Hip Flashcards
CAM deformity
Presence of excessive bone in the femoral head-neck region
An excessive (>60°) alpha angle
EMG studies have concluded that what exercise in weight bearing that produces significant gluteus medius muscle activity?
SL squat
Only direct muscular attachment to the sacrum
Piriformis
What 2 ligaments form the walls of the greater and lesser sciatic foramina
Sacrotuberous and sacrospinous ligaments
The amount of hip ROM is determined primarily by what?
Depth of the acetabulum and capsuloligamentous restraints
T/F: the entire femoral head is covered in hyaline cartilage?
False, all but the fovea (attachment of ligamentum teres)
Does the hip cartilage have vascular or neural supply?
It is limited with vascularity and aneural
Can pain in the hip be a result of cartilage involvement?
No, it’s aneural
Name of ligament connecting femur to acetabulum and location of attachment on femur
Ligamentum teres, fovea
Normal angle of inclination of the femoral neck/head
120°-125°
Coxa vara
- angle
- presentation
Angle of inclination <120°
Developmental or acquired
LLD, limping gait pattern, functional hip abd muscle weakness
Coxa valga
- angle
- presentation
Angle of inclination >135°
Compromised jt congruency = instability
Hip version (torsion) angle
Normal 8-20°
Anteversion of the hip
- high/low version angle
- in/out toeing
- Excessive ROM/limited ROM
High angle (>20°), In-toeing, excessive IR, limited ER
Retroversion of the hip
- high/low version angle
- in/out toeing
- Excessive ROM/limited ROM
Low version angle, out toeing, excessive ER, limited IR
What part of the proximal femur is most susceptible to fx?
Inferior area of the femoral neck (no trabuculae bone in that region)
Pincer FAI
Acetabulum has too much bone laterally (aka “over-coverage”)
Measured by LCEA (>40°)
Commonly associated with a retroverted acetabulum
Imaging of choice for diagnosis/assessment of acetabular angles (all)
CT
What region is cartilage the thickest in the acetabulum?
Superiorly (corresponding with weight bearing function)
What is located at the central acetabular fossa?
Fat pad, no cartilage
Are hip labral tears associated with degenerative changes
May be a precursor to cartilage damage due to not being able to distribute forces widely (happens in small area)
3 primary extra-articular ligaments
1) Iliofemoral
2) Pubofemoral
3) Ishiofemoral
What region of the hip is the capsule the thinnest
Posterior/inferior
Iliofemoral ligament limits what motion?
Extension, ER, add (superior band), abd (inf band)
Pubofemoral ligament limits what motion?
Abduction, secondary extension
Ishiofemoral ligament limits what motion?
IR, ext
Relevance of ligamentum teres in pediatrics
Thought to provide blood supply early on and decrease into adulthood
T/F: ligamentum teres plays a role in stability at the hip
Possibly, studies suggest it may help
Primary flexors of the hip
Iliopsoas and rectus femoris
Secondary flexors of the hip
Sartorius, TFL, pectineus, adductor longus
Young athlete, kicking sport, anterior hip pain should be screened for what?
Proximal rectus femoris apophyseal avulsion
Primary extensors of the hip
Gluteus max, HS
Secondary extensors of the hip
Glute Med, adductor magnus
T/F: the glute max also helps with hip abd and ER
True
Primary hip abductors
Glute med, glute min
Secondary hip abductors
TFL, glute max, piriformis, sartorius
All depends on position of the hip
Primary hip adductors
Adductor complex (add brevis, add longus, add magnus), pectineus, gracilis
T/F: there are no primary hip internal rotators
True, IR is not the primary function of any muscle in the hip region
3 clinically relevant bursae in the hip/pelvic region
1) Greater trochanter bursa
2) Iliopsoas bursa
3) Ischial bursa
Borders of the femoral triangle (anterior hip)
Upsidedown triagle shape:
Top = inguinal lig.
