Hip Flashcards
Does intra-articular hip pain a localized or global set of symptoms
Intra-articular hip pain really goes into just the hip
What is the normal range for femoral torsion
How do you measure it
Normal 8-15°
Under 8° toes out Increased ER- retroversion
Over 15° toes in -Increased IR Anterversion
Craigs test: prone, measure angle between tibial shaft and table when the greater trochanter is most lateral
Describe character traits of someone with developmental dysplasial
Mostly girls, White, unilatera
Signs and symptoms of developmental dysplasia
limited or asymmetrical abduction asymmetrical thigh false positive Galezzi, telescope, or ortolani signs
Developmental dysplasia treatments
Below 9 months:Abduction diaper Pavlik harness
Past 9 months: abduction orthosis or surgery
Open packed position of the hip
FABER
One of the only joints where openpacked position is optimal articular contact, not the closed packed position.
Flexion and external rotation tend to uncoil the ligaments and make them slack
How do you distinguish Synovitis from septic arthritis
Septic arthritis:
Will present with fever, malaise and decreased appetite. Young: two years old, Hip held an open pack position to due to pain
Tx: Aspiration, IV and antibiotics.
Synovitis
inflammation of synovial lining
Not medical emergency like septic arthritis. Usually has upper respiratory infection. Can lead to AVN. Decreased hip IR due to pain, fever LESS than 101
Tx: managed with partial weight-bearing now and imaging needed due to soft tissue origin
Describe leg calves Perthes disease
Very young boys, AVN of femoral head, self limiting, unilateral
pain at night, decreased hip abduction and external rotation, most comfortable position an open pack position and present with hip flexion contracture. Psoatic limp is worst in the day, Obligatory adduction
Treatment: promote optimal compressive forces and Osteokinematic compressive F for spherical head to develop, usually have THA at early age
Describe SCFE
Occurs in skeletally immature patients boys 10 to 16 years old
- Growth plate defect
- 50% or bilateral
- Gradual onset with medial side hip pain
Decreased extension and hip IR and increased hip flexion angle
- Images: A-P frog leg
- 3 Grades: greater than 50% slippage = grade 2
- treatment: ORIF
SAME DAY OR ER REFERRAL
in very active or fat boys
What are non-musculoskeletal origins of hip pain
Appendicitis: Mcburey point 3.8-5.1 cm (1.5-2 inches) from the navel to the RIGHT ASIS,
Hernia
Kidney/Uterur referral
Hip OA cluster
What is the most specific OA finding
*Moderate anterior or lateral hip pain with weight bearing activities
*Morning stiffness >60 minutes
Decreased IR and Flexion by >15° difference from CL side, or <25 IR ROM
*Painful IR
* > 50 years
Decreased IR is most Sp, but any ROM loss could be due to OA
Intra-ariticlar hip pain sign
FABER
Hip Labral tear cluster
Hip locking
Catching, clicking pain
Instability, instances of giving way
Anterior hip pain
Diagnosis of Labral tear anterior vs posterior. Which is more common?
Rule out labral tears using FABER, if (-) than tear isnt there. FABER is a intra-articular sign. Clicking is a good way to rule in, moderate association
Resisted SLR tests the posterior labrum. Test position is in ER and ABD
Femoral impingement test: will test the anterior and superior labrum, position of IR and ADD for test.
Hip labral tear MOI
Extension and ER
Surgery for hip displasia
PAO to correct loss of coverage
H.D is a combo of pincer and CAM deformity
Illiopsoas bursitis
Pain with direct palpation and MMT resisted hip flexion
May have snapping
Due to over use
pain over anterior hip
Femoral neck stress fracture
Can be tension (worse) or compression fracture (Compression at femoral neck)
Consider bone health and frail females
May not see fracture for 3-4 weeks but MRI is gold standard
Osteitis pubis
Can occur after lower abdominal Sx like bladder or prostate surgery
Overuse related to muscular imbalance in pelvic instability. Ab muscles and posterior vertebral muscles work together to stabilize pelvis.
