Hip Flashcards
Acetabulum orientation
ventromedially to dorsolaterally in teh transverse plane and carniolaterally to caudomedially in teh frontal plane
Collodiaphyseal angle
starts at 150* from the femoral diaphysis at birth and decreases to 120-130 by adulthood due to WB
CD angle <120
coxa vara - can result in potential shearing stresses that damage the epiphyseal plate of femoral head
Excessive CD angle
-coxa valga - can lead to altered muscle activity and intraarticular forces in the CFJ as well as altered cartilage response
CFJ
Coxafemoral joint
Center edge angle
-is the angle between the acetabulum and the femoral head in teh frontal plane
Center edge angle
30*
Center edge angle <30*
means dysplastic changes in teh joint
Anterior rotation of femoral neck changing over a lifetime
goes from 40* to 9* from the line between the distal femoral epicondyles
Anteversion
- excessive naterior rotation
- hip IR is increased and hip ER is decreased in order to maintain the 90-100 total rotational ROM in transverse plane
- compression forces on teh cartilage and may expose person to tendinopathies
- best fixed by positional adaptation before pubsecence vs. surgical
Retrotorsion (retroversion)
- decreased torsion angle
- decreased hip IR and increased hip ER
- could produce early degenerative changes in anterior superior acetabular labrum due to close proximity and impact of femoral neck
Cartilage and the humeral head
2/3 covered in hyaline cartilage
-center lacks cartilage to allow insertion of teres ligament and neurovascular supply
Gothic arch
-cartilage of acetabulum forms this - where cartilage is least developed in the far superior region of the dome and discontinuous in teh floor and anterior inferior region
Pulvinar acetabuli
-layer of fat found on the floor of the acetbulum that migrates out with change sin pressure
Where is cartilage most developed in the acetabulum?
In the anterior and posterior superior surface of the gothic artch because that is where femoral head has greatest contact and loading during gait
Who experiences greater stress on cartilage - men or women?
Women - and any dysfunction in muscles around the joint could lead to increases in force imposed on joint and early degeneration
Labrum
- serves to enlarge articular surfaces
- acts as an attachment for joint capsule
- assists in maintaining fluid pressurization
- provides proprioceptive sensory info regarding hip position and movement
Loss of labrum
-can produce a reduction in articular seal, fluid pressurization, load support, and joint lubrication
Vascularization of the labrum
- similar to the meniscus
- outer margins are well vascularized and inner sanctum is less vasculrized
- superior is also less vascularized leading to this are being more susceptible to tears
Capsule - 3 different fiber systemes
1) longitudinal - along the length of capsule from proximal to distal creating a tensile strength
2) transverse - circular fashion around capsule at the neck creating Zona Orbicularis - region where capsule narrows
3) Arcuate fibers - loops at the proximal insertion at the labrum reinforcing the insertion
Ligamentum teres
- arises from transverse acetabular ligament
- attached to periosteum
- aids the capsule in maintaining the reduction of the femoral head whiel acting as a conduit for the neurovascular supply
- recognized as a significant potential source of pain and mechanical symptoms
Iliofemoral ligament
1) Pars inferioris - constrains hip extension
2) pars superioris - constrains hip ext, adduction, ER
Pubofemoral ligament
-constrains hip extension, abduction, ER
Ischiofemoral ligament
-works with the arcuate ligament to provide hip stability during quiet standing - taut in the upright position
Inguinal canal
- formed by numoerous tissues and is highly variable
- ilioinguinal nerve is located in the canal
- can be a site for nerve entrapment and hernia
Capsular pattern
- arthritic patients
- IR limits are greatest compared to other limitations
- specific definition of capsular pattern is not consistent in the literature
- variable combination of limits in flexion, ext, abduction
Hip arthritis
- can be nontraumatic or traumatic
- c/o groin and anterior thigh pain during functional activities (sitting, walking, ascending stairs)
- passive movement limitations
Predictor variables for arthritis
- looking for 3/5
1) self reported squatting as agg. factor
2) active hip flexion causing lateral hip pain
3) scour test with adduction causing lateral hip or groin pain
4) active hip extension causing pain
5) passive internal rotation = 25*
Treating hip OA
-joint specific low velocity mobs in a traction direction
Other diseases with capsular pattern
- RA
- gout
- reiter syndrome
- psoriasis
- ankylosing spondylitis
- onset of legg-calve-perthes
Coxarthrosis
- common hip joint disorder that may or may not cause pain
- diagnosis = radiographs
- can develop synovitis as result of overuse or from an accident
- can be primary or secondary
Primary coxarthrosis
- genetically coded and typically occurs w/ advancement in age
- patients >40
- can be (B) or unilateral
- more often seen in females (and is usually more severe in females)
Secondary coxarthrosis
- articular erosions that emerge as result of other underlying condition (joint instability, dysplasia, previous intraarticular fracture, long standing loose body, disease)
- patients >25
Treatment for cosarthrosis
- manual therapy has been shown to be effective
- surgery for intractable pain or severe functional limitation
Best approach for THA
-controversial
Pre-operative PT for THA
- shown to decrease post-acute care services
- preop abductor strength and knee extension strength are reliable predictors of ambulation ability following THA
Anterolateral THA
-return to earlier side sleeping, driving, and riding in automobiles, and work activities sooner than those with precautions
Transient synovitis
- viral, autoimmune, or microtraumatic
