Hip Flashcards
degrees of freedom of hip joint
3, 6 osteokinematic directions
capsular pattern
joint specific pattern of restriction of passive movement
hip capsular pattern
flexion>IR>abduction limitations
open packed capsular restriction
flexion and ER
How does hip joint congruency differ from other joints?
Very congruent, meaning less accessory movement so mobilizations are less effective
increased stability with mobility
femoral head vascularity
ligamentum teres - 1/3
circumflex
superior/inferior gluteal arteries
4 major ligaments of the hip
iliofemoral: anterior, Y
pubofemoral: anterior
ischiofemoral: posterior
ligamentum teres: blood supply and stabilize at 90 flexion
stabilizer muscles of the hip
psoas, hip rotaters
hip clock orientations
felt around greater trochanter
12: glut med
1-2: glut min
3: glut max
4-5: vastus lateralis
6-7: quadratus femoris
8-10: conjoint tendon
10-11: piriformis
flexors of the hip
iliacus
TFL
sartorius
rectus femoris
adductor longus
pectineus
assist: gracilis, adductor brevis, glut min anterior fibers
extensors of the hip
glut max
hamstrings
adductor magnus posterior fibers
assist: glut med
abductors of the hip
glut med
TFL
superior glut max
glut min
assist: sartorius, rectus femoris, piriformis
adductors of the hip
adductor group
pectineus
gracilis
Assist:
obturator externus
internal rotaters of the hip
no pure internal rotaters
TFL
glut min
glut med
adductor longus/brevis
semimebranosus/tendinosis
external rotaters of the hip
obturator internus/externus
gemellus sup/inf
quadratus femoris
piriformis
glut max
posterior glut med
biceps femoris
functional mobility at hip
shoe tying: 120 flexion
sitting: 112 flexion
squatting: 115 flexion/ 20 abduction/20 IR
up stairs: 67 flexion
down stairs: 36 flexion
put on pants: 90 flexion
normal angle between head of femur and neck
125 degrees
How does the angle at the femoral neck change the hip?
increased angle: coxa valga
decreased angle: coxa vara
coxa valga
creates increased stress across joint surfaces
shortens hip abduction moment arm to be disadvantageous
increased LE length
creates varus at knee, stress to medial side
more likely to get FAI
coxa vara
more horizontal femoral neck
increased downward shear force
decreased angle of pull for hip abduction
creates valgus at knee, stresses lateral side
more prone to fx due to increased torsional/shear force
femoral anteversion
neck is oriented anterior, smaller angle of head and neck in transverse plane
results in hip IR and in toeing
femoral retroversion
increased angle of femoral neck and head in transverse plane
results in hip ER and out toeing
avascular necrosis of femoral head
dead bone/bone marrow into subchondral plate cause by lack of blood flow to femoral head
PT treatment of avascular necrosis
the aftermath, we can catch condition but primary treatment is surgery
subjective findings of avascuar necrosis
groin pain radiating to lat hip, knee, buttock
deep throbbing
intermittent gradual onset
antalgic shift
risk factors for avascular necrosis
corticosteroid high cumulative dose
alc use
systemic lupus
sickel cell
trauma
cancer
objective findings of avascular necrosis
painful ROM esp IR OP
pain w SLR
antalgic gait
complications of avascular necrosis
incomplete Fx
superimposed degenerative arthritis
Legg Calve Perthes Disease
osteonecrosis of femoral head in kids 4-10
malformed bone due to less blood supply
unilateral
4x more in boys
disorder of epiphyseal cartilage
subjective findings of Legg Calve Perthes DIsease
vague groin ache radiating medial thigh to inner knee
muscle spasm
objective findings of Legg Calve Perthes DIsease
limp/leg drag
thigh muscle atrophy
child small for age
positive trendelenberg
out toeing involved side
decreased abduction/IR
hip flexion contracture
Legg Calve Perthes DIsease treatment
monitoring by physician if mild/mod
severe: operative
slipped capital femoral epiphysis
displacement of femoral head from epiphysis/growth plate during growth spurt
anterior displacement of femoral neck
common in adolescents
subjective findings of slipped capital femoral epiphysis
pain worse w activity
groin/med thigh pain with some knee or lower thigh pain first
dull/aching
leg weakness
no Hx of trauma necessary
objective findings of slipped capital femoral epiphysis
walk w difficulty and limp, ER involved foot
decreased hip ROM in IR, adb, flexion
IR loss is greater in flexion
ER with passive hip flexion
involved extremity 1-3 cm shorter
risk factors for slipped capital femoral epiphysis
obesity
male
sports involvement
slipped capital femoral epiphysis interventions
relieve symptoms
contain femoral head
restore ROM
surgical fixation if necessary
femoral neck stress Fx
result of accelerated bone remodeling as response to repeated stress
neck is weak point due to angle and lack of trabeculae in area
who gets femoral neck stress Fxs?