Lat = sartorius
Med = Add longus
Floor = iliopsoas and pectineus
What is the primary arterial supply for the leg
Femoral artery
Relevance of the femoral medial and lateral circumflex arteries
Branch off femoral artery, supply innervation to femoral head, if compromised causes AVN
Femoral nerve has what root levels
L2-L4
Vascular supply of the posterior hip
Branches of the internal iliac artery
Glute max and glute med/min/TFL are innervated by which gluteal nerves
Glute max = inferior gluteal
Glute med/min/TFL = superior gluteal
Loose packed position of the hip
30° flexion, 30° abduction, slight ER
Position for hip maximal articular congruency
90° hip flexion, slight abd and ER (quadruped)
However, position where jt dislocation is most common
Trendelenburg sign = drop ___ cm’s
> 2cm
Corticosteroid use can lead to what 2 conditions in the hip
AVN and fractures
Fluoroquinolone antibiotics can cause what condition at the hip
Gluteal tendinopathy
So if you have a pt with tendonitis and no MOI or other cause, screen for antibiotics
Slipped capital femoral epiphysis
- What is it
- Age range
- Sex
- Risk factor
- Unilat vs bilat
Growth plate is damaged and the femoral head moves (“slips”)
8-15 y/o, males, increased risk with obesity, bilat is common
If stable = non-surgical
If unstable = surgery
Legg-Calve-Perthes disease
- What is it
- Age range
- Sex
Disrupted blood supply to femoral head is temporarily interrupted = transient necrosis of the bone and deformities
4-10 y/o, boys
Self-limiting, non-surgical most of the time unless severe
Coxa saltans
aka Snapping hip syndrome
Iliopsoas over femoral head or proximal iliotibial tract over the greater trochanter
“C” sign typically indicates
Hip pain, impingement
Clinical prediction rule for inflammatory back pain - AS (can be hip as well)
1) Age <40 y/o @onset
2) Insidious onset
3) Better w/ exercise
4) No improvement w/ rest
5) Pain during 2nd half of night that improves w/ walking
How to differentiate between infection of the hip and gout
Typically will have big toe pain with gout
Reiter syndrome
aka Reactive arthritis
Type of arthritis that occurs due to an infection
Think: Can’t see, can’t pee, can’t climb a tree
Symptoms of hip fx
Extreme pain, extreme difficulty WB/flexing
and rotating hip/ambulating
AVN
30-50 y/o
Atraumatic
Very commonly had corticosteroid use
Pain >6wks
No ROM deficits early, but can mimic OA late
- D/T loss of blood supply
2 risk factors for stress fractures in endurance athletes
Female, previous stress fx
Female athlete triad
Low energy availability, menstrual dysfunction, low bone mineral density
Can put them at higher risk for stress fx’s
Compression-sided femoral neck stress fractures (FNSF)
Inferior-medial neck, LOW risk, non-surgical
Tension-sided femoral neck stress fractures (FNSF)
Superior-lateral neck, HIGH risk
Pubic rami stress fx
LOW risk, non-surgical, pain at inguinal/perineal regions
Symptoms of stress fx
Gradual onset, worse w/ activity and better w/ rest, pain at end-range PROM (specifically IR)
Patellar pubic percussion test
Stethoscope over pubic tubercle, tap on ipsilat patella
+ = lack of/diminished sound, pain
Good for femur fx’s, but unknown for stress fx’s
Gold standard for diagnosis of stress fx’s
MRI
Common Lumbopelvic screening tests
Prone instability test, thigh thrust, prone knee flexion test, lumbar ROM (single and repeated), neural tension tests, SIJ provocative tests
Are the SI joint cluster findings good at ruling in (specificity) or ruling out (sensitivity) SIJ pain?
Ruling OUT = 94% for 3/5 positive tests
To rule out pelvic involvement in hip pain what is the best outcome measure?
