
2. PATS (progressive agility; trunk stabilization)
Limited Support:
1. Massage
2. Flexibility
3. Electrophysiological agents

49
Q

Recommended rehab stages for hamstring strains?

A

Phase I includes
a focus on minimizing pain and edema, protecting scar formation, initiating low-intensity,
pain-free exercises of the entire lower extremity and lumbopelvic region. Phase II
includes an increase in the intensity and range of motion of exercises and initiation of
eccentric actions of the hamstring muscles. Phase III involves more aggressive and sport-
specific movements through full and unrestricted range of motion

50
Q

Meralgia Paresthetica

A

Entrapment of the lateral femoral cutaneous nerve. This nerve exits below the inguinal ligament and goes anterior to the AIIS. It provides sensation to the anterior and lateral thigh. Can be from obesity, pregnancy, tight clothes, abdominal swelling. Usually more symptoms in standing/walking since there is more tension around the inguinal ligament. Differential would be L3 radic or femoral neuropathy. During exam, can palpate the lateral part of the inguinal ligament where nerve passes (may be painful).

51
Q

Legg-Calve-Perthes Disease

A

Idiopathic avascular necrosis of the proximal femoral epiphysis in children. Can be detected with radiographs or in early stages with MRI. Treatment usually observation for those under 8, femoral and/or pelvic osteotomy in those over 8. Male:Female is 5:1. Ages 4-8 is most common age of presentation. Bilateral in 12% of cases. Symptoms may include intermittent hip, knee, groin, or thigh pain. Usually loses hip IR and abd ROM. May have trendelenburg gait or painful/painless limp.

52
Q

Slipped Capital Femoral Epiphysis

A

Slippage of the metaphysis relative to the epiphysis. Most commonly seen in adolescent obese males (males 2x more likely). Diagnosis made with radiographs. Ages 10-16 most common (during puberty). About 25% of time is bilateral. Treatment is pin fixation. Metaphysis translates anteriorly and externally rotates. Mostly atraumatic, pain usually present several months. Pain in hip most common but can often have knee pain and lead to missed diagnosis. Patient usually prefers to sit in a chair with affected leg crossed over other. Usually antalgic gait with ER’d leg or trendelenburg. Loss of hip IR, abd, and flex.

53
Q

ITB Syndrome

A

Pain at lateral knee (superior to joint line). Often has weakness of hip abductors. Thought to compress innervated adipose tissue under ITB. Impingement zone occurs at around 30 degrees knee flex during foot strike and early stance phase of running. Pain usually when foot hits ground or when coming down stairs.

54
Q

Snapping Hip Syndrome

A

Snap or click in/around hip when in motion. Classified as external, internal, or intra-articular in origin. External (most common) is ITB snapping over greater trochanter. Internal is iliopsoas over bony prominence of pelvis. Intra-articular is least common. Higher incidence in sports that involve repetitive hip flexion/extension. More common in females. External snap can be evaluated clinically but internal likely needs US.

55
Q

Femoral Stress Fracture

A

Neck stress fractures are high risk for complications (particularly displacement); shaft stress fractures are low risk. May complain of hip or groin pain that is worse with weight bearing and ROM (especially IR). 2 types of neck stress fractures: tension-type and compression-type. Tension-type involves the superolateral aspect and are highest risk for complete fracture. Compression-type involves inferomedial neck. Femoral shaft stress fractures usually cause poorly localized, insidious leg pain often mistaken for muscle injury. Fulcrum test can be used. If no evidence of cortical break on imaging, a non-surgical approach can be attempted. MRI has highest sensitivity/specificity. May want to be limited WB with crutches for 6-8 weeks (but up to 14) until the pain is completely gone and then go from TTWB to PWB. Only progress activity with clear evidence of fracture union. Return to sport can be 3-6 months but sometimes up to a year.

56
Q

Cam and pincer morphology

A

Can lead to damage of articular cartilage and labrum. Higher instances of cam in men and pincer in women. FADIR test is not specific and looks at anterior rim of acetabulum. Pain associated with posterior rim can be provoked by passively bringing hip from flexion to extension while keep maintaining hip abd and ER. Often have strength deficits with hip flexion and adduction.

57
Q

Labral Repair Rehab

A
  1. If tear in anterior/superior region of joint then period of partial WB implemented for 2-4 weeks (more stress in this area)
  2. If posterior repair then ROM may be limited to 90 flex and neutral IR
  3. If anterior repair then ROM may be limited to 10 for extension and neutral for ER.
  4. WB and ROM restrictions typically persist for 4 weeks (then can progress these)
58
Q

Resisted External Derotation Test

A

Great test for gluteal tendinopathy.
+LR: 32.6
-LR: 0.12

59
Q

FADDIR Test

A

Not good for ruling in. Better for screening.

60
Q

Thomas Test

A

For labral tear:
+LR: 11.1
-LR: 0.12

61
Q

Patellar-Pubic Percussion Test

A

Stethoscope is on the pubic tubercle, no the pubic symphysis.
+LR 6.11
-LR 0.07

62
Q

Fulcrum Test

A

+LR 3.7
-LR 0.09

63
Q

What are the 4 types of labral tears?

A
  1. Radial flap
  2. Radial fibrillation
  3. Longitudinal peripheral
  4. Abnormally mobile
64
Q

Movements to avoid with labral tear and FAI?

A

Deep flexion and rotational stresses

65
Q

What should hip adductor to abductor strength ratio be?

A

At least 80% to decrease risk of adductor injury.

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