Hip Flashcards
Prevalence in osteoporosis vs osteopenia
both W>M over 50. Especially osteoporosis
Osteoporosis recommendations
-Screening for rfs >50
-BMD testing for females >65, males >70 (younger post-menopausal women w/ 1 major or 2 minor rfs)
Hip fx stats, progs
-Mostly sustained by people >65
-Survivors have shortened life expectancy
+ prog: sx in 48hrs
- prog: males, >86, >2 comorbs, anemia, mini mental test <6/10
Femur fx prognosis and categories
Prog: displaced vs non, comminution, vascular integrity, reduction, fixation.
-high risk thrombosis/embolism
-intertrochanteric: between trochanters
-subtrochanteric: below trochanters
monitor for AVN and non-union
compression fx more stable than tension fx
Hx with hip fx
-older adult
-trauma vs spont.
sxs hip fx
where pain is
severe groin and anterior thigh pain (more likely than lateral pain)
Hip fx examination
-shortening of LE
-limited/painful squat
-painful/limited AROM/PROM all directions
-pain/weakness with strength testing
+fulcrum and PPT
Hip fx surgical procedures
arthroplasty
external fixation (rare, temp.)
ORIF- full WB 8-12 wks postop
intramedullary fixation
AVN of the femoral head
basically what it is
-Progressive ischemia w/ secondary bone cell death
-Collapsing of bone, leads to degenerative arthropathy
-managed surgically
Hx AVN
30-50s
Rfs: trauma, corticosteroid use, alcys, coagulation disorders, HLD, smoking, autoimmune disease, etc
AVN pain location
deep groin, buttock, and knee pain
AVN examination
-Limited squat
-limited/painful AROM and PROM (IR especially)
-pain/weakness w/ resistive testing
AVN prognostic indicators
Extent of lesion
Location
Bone marrow edema presence
Osteoarthopathy stats
> 65 w/ hip or knee OA
radiography: joint space loss, osteophytes, sclerosis
-symp. vs asymp.
Osteoarthropathy hx
-insidious
-hx of trauma
-family hx
-obesity
-hypermobility
-joint shape abnormality
-physical activity levels
->50yo
Osteoarthropathy sxs
-dull and achy most, but sharp buttock, groin, thigh, and knee pain when aggravated
-C-sign
-hip stiffness (sitting/inactivity)
-difficulty donning pants, socks, shoes
-Stair ambulation issues
Osteoarthropathy examination
-limited hip AROM/PROM, painful at end range (especially IR, flexion, ABD)
-+Scower
+/- weakness/pain w/ resistive testing (bc we avoid end range with MMT)
joint hypomobility
CPR for hip OA
- report squatting as an aggravating activity
- lateral pain w/ active hip flexion
- passive hip IR <=25
- pain with active hip ext
- +scower w/ ADD
(having >=4 is best predictor)
Labral tear correlated with
degenerative oa
developmental hip dysplasia
aspherical femoral head
slipped capital epiphysis
legg-calve-perthes disease
hip trauma
athletics with repetitive pivoting/flexion
FAI
Most common sxs of labral tear
-insidious onset
-groin pain mostly
-activity related pain
-night pain
-locking, pain in walking and pivoting
-limping slight
-requires banister with stairs
FAI 2 types
Cam: increased size of femoral head, irregular junction with neck
-leads to anteriosuperior labral and cartilage damage
Pincer: increased protrusion of acetabular rim
most common is a mixture
FAI hx
hockey players, golfers, dancers, football and soccer players
FAI sxs
sharp, deep anterior pain
pain/limit with deep squat (deep flexion motions)
cutting, lateral movements
hip IR/ ABD motions
-may have painful ER motions with extensive lesions
FAI examination
Cam especially
Cam: hip flex/ABD/IR ROM painful/limited (may have bony end feel)
+ FABER and FADDIR
MRA/MRI to measure angle and identify lesions
Loose bodies - what is it? Characteristics?