PGQ
Tests to assess lumbopelvic stability:
- Sagittal plane
- Frontal plane
- Rotational stability
Sagittal: Front plank
Frontal: Side-plank
Rotation: SL bridge
MMT for glute med vs min
Sidelying for both
- Glute min is in neutral (flex/ext/rotation)
- Glute med is slight ext and ER
Tests for anterior microinstability of hip joint
1) AB-HEER
2) HEER
3) Prone instability
+ test = pain in ant hip/groin
4) Log roll
+ test = increased ER of femur vs opposite
NOTE: cluster of 3 tests = 95% chance of instability
What is the most accurate test overall for anterior microinstability of hip joint
AB-HEER test
(SN/SP in 80’s)
Test for greater trochanteric pain syndrome
Gluteal de-rotation (high SN/SP)
SLS test (high SN/SP)
Deep gluteal syndrome
Defined as pain in the buttock area caused from a non-discogenic entrapment of the sciatic nerve possibly by the piriformis muscle
Tests for deep gluteal syndrome
Active piriformis test (Mod SN/SP)
Seated piriformis test (SP HIGH)
If used in combo with each other: SN 91% and SP 80%
Ischiofemoral impingement (IFI)
Abnormal contact between lesser trochanter and ischium
Tests for IFI
Long-stride (Better of the 2)
Sidelying ischiofemoral impingement test
Tests to determine chronic proximal HS muscle involvement (cluster of 3)
1) Puranen-Orava test
2) Bent knee stretch test
3) Modified bent knee stretch test
NOTE: if traumatic onset, early testing that stresses the tissues inappropriately are CONTRAINDICATED
Functional tests to assess valgus collapse of LE during dynamic task
Also have the 2 tests been validated?
Step-down, SL squat
Used to assess control of multiple jt’s during SL dynamic task
Yes, the tests have been validated in non-arthritic hip pain population (shown to have less pain and greater functional ability)
SL squat > step-down
STAR Excursion Balance Test
Used to assess control of multiple jt’s during SL dynamic task
Assesses combo of strength, flexibility, balance, and proprioception
Tests for functional performance in arthritic hip pain
6MWT, 30” chair stand, step test, TUG, self-paced walk, timed SLS, 4-square step test, stair measure
MDC for 6MWT
48ft
MDC for 30” chair stand test
3.5 reps
MDC for step-test
3 steps
MDC for SLS test
10.8 seconds
Common cluster of findings in FAIS
Primary complaint is groin pain, “C” sign, functional limitations that involve end-range jt positions (especially in a repetitive manner), strength deficits (hip abd and ER/IR), tight hip flexor muscles (maybe)
T/F: FABER and FADIR tests are both good for FAIS?
False, only FADIR has shown screening utility
Is FAI a precursor to hip OA
Yes
Applicable functional measures for FAIS and microinstability
Step-down, SL squat, SEBT test (better in FAI)
Special test(s) for FAIS
FADIR
Special test(s) for hip microinstability
- Log-roll, FABER,
AND 3 specific for anterior jt instability:
AB-HEER, HEER, prone instability
may also have + Beighton scale
Mechanical risk factors for hip OA
FAI, dysplasia, previous injury to the jt structures, high BMI
What ROM loss is most prominent in hip OA
IR
Special test(s) for hip OA
Scour, FABER, Long-axis distraction
NOTE: these tests are NOT included in OA cluster of findings
Microinstability of the hip is most commonly caused by what?
Insufficient stabilization of the joint from the capsuloligamentous structures (anterior jt capsule and iliofemoral lig) that is caused by repetitive microtrauma
Clinical presentation of hip microinstability
Groin/deep hip pain, “C” sign, functional difficulties w/ activities that combine loading the hip in ER/EXT, strength deficits (abd/rotators)
Beighton scale
- what body parts
- what is threshold for laxity
Pinkies (>90° ext), thumbs (to forearm), knee and elbow hyperext (>10°), palms on floor
4/9 = threshold for presence of jt laxity
What is the single leading factor related to hip OA before 50 y/o?
Hip dysplasia
Hip dysplasia clinical findings
Hip ROM WNL or excessive, weakness (iliopsoas and hip abd), labral pathology, + FABER and FADIR (may be false +), + anterior hip instability tests
Cluster for diagnosis of arthritis hip pain (OA)
1) Moderate ant or lat hip pain w/ weight bearing activities
2) Morning stiffness <1hr
3) Hip IR ROM <24°
OR
Hip IR and FLEX 15° less vs opposite side
4) Pain w/ PROM IR
What balance tests are appropriate for hip OA?
BERG, 4 square step test, timed SLS test
What functional outcome tests are appropriate for hip OA population?