- tests: compression test Faber decreased hip range of motion SI joint dysfunction pubic symphysis gap test adductor muscle testing unilateral and bilateral
- Pain with kicking?
How do you rule in Nerve entrapment.
If no pain and just weakness, rule in nerve entrapment.
How can you tell Obturator N. entrapment from lateral femoral cuteanous nerve and Inguinal nerve entrapment
-Obturator N: medial thigh pain with exercise and adductor weakness
-Inguinal N: Groin and scrotal pain, overdoing it, Ab mus hypertrophy, preg. Hip hyper extension will bring on symptoms
-Lateral femoral cuteanous nerve: Sensory only over lateral/anterior thigh. Also known as merlagia parethestica
How do you rule down SIJ pain with hip concerns
SIJ pain will not present in anterior hip
Pain will be in groin, thigh and butt and mostly PSIS
How can you rule up kidney involement with hip pain?
Costovertebral thumb test by thumping first over ribs to vibrate kidneys
unrelieved by position
Signs and symptoms in piriformis syndrome
Pain in glutes
Aggravated with sitting
Tenderness over greater sciatic notch
Increased pain with piriformis tension: Add+IR with palpation of greater sciatic notch
Active piriformis test: Side lying, resistance in FABER
What does the sciatic nerve branch into
L4-S3
Branches off to the tibial nerve and common peroneal nerve.
-Common peroneal nerve goes to short head biceps and and splits into the superficial (innervates lateral leg muscles) and deep peroneal nerve to innervate anterior leg muscles
what is the sciatic nerve innervation and what the relationship to the pirifomris
L4-S3, Sciaitc N runs through the piriformis and superior gluteal nerve innervates the piriformis
What does the sciatic nerve innervate?
.
hamstring muscles, adductor magnus, and glutes (via inferior gluteal N
Can be tested with the SLR test
What is Maralgia paresthetica
Sensory loss of lateral femoral cutaneous nerve L1 - L3
Burning, aching, numbness, buzzing lightning over lateral anterior thigh.
Must rule out lower back pain
Relief with sitting may occur due to decreased pressure on inguinal nerve
Tests: Pelvic compression test to decrease pain, Femoral N neuro dynamic testing
How can you distinguish: Bursitis, Glutemedius and minimus tendinopathy, tendon tear, and IT band, snapping hip syndrome
-Bursitis will feel boggy to palpation
- Tendinopathy will react to activity and will have muscle based signs such as weakness, trendelenburg and + ER derotation test
-Tear will have a related MOI and dramatic weakness
- IT band syndrome/ snapping hip will have + Obers test, TFL hypertrophy, snapping will distinguish it from IT band pathology
-Internal snapping hip is also known as coxa sultans and affects the femoral head and the illiofemoral ligament
What is Coxa Sultans
- Internal snapping hip is a syndrome
- Caused by the snapping of the iliopsoas tendon over the underlying hip capsule and femoral head.
- Popping with repetitive active hip flexion and extension
- doen’t have to snap to make the diagnosis
What is elys test
Patient lays prone and you flex one knee. Also called Thomas test.
Positive for rectus femoris tightness if the hip of the leg that is flexed pops up off the table
What is the FAI progression
FAI can be associated with labral tears.
Impingement and related tears can lead to joint arthritis
Labral tears are due to bony issue or abnormality and can lead to FAI or developmental dysplasia
What are types of hip impingement
CAM - “Fat neck” aspherical femoral head with bony prominence at antero-lateral head and neck junction
impinges on rim. Lleads to superior OA. Seen in young athletic males
FADIR causes pain and is better test than FABER.
PINCER- over coverage of head by acetabulum, which pinches neck.
Can lead to posterior-inferior or central OA. Middle aged females
Ext and ER cause pain
What is the imaging gold standard for FAI
MRA because MRI can miss bony cysts
What are characteristics of FAI
Anterior hip pain, they will point to hip C-sign
Coxa valga, > 135*
Clicking
ER and Ext MOI
“ACE”
What are intra articular tests
Fitzgerald
FABER
Scour
Resisited SLR
Distraction
Impingement tests
What are recommneded compoents to at least inclide in hip OA exam
ROM in all planes
Faber, Scour test
NPRS
What is the MCID for the WOMAC, what should it be used for?