military recruits/athletes/runners
older persons: superior neck/tension Fx
younger persons: inferior femoral head/compression fracture
femoral neck stress Fx subjective findings
sudden hip pain associated w change in training
deep thigh pain
pain in WB and end range motion
radiate into knee
night pain
femoral neck stress Fx objective findings
negative physical exam
empty end feel or pain at end range IR/ER
pain w resisted hip ER
+ resisted SLR
+ ausculatory patellar/pubic percussion test
+ fulcrum test
diagnose w MRI, not xray
ausculatory patellar/pubic percussion test
place stethoscope over pubic symphysis
tap patella and note sound
repeat on both sides
+ is diminished percussion on side of pain
femoral head stress Fx intervention
surgical for tension Fx
compression: bed rest to NWB until WBAT once pain free
progress weight bearing
hamstring strain
1 or more hamstring muscles
partial, often in eccentric phase w tension while lengthening
hamstring strain subjective findings
distinct MOI
running or deceleration
pop at injury
posterior thigh pain
worse w knee flexion
hamstring strain objective findings
tenderness with passive stretching
tender to palpation
pain w resisted knee flexion
isolate muscle w IR/ER
hamstring strain intervention duration
grade 1: continue activity as tolerated, pain as guide
grade 2: 5days-3weeks
grade 3: 3-12 weeks
sample hamstring strain interventions
prone curls
supine stretch
machine loaded curls in prone/seated
SL bridge
good mornings
lunges
SL squats
nordic curls (eccentric)
ball hamstring curls and hamstring bridges
barbell deadlift
SL deadlift
dumbbell swing
Adductor tendinopathy
MOI, involved muscle
mostly comonly adductor longus
common adductor pathology proximally
caused by repetitive loading with twisting/running
muscular imbalance of stabilizing muscles of hip
subjective findings of Adductor tendinopathy
twinge/stab pain in groin
edema/ecchymosis
aggravated by running, directional changes, kicking, SL exercise, lunges
Adductor tendinopathy objective findings
pain w passive abduction or resisted adduction
bias different adductors at different levels of hip flexion
0: gracilis
45: add longus/brevis
90 + abduction: pectineus
Adductor tendinopathy interventions
acute: RICE or POLICE (protect, optimal loading, ice, compression, elevation)
Sub acute: isometrics
gentle stretching
graded resistance
gradual return to full activity
good prognosis
Adductor tendinopathy sample exercises
supine stretch
hamstring stretch
sidelying lift
SLR
resisted hip flexion
side plank
resisted hip abd/add
hip OA subjective findings
insidious onset
buttock/groin/thigh/knee
dull or sharp
worse w activity lastin several hours after
antalgic gait
hard to climb stairs/put on socks
hip OA objective findings
restricted IR/abd/flexion
pain at end range
pain to resisted hip flexion/adduction
+Scour
+FABER
hip OA interventions
relief symptoms
minimize disability
reduce progression
education
modalities for pain relief
weight management
add AD if needed
manual mobilization
passive stretch
strengthen stabilizers
Snapping hip
snapping/pop sensation occuring with moving tendons around the hip over bony proiminences
causes of snapping hip
internal: iliopsoas snap over femoral head, lesser trochanter, tenosynovitis
external: ITB/glut max snap over greater trochanter
intra articular: synovial chondromatosis, Fx fragments, labral tears, loose body
snapping hip subjective findings
snap/pop greater trochanter area with ambulation