6MWT, stair climbing, 30” chair stand test
Coxa saltans external vs interna
Coxa saltans externa: laterally by the ITB
Coxa saltans interna: iliopsoas tendon
Ilipsoas complex injuries are common in what sports?
Dance, football, soccer, ice hockey
Any running or kicking sport
Adductor complex injuries are common in what sports?
Ice hockey and soccer
What muscle is most commonly affected by adductor complex strain
Adductor longus
Risk factors for hip adductor muscle injuries
- Previous groin injury
- Poor offseason training (ice hockey <18 sessions)
- Hip muscle weakness
- Decreased hip ROM
- Lack of sport-specific training
(Flexibility/strength) deficits have a stronger association with injury in hip muscle strains, specifically adductor complex injuries.
Strength
Athletic Pubalgia
aka “Sports Hernia”
Abdominal and groin pain likely from weakening or tearing of the abdominal wall WITHOUT evidence of a true hernia
Commonly associated with adductor pain
Cluster of signs/symptoms of Athletic Pubalgia
1) Deep groin pain
2) Pain increases w/ exertion, decreases w/ rest
3) TTP pubic rim 2-3cm lat to pubic tubercle
4) Pain w/ resisted hip add
5) Pain w/ resisted ab crunch
Signs of immediate concern and referral to rule out HS tendon avulsion
Proximal posterior thigh pain w/ traumatic onset, inability/unwillingness to bear weight, visible ecchymosis, palpable deficits in proximal HS
Cause of LE numbness/tingling post-HS injury
(NOT lumbar related)
Large hematomas can compress sciatic nerve
More (distal/proximal) HS pain has been associated with longer recovery peroids
Proximal
Is the width and length of the tender region in HS injuries important in prognosis?
Width = no
Length = predictive of return to sport
Strongest predictor of a future HS injury?
Previous HS muscle injury
Risk factors for HS injury
- Previous HS injury
- > age
- Previous knee injury/surgery
- Weakness
- Decreased muscle length
- Overall limb stiffness
- Poor lumbopelvic stability
- SIJ dysfunction
- Proprioceptive deficits
T/F: Recurrent HS injuries can lead to reduced sciatic nerve mobility
True, slump test has been recommended to assess
Tightness in (quad/HS) has been shown to be associated with increased HS injury risk
Quadriceps
No association between HS tightness and injury!!
T/F: Isolated HS strengthening and stretching is better vs agility and core stab program for reduction of HS re-injury rates
False, core stab and agility is BETTER vs isolated HS work
Special tests for GTPS
FABER, gluteal de-rotation, SLS tests
NOTE: in athletic populations more dynamic SL activities may be indicated (step-downs, SEBT etc)
Demographics of GTPS
Women, 40-65 y/o, can be in athletes
Hallmark symptom of GTPS and common functional deficits
Lateral hip pain
Lying on side, stairs, walking, standing, sometimes sitting
Recently, (more/less) emphasis has been placed on length of the ITB-TFL muscle fascial complex when assessing GTPS
LESS, more focus on strength (movement dysfunction)
4 Clinical signs/symptoms for piriformis syndrome (w/ or w/o sciatica)
1) Buttock pain
2) Pain with sitting
3) TTP near greater sciatic notch
4) Pain w/ maneuvers that cause tension of piriformis
What special tests are indicated for piriformis syndrome
Active piriformis test & seated piriformis test
When combined = Good screening and diagnostics
Can also use step-down task - as poor eccentric piriformis strength may contribute to excessive adduction and IR
Special tests for IFI
Long-stride test & side-lying IFI
NSAID use in hip OA
NSAID use is effective tx for symptoms (per CPG)
HOWEVER, some evidence associated it with increased fx risk in high activity population, may also increase progression of hip OA
Interventions for FAIS
1) Early education and activity modification (avoid provoking positions)
2) Stretching (especially hip flexors)
3) Jt mobs
4) Strengthening (emphasize abd and rotator muscles)
5) Neuromuscular control/recruitment (i.e. perturbations)
6) Task-specific (step-downs, SL squats etc)
7) Lumbopelvic stab activities
Is there return to play criteria for FAIS?