12-22% is MCID. Shoulder be used with hip OA
What are risk factors for OA
low socioecomnic status
devepopmental dx
decreased ROM
Increased bone mass or BMI
subchondral cycts
Which tests can detect hip impingment
Hyper-mobiltiy is different than micro-instability
Log roll
FABER: < 3 inches between the lateral knee joint line and table with the leg in the FABER position is suggestive of increased laxity of the hip joint
- Anterior instability test: AB-HEER, prone instability, and HEER
- Beighton scale >5/9
What are A level interventions for hip OA
Manual therapy, flexibility, strength and endurance
What are B level interventions for hip OA
Patient education with exercise or MT
US: 1 MHZ/1 watt 5 mins
What is drehmans sign
Decreased IR and ER. Obligatory ER and ABD during passive hip flexion ROM in SCFE and LCPD.
Stress Fx
Suspect females with female athlete triad or REDS: Poor nutrition loss. Decreased bone density
Endurance athletes
Consider history: previous stress fx, load and rest
Describe AVN
Can happen in 30-50s
Mimics OA
Refer/ suspect of no improvement in 6 weeks
Corticosteriod use x 3 months mg/day is a risk fx
What is the difference between apophysitis and in avulsion for ASIS
Both:Can range from 12 to 25 years old and have pain with active flexion
- Sartorious attaches to ASIS
Avulsion: will include fracture from insertion site, MOI is traumatic. Imaging with xray to confirm, ORIF
Apophysitis: overuse, treat with rest load management and Progressive strengthening
FAI is an umbrella term for which deformities and concerns
Femoral acetabular impingement syndrome deformities include CAM and pincer deformity’s.
Labral tears are you continuum of FAI syndrome progression
What are signs and symptoms femoral acetabular impingement syndrome
Younger population, C sign, aggravating factor of FADIR
Clicking is associated with labral tears
Which impairments are associated with femoral acetabular impingement syndrome
Hip weakness, anterior pelvic tilt, shortened hip flexors, weak core
What would you expect to find in a patient with hip microinstability
Hyper-mobility controbutign the micro instability, pain, apprehension, possible connective tissue disorder with at least four out of five score on Bighton score for mobility
A patient with underlying hip micro instability would have familiar symptoms with which motions?
External rotation + extension is a feeling of apprehension.
Will present with ER and shortened hip flexors
Cluster: or Abduction Hyperextension External Rotation Test (AB-HEER performed in SL), prone instability, HEER tests (pretty much the thomas test)
Which test of the apprehension test for hip micro instability has the best sensitivity and specificity
AB - HEER
AB-HEER
Hip OA treatment Do’s and Dont’s and maybes
DO: MT with exericse to progress and maintain ROM with EDU and Ultra Sound
MAYBE: WBing, gait, balance, weight loss
DONT: bracing
How do you treatment interventions differ from FAIS and labral tears
FAIS: treated with activity modification flexibility and joint mobilization address pain and tightness
Labrum: address weakness and control impairments via strength endurance and control
Which locations are predisposed to snapping hip syndrome of the hip
Lateral hip: also known as greater trochanteric pain syndrome
Anterior hip also known as Coxa sultans. Illopsoas tendon snaps over anterior capsule.