snap caused by subluxed iliopsoas tendon in groin/hip while flexed
may be pain if bursa inflamed
snapping hip objective findings
IT band subluxing on standing/rotation
palpable snapping while extending from flexed
Obers
Thomas
snapping hip intervention
improve muscle length
improve strength imbalances
often conservative treatment
trochanteric bursitis
common cause of lateral hip pain second to OA
GTPS: greater trochanteric pain syndrome
trochanteric bursitis subjective findings
lateral thigh, groin, gluteal pain
worse lying on involved side
radiate distally
pain worse in sit to stand or recumbent
better after a few steps, worse after walking 30 min
STM will make bursa worse but muscle better to differentiate
trochanteric bursitis objective bursitis
reproduce pain w palpation or stretching of ITB
resisted abd/ext/ER painful
tight hip adductors
Obers
modified obers
trochanteric bursitis intervention
stretch soft tissue lateral thigh
flexibility of ER/quad/hip flexors
strengthen hip abductors/muscular balance w adductors
orthotic if needed
responds well to conservative
hip labral tears
MOI
from trauma, FAI, capsular laxity/hypermobility, dysplasia, or degeneration
often undiagnosed
hip labral tears subjective findings
anterior hip/groin pain
click/pop/locl/give way
hip labral tears objective findings
+ anterior hip impingement test
similar to FAI presentation
aggravation w activity
painful faber/faddir
hip labral tears intervention
conservative management for a few months
limit pivoting
strengthen
assess foot motion
surgical: arthroscopic debridement of tear
FAI treatment
restore mobility/function
decrease pain
avoid surgery
avoid progression to OA and labral tear
prevalence of FAI
20-40 y/o
athletes 15% of cases
repetitive end range hyperextension/flexion w abduction
slip/twist injury
types of impingement
CAM: aspherical femoral head impinging rim of labrum; provoked by FADDIR; superior OA; young males
PIncer: acetabulum over covers femoral head impinging neck of femur; middle aged females; provoke by hip ext/ER
CAM/pincer prevalance
86% have both
CAM/pincer ROM limitations
IR/ER, flexion, add progressively more limited
FAI symptoms
C sign
dull ache
worse w prolonged sitting
sharp catch w pain in activity
faddir increases symptoms
limp
struggle with ADLs
non surgical FAI treatment
activity changes: avoid provoking activities
NSAIDs
PT: improve hip ROM and strengthen supporting muscles
surgical treatment FAI
arthroscopic clean out of damaged labrum/cartilage
trim bony rim and femoral head
surgical vs conservative FAI treatment
surgical has better statistical difference between pre and post outcomes than physical therapy
FAI post op protocol phase 1
1: 4-6 weeks protect, restore ROM, control pain/inflam, NM control
progress to 2 when FWB, 75% ROM, NM control patterns, minimal pain
FAI post op protocol phase 2
2: CKC exercise, balance, stretching, STM
progress to 3 when pain free gait FWB, full ROM, 60% hip flexion strength
FAI post op protocol phase 3
3: restore muscular endurance and strength, NM control/balance/proprioception
6-8 weeks post op
introduce single leg strengthening, closed chai
FAI post op protocol phase 4
4: sports specific, 8-16 weeks post op
to return to sport need 85% hip flexion str, full pain free ROM, perform drills at speed, complete sport related testing
plyometrics, mechanics, jogging
Common hip problems by age
newborn: congenital dislocation
2-8: avascular necrosis, legg calve perthes, synovitis
10-14: SCFE
14-25: stress Fx
20-40: labral tear
40+: OA