No, but recommended to use the one for knee injuries
Interventions for hip microinstability
1) Education and activity mod (avoid repetitive end-range motions that stress passive stabilizers - ext and ER)
2) Neuromuscular re-ed (perturbations)
3) Strengthening (NWB in mid-range, progress to end-ranges as appropriate, ALSO hip abd/rotator/core are emphasized!)
Caution and possible avoidance of: stretching and mobs (especially those anteriorly)
Interventions for hip dysplasia
1) Education & activity modification (Joint protection strategies, cross training or training volume modifications)
2) Exercises to address muscle weakness (progressive, not aggressive), postural control, and motor control deficits
3) Gait/running pattern training
Caution and possible avoidance of: stretching and mobs
Interventions for hip OA
1) Education & activity modification (AD, jt protection strategies, BMI management)
2) Strengthening (especially glute med) w/ dosage (2-3x/wk 2-4 x 8-12 reps)
3) Manual therapy (Mobs, STM)
4) Flexibility/stretching (at least 60” total stretching time)
5) Endurance as appropriate
6) Functional/gait/balance training
7) Aquatic therapy if severe
8) Aerobic exercise (affects central pain mechanisms and mood)
T/F: Combo heat and US with exercise is superior to just heat and exercise
True
NOTE: only demonstrated by one study
Weight bearing restrictions for PNSF and pubic rami fx’s
Lasts 6-8 wks, prevent further progression of fx
What type of exercises are appropriate for PNSF and pubic rami fx’s?
NWB exercises that address impairments, caution w/ supine and side-lying SLR activities, do emphasize glute med
Can also use aquatic therapy for “weight bearing” early on
When can you progress exercises in PNSF and pubic rami fx’s? (from initial program)
When radiographic evidence shows fracture union
Weight bearing restrictions S/P fixation of tension-sided fx’s
AND
Return to sport timeline
NWB 6wks, PWB 6wks
Return to sport ~3-6 months
Are NSAIDS indicated for extra-articular injuries of the hip?
Use has been debated, there is a study that shows it can reduce strength loss, muscle soreness, and blood creatine kinase levels following ACUTE muscle injuries
Interventions for iliopsoas complex injuries
1) Activity modification (avoid provoking activities, cross train to avoid deconditioning)
2) Stretching (can be used in combo w/ STM)
3) Gradual strengthening (LE/core)
4) Endurance exercises (this in combo w/ lumbopelvic strengthening should start early)
5) Return to sport/activity (when appropriate)
Interventions for adductor injury
1) Education & activity mod (avoid excessive tension to adductors
2) Early on - gentle ROM hip/knee AND lumbopelvic stab
3) STM (evidence is lacking but favorable results have been noted)
4) Flexibility activities (ONLY once symptoms are stable)
5) Strengthening (isometric->concentric->eccentric)
What is the criteria to progress out of the protective phase of rehab when it comes to adductor muscle strains?
Tolerance of therapeutic exercise, low-level ADLs, and symptom stability
What is the adductor to abductor ratio?
In hockey players, you are 17x more likely to have an adductor strain if the muscle is less than 80% of their abductor strength
What test should be used to evaluate return to sport in adductor strains?
Copenhagen 5” adductor squeeze test (0°, 30°, 45°, 90°)
NOTE: best @ 45° hip flexion
During EARLY stage of HS strain rehab how long is max recommended time for immobilization
Max 3-4 days = to prevent excessive scar tissue formation
During EARLY stage of HS strain rehab are mobilization and excessive stretching recommended?
NO, should be avoided
After short period of relative immobilization, ROM exercises in pain-free range is recommended
T/F: Toe-touch or NWB gait patterns with crutches are recommended post-HS strain
FALSE, they may actually create excessive tensile loads on HS
INSTEAD, use flat foot and normal mechanics
Interventions for EARLY phase of HS strain
- 3-4 days immobilization
- AVOID excessive stretching or early mobilization
- After short period of rest = ROM exercises in pain-free range
- Can use crutches if needed (only normal pattern or flat foot)
- Therapeutic exercise = low intensity, within pain-free ranges (isometrics)
Interventions for INTERMEDIATE phase of HS strain
- LE and lumbopelvic strengthening (HS - progressive resistance, start w/ isotonics @mid-range)
- Stretching (if no significant weakness)
- Neural mobs prn
- SL balance and proprioception
Interventions for LATE phase of HS strain
- Strength and flexibility progression (end-range, lengthened state, eccentric, high velocity)
- Progress balance/proprioception
- Sport specific or work training
If significant HS weakness is noted in intermediate phase of rehab is aggressive end-range stretching encouraged?