-free floating body (cartilage/bone) within joint
-vary in size
-secondary to degen. changes in hip
- may cause muscle inhibition (weak, discoordination)
Hx loose bodies
-chronic hip pain
-advances OA
-prior traumatic hip dislocation
-Prior AVN
Loose bodies sxs
-anterior hip/groin pain
-catching, locking, clicking, giving way LE (mechanical issue)
-sudden pain w/ WB activities
Loose bodies examination
limited AROM/PROM with catching/grinding
springey end-feel w/PROM
Loose Bodies implications
identify, refer, managed with arthroscopy
Snapping hip 3 categories
Intra-articular
Internal
External
Intra-articular SHS
synovial chondramatosis (tumor)
loose bodies
labral tears
long head biceps over ischium and iliofemoral lig over femoral head
Internal SHS
iliopsoas over femoral head, lesser trochanter, pectineus, iliopectineal eminence
fibrosis/tenosynovitis of iliopsoas tendon
snapping/ painful anterior hip (especially extending from flexed position)
pain/snap with movement from FABER position to ext, ADD, IR
External SHS
ITB/glut max over GT
lateral hip pain/snapping
aggravated by running on slanting surfaces, directional change on planted LE
-observed at:
hip: increased compression on soft tissue structures btw GT and ITB
knee: btw lateral femoral condyle and ITB
ITB contracture vs weak glut med and hip ERs
Painful Ober test
lead to GT bursitis
Tendon acute injury Phase 1
inflammatory
first 3 days
tendon healing phase 2
reparative/collagen
within first week
increased fibroblasts through week 4
collagen fibers initially disorganized and random
they become more aligned and perpendicular to long axis over time
tendon healing P3
remodeling
collagen/cell re-alignment typically complete by ~2 months
Why do we want controlled tensile loading for healing?
parallel organization associated w/ improved tissue strength
motion can aid in preventing cross-linkage between tendon tissue and sheath tissue
tendinopathy- involved structures
rectus femoris
iliopsoas
gluts
tendinopathy hx
internal SHS
Tendinopathy sxs
anterior thigh/groin pain
Tendinopathy examination
painful/weak resisted hip flex
painful/limited hip ext and IR ROM (guarded/empty end feel)
Muscle tissue injury- strain degrees
-DOMS possibly
-Contusion (bruise)
-Strain:
1st: min. structural damage
2nd: partial tear
3rd: rupture
Muscle strain healing
excellent regenerative capacity
outcome and time affected by type, severity, extent
Muscle strain phases
Destruction: gap forms with disrupted fibers
-tissue necrosis and development of local hematoma /edema
Repair: hematoma forms, primary matrix forms/ fibroblasts synth. proteins, collagens produced
Remodeling: tissue matures and contracts
Muscle strain examination
tender to palp. muscle bellies with palpable defect
antalgic gait
ecchymosis/edema several days
pain/weak RT, limited/pain AROM w/ concentric contraction
pain/limited A/PROM placing stretch on musculotendinous unit (90-90, SLR test)
Strain: Hamstrings
what muscle is difficult
rfs
RTS criteria
Biceps femoris: greater recovery time and risk for recurrence
Rfs: prior hx, hammy weakness, older athletes
RTS criteria: jogging 70% baseline, RTS at 90-95% baseline
Hamstring strain hx
distinct injury/audible pop
MOI: sprint w/ trunk flex and fast running
Strain: ADDS
rfs, MOI, sx
rfs: prior hx, decreased ROM hip ABD
soccer,hockey
MOI: directional change when running
sx: groin pain (worse quick stops/starts)
Strain: Iliopsoas
MOI
sxs
MOI: forced hip ext during active hip flex
sx: anterior hip/groin pain, painful high stepping
Strain: Quads
most difficult muscle
rfs
MOI
Rectus femoris worse prognosis- longer recovery
rfs: older athletes, dry playing field, shorter, dom. LE strength/flex
MOI: kicking while running, sprinting (accel/decel)
Strain: glut med/min hx
fall, increased duration/frequency of loading, sport-related injury
middle-aged women
Strain: glut med/min sxs
buttock/lateral hip/ groin pain
Bursitis- Trochanteric
greater risk: 40-60y/o
W>M
lateral hip pain, tender GT,
+FABER, pain rotation, ABD/ADD, radiating pain down lateral thigh
pain hip ABD against resistance
Bursitis- Iliopasos/Iliopectineal