- more common in males under age 6
- rare in adults
- hx usually includes preceding illness and patient presents with antalgic gait
- slight capsular pattern
Slipped capital femoral epihpysis (SCFE)
- non-capsular pattern
- femoral head epiphysis slides off femoral neck
- variable limitations in hip IR and flexion
- traditionally affected males more than females (2:1), but recent netherlands study found no gender difference
- affects in pubescent years (13 to 15 for males, 11 to 15 for females)
- 30% chance of (B) involvement
- overweight and underdeveloped
S/S of SCFE
- muscle guarding
- limited IR, increased ER,
- Drehmann’s sign
- Trendelenburg test = +
- greater risk for developing necrosis of teh femoral head
Drehmann’s sign
-obligatory abduction and ER during passive flexion
Treatment of SCFE
-surgical percutaneous pinning in situ followed by PWB and ambulation w/ AD for 4-6 weeks
Ischemic necrosis of femoral head
- presents with variable hip motion limitations
- can occur in children or young adults
- associated with LCPD and SCFE in children, but etiology is less clear in adults
- may produce a drehmann sign
diagnosing necrosis via x-ray
-requires lauenstein position (frog leg)
Stages of LCPD
1) 25% of femoral head is involved
2) 50% of femoral head produces subchondral fracture in shape of half moon along with intact anterior pillar of femoral head
3) 75% involved producing progressive femoral head collapse
4) involvement of entire head adn plate - aggressive femoral head disintegration
Treatment for LCPD
- stage specific
- best managed by specialist
- conservative management = joint surface containment and remodeling through bed rest w/ traction into hip abduction, serial casting, functional orthoses (not recommended for patients > 6 yrs old who have >50% head involvement)
Avascular necrosis and non-surgical treatments
-new research suggests that several minimally nonsurgical treatment options may be promising in adults with early stages of necrosis
Osteochondritis dissecans
- can occur w/ or w/o loose body
- begins with inflammation of cartilage and subchondral bone
- can be result of micro or macrotrauma
- some loose bodies can be managed conservatively while others require surgery
Primary bone tumors
-usually malignant In order of decreasing frequency: -chondrosarcoma -ewing sarcoma -osteosarcoma -fibrosacroma -langerhans cell histiocytosis
Snapping hip (coxa saltans)
- can be intra or extra-articular
- intra=snapping of iliopsoas tendon over iliopectineal eminence
- extra = thickening of iliotibial tract at greater trochanter, iliopsoas at pectin pubis, glute max fibrosis, proximal hamstring at ischial tub
- motion limitations with walking esp when hip moves into flexion, IR, ER
Stress related avulsion
- can occur with macro and/or microtrauma
- presents with an initial severe pain followed by reudced pain and increased weakness
- recorded in adductors, sartorius, iliopsoas, biceps femoris, rectus femoris
Diagnosing avulsion
-mri or diagnostic ultrasound
Treatment of avulsion
-best treated with conservative care - 4 to 6 weeks of rest with gradual resumption of activities
friction massage
- found to stimulate fibroblast proliferation and promote tissue healing through increased fibroblast recruitment
- can produce temporary analgesia through application of a noxious stimuli - requires about 2 minutes to reach a painfree threshold for hours to days o frelief
Causes of buttock pain
- lumbar issues
- sij
- periarticular structures
- tension
- compressive irritation
- adhesion of lumbosacral root or dorsal root ganglion
Piriformis syndrome
- can produce buttock pain secondary to nerve compression and irritation
- can begin with blunt trauma to buttock region or overuse activities
S/S of piriformis syndrome
- increased pain in buttock with walking activities, sitting may decrease pain
- pain can refer into posterior thigh to knee when more severe
- FAIR test position = approximates the nerve closer to the ischial spine in a more aggressive fashion = greater risk for injury
Trochanteric bursitis
- diagnosed by positioning hip in full flexion, adduction, and er/IR for reproduction of pain
- will not cause pain during slr or slump test
- confirm diagnosis with palpation and differentiating tenderness associated with glute med tendinopathy
management of bursitis
- injections
- habit changes
- changes in sitting behaviors
Pudendal nerve entrapment
- sharp, burning buttock pain
- pudendal nerve = S2-4
- nerve can get entrapped between the sacrotuberal and sacrospinous ligaments, in the pudendal canal
- may be accompanied by burning in perineal area that worsens with sitting and improves with standing
- symptoms could be related to childbirth
- may be irritated by bicycling
Treatment of pudendal nerve entrapment
-can be treated by nonop management including relaxation of pelvic floor muscles and implementing strategies to minimize compression
(B) resisted adduction to diagnose groin pain
-valid, sensitive, and specific to diagnose sports-related groin pain that is frequently accompanied by bone marrow edema
Most common cause of groin pain
-increased tendon load during directional change type of sports associated with stress shielding in teh insertion of the tendon
Conditions w/ painful resistive hip adduction
- acute adductor tendinopathy
- chronic adductor tendinopathy
- rectus abdominis
- obturator nerve
- osteitis pubis
- ossifying myositis
- symphysitis
- SIJ affliction
conditions with painless resisted hip adduction
- urological
- gynecological
- vascular
- lymphatic
- herniation
- hip joint labrum
- stress fracture
- psoas tendinopathy
- psoas bursitis
- nerve entrapment
- incompetent abdominal wall
- lumbar spine affliction
- t/s affliction
Sportsmans hernia (hockey hernia, athletic pubalgia)
weaknenng or tearing of transversalis fascia, conjoined tendon, or internal oblique fibers creating an inside out hernia