NO, it should be avoided as musculotendinous unit is weakened and can’t prevent further injury during stretching
What criteria is needed to switch from HS concentric strengthening to eccentric?
When good tolerance to all activities AND >50% HS strength vs opposite limb
Return to sport criteria for HS injuries
None, can use H test (SLR 3x/quick w/ knee extended) can test apprehension
Best sleeping position for those with severe GTPS
Supine w/ slight hip abduction
Primary goal for tx of GTPS
Manage load and compressive forces at the greater trochanter region through strengthening (gluteals) and optimizing movement patterns
Primary goal of tx for piriformis syndrome
Reduce muscle irritability and decrease compression of the sciatic nerve (if involved)
Interventions for piriformis syndrome
- Education/activity mod: minimize compression or lengthened state of the piriformis (avoid crossing legs, lying on one side w/ top leg crossed over, sitting on wallet)
- STM: may be helpful as long as it doesn’t progress symptoms
- Stretching (not aggressive)
- Strengthening of hip/lumbopelvics
Goal for tx of ischiofemoral impingement (IFI)
Minimzing the position of impingement of the quadratus femoris within the QFS
What muscle group tightness may play a big role in IFI
Hip adductor tightness
Interventions of IFI
- Education and activity mod: MOI and pain management strategies
- STM (limited evidence)
- Dry needling (limited evidence)
- Jt mobs (if capsular limitations)
- Stretching (especially adductors, stretch them in extension)
- Strengthening (especially abd and ER’s) of LE’s and lumbopelvic
Evidence for jt mobilization in hip OA vs non-arthritic hip
Hip OA = STRONG
Hip non-arthritic = limited (use expert opinion)
Evidence for dry needling in management of hip pain
Limited, may help for short-term pain relief (<12wks)
Exercises that demonstrate relatively isolated glute medius muscle recruitment
- Side-plank w/ hip abduction
- Side-plank to neutral position
- Front plank w/ hip ext
- Side-lying hip abd
Compound movements that show high glute medius recruitment:
SL squats, reverse lunges, variations of step-downs
3 exercises with highest gluteal medius vs TFL recruitment ratio
1) Resisted clamshell
2) Resisted side-steps
3) SL bridge
What exercise and its variations result in the greatest amount of glute max recruitment?
Other exercises show high potential for glute max muscle recruitment?
Step-ups
Other for glute max: hip thrust, squat, deadlift, lunges
T/F: Lumbopelvic strengthening should be a standard consideration for ALL hip pathology
True
Is use of bio-feedback for lumbopelvic stab activities indicated in hip population
Yes
Are balance and gait training indicated in tx of hip pathology
Weak evidence for OA population, BUT it should be used to reflect goals and functional demands of the patient
Outcome measures for non-arthritic hip conditions
1) Hip Outcome Score (HOS)
- ADL and sports
2) 33-item International Hip Outcome Tool (iHot-33)
- QOL in active patients
3) Copenhagen Hip and Groin Outcomes Scale (HAGOS)
- longstanding hip/groin pain
Outcome measures for arthritic hip conditions
1) Western Ontario and McMaster Universities Arthritis Index (WOMAC)
- Instrument of choice for assessing consequences of hip or/and knee OA in elderly
2) Hip disability and Osteoarthritis Outcome Score (HOOS)
- QOL in pt’s w/ hip disability and OA
3) Modified Harris Hip Score (MHHS)
- Low level tasks
LCEA angle
Lateral central edge angle (LCEA)
- Normal 25°-39°
LCEA <25° = (overcoverage/undercoverage)
Undercoverage = dysplasia
LCEA ≥40° = (overcoverage/undercoverage)
Overcoverage = pincer FAI