frequently un-recognized
anterior hip pain
pain/limited hip flex ROM
pain/limited hip ext and ER
tender to palp/ between anterior joint and iliopsoas
GTPS
where tender
may involve what
correlations
TTP GT with pt side-lying
may involve glut max/med/min bursae, muscle attachments, other soft tissues
correlations: hip/lumbar/knee OA, tendinopathy, ER strain
prevalence with mechanical LBP, and knee OA
GTPS hx
females
obesity
LBP/ chronic arthropathy of hip/knee
middle age/older
GTPS sxs
pain greater at night
aggravated w/ standing >15min
radiating sxs (paresthesia/pain)
limits/pain w/ donning and doffing socks/shoes
sxs radiate to knee or below knee
GTPS examination
excess ABD vs ADD during gait
TTP lateral hip
ITB tight
+FABER, resisted external derotation
pain/limit hip ADD ROM (possibly IR too)
Pain/weak hip ABD and ER RT and AROM
Nerve entrapments -how to find
-remember pathways
-start prox, work dist
-is structure sensory, motor or both
-potential mechanisms for compression
3 categories PN injuries
-compression (low and high pressure)
-interruption of axonal continuity
-stretching (tensile)
Low pressure compression injury
-impaired circulation in epineural for prolonged time
-depletion of O2 in endothelial cells of capillaries-increased vascular permeability
-leaking of fluids/protein into endoneural space (edema)
-Increased EFP -occludes vessels that penetrate perineurium
-endoneural edema and O2 depletion
Sciatic N vs Obtuator N- potential areas of compression
S: piriformis, ischial tuberosity/GT, long head BF
O: overlying fascia
S vs O -motor distribution
S: hammys, fibular and tibial distributions
O: ADDs/IR
S vs O -sensory distribution
S: lower leg tibial and fibular dist.
O: medial thigh and knee joint
S vs O -clinical indicators
S: Achilles and hamstring DTRs diminished
O: hx pelvis fx, THA, pelvic sx, prolonged labor
Femoral N vs Lateral femoral Cutaneous N. -areas of compression
F: inguinal canal
LFC: inguinal canal
F vs LFC -motor dist.
F: knee extensors
LFC: N/A
F vs LFC -sensory dist.
F: anterior thigh/lower leg
LFC: anterio-lateral thigh
F vs LFC -clinical implications
F: diminished patellar reflex, aggravated hip ext, EMG good prog for recovery in year
LFC: latrogenic, compression from belts, obesity, pregnancy, improves with hip flex/sitting, worsens standing/walking
Avulsion fxs characteristics
who gets them
involving?
M>W
2nd decade (young athletes, growth plates)
mimics apophysitis
involving: ischial tub., AIIS, ASIS, pubic symphysis, iliac crest, LT/GT
Avulsion fxs hx
vigorous activities
Avulsion fxs sxs
known trauma
local pain (worse w/ activity, better w. rest)
Avulsion fxs examination
TTP
antalgic gait/limp
hematoma
crepitus
muscle guarding
limit/pain hip ROM (stretching contractile unit)
pain/weak RT (of action unit does)
Stress fx pathophys
repetitive microtrauma
osteoblastic activity lags compares to osteoclastic activity
may progress to cortical disruption (clear fx line) then complete fx
Fatigue fx vs insufficiency fx
F: normal bone, abnormal stress
I: abnormal bone, normal stress
Low risk stress fxs
compressive
managed w/ activity
-pain free activity 4-8wks
location: femoral shaft, medial tibia, ribs, ulna shaft, mets 1-4
High risk stress fxs
prog worsens with time required for dx
prolonged NWB
locations: femoral neck, patella, anterior tibial diaphysis, medial malleolus, talus, navicular, prox 5th met, 1st MTP seasmoids
Stress fx hx
why it happens
what’s affected
rfs
insidious, progressive
ADLs affected with progression
continual pain w/ pathologic progression
increased training intensity
rfs: females, amenorrhea, smoking, steroid use
Stress fx sxs
focal pain
exercise-induced pain
night pain
stress fx examination
what pt will present like
local tenderness
limited ROM at joint area (guarded or painful end feel)
palpable guarding
possible local swelling
MRI, bone scan
Stress fx HIP sxs
5% of all stress fxs (that’s high)
exercise-induced pain
hip,groin, thigh, or referred to knee pain
night pain
WB activity aggravates
Stress fx hip examination
specifically pain and dx
diffuse groin/hip pain
+PPPT, fulcrum
MRI, bone scan findings