Locations of snapping: Iliopsoas over the femoral head,
proximal lesser trochanter,
iliopectineal eminence
Gluteus maximus over the greater trochanter
Distinguish athletic pubalgia from Ostitus pubis
Athletic pubalgia
weakness/injury of the posterior inguinal wall distal to the abdominal attachment at pubis
Cluster: deep groin pain increased with activity, pubic ramus tenderness 2 to 3 cm lateral pubic tubercle, pain with resisted crunch and hip abduction
Osteitis Pubis:
chronic, 30-40s, serere burning and ache
How to distinguish hamstring grades 1 2 and 3
Grade 1 : Majority of fibers are intact, less than 15° deficit active knee extension test
Grade 2: Partial fiber disruption, limited walking ability, 1 to 2 day activity limitation 16 to 25 AKE test, larger area, Echymosis may be present
Grade 3: complete tear, deformity present, extreme inability to walk 26 to 35° deficit in AKE test
Largest risk factor for hamstring injury
previous HS injury
when to consider avulsion for hamstring injury
Presence of Echymosis, unable to weight bear, palpable deformity
Predicting factors of hamstring injury extent
Greater percentage of hamstring tenderness, older age, proximal location
Hamstring injury prevention
Nordic hamstring exercise in superior exercise warm-up, strengthening, RTS movement
How to distinguish ishiofemoral impingement from hamstring injury
distinguish impingement from hamstring using active and passive range of motion of knee flexed and extended. Hamstring MMT shouldn’t recreate symptoms in impingement.
What are differential diagnosis for greater trochanteric pain syndrome and how to distinguish
Bursitis, external snapping hip, Glute minimus/medius tendon apathy or can be distinguished from one another with palpation.
GTPS will have aggravating factors of pain with active adduction, hip weakness, pain with direct pressure such as laying on the side prolonged activities of walking
What is the underlying cause of GTPS
Tissue compression over GT due to overuse, leads that TFL hypertrophy and/or weak ABductors ,tissue compression and poor frontal plane control (Trendelenburg). This leads to impairments such as TFL hypertrophy and pain cycle.
Patient profile GTPS and differential diagnosis
Females in 40s to 50s and athletes. Rule out hip OA.
Related to muscular impairments
excess IR and ADD may cause TFL adn IT issues
aggravation with laying on side and prolonged activities
How to distinguish gluteal tendinopathy versus gluteal tendon tear
Gluteal tendinopathy will present in middle/older woman with weak abductors and external rotators. Trendelenberg sign will be present pain, single leg stance with less than 30 seconds positive the rotation test
Glute tear: Will present with more severe weakness with the potential for severe pain and Echymosis if a cute. To be treated with irritability level based interventions
What is return to sport criteria for hip flexion and abduction injuries
Adductots strength greater than 80% of hip abductors
What are the short term, intermediate and long-term goals for hip hamstring injury rehab progressions
Acute: symmetrical ROM, normalized gait, no pain with submaximal isometrics
Subacute: symmetrical hamstring strength, adequate control, eccentric exercises OK, symptom free jogging
Late RTS goals: strong and pain-free all ROM, no apprehension with H - test, plyos high velocity and perturbation training
What is the pain monitoring model for hamstring injury rehab progressions
<4/10 pain during tx for optimal strength gains
Characteristics of femoral nerve neuropathy versus saphrenous nerve neuropathy
Femoral nerve neuropathy: quad weakness, entrapment is at the hip flexor if hip flexor weakness is present. hip flexion is spared if the entrapment is under the inguinal ligament. Decreases patella DTR and sensation in thigh and saphrenous pattern (medial knee, lower leg, medial foot, first MTP)
Saphenous nerve neuropathy sensation only in saphenous nerve pattern
Distinguish obturator nerve neuropathy from lateral femoral cutaneus nerve neuropathy
Obturator nerve neuropathy
will affect adductors and sensation at the medial thigh. Entrapment at adductors. Expect aggravation with hip extension and adductor stretch
LFCN
No weakness sensation loss ONLY over lateral thigh
Aggravated with tight belts/clothing.
+ tinel test at ASIS or just medial to it.
Also known as meralgia persthetica
What are aggravating factors for OA
Weight-bearing, not necessarily sitting, suspect greater trochanteric syndrome
What are aggravating factors for FAI
Hip flexion
What are aggravating factors for GT syndrome
Adduction, direct pane over area, pressure
What are aggravating factors for glute tear
Extreme weakness with MMT and single leg stance. Distinguishes from tendinopathy
