Hip Flashcards
Hip Joint ROM needs for functional activities
120 flexion
20 abduction
external rotation
What 3 joints support the hip
Iliofemoral
Pubofemoral
Ischiofemoral
What do the 3 ligaments collectively limit
hip extension
–tightly coiled around capsule in extension to give hip stability
Anterior hip Joints
Iliofemoral-Y ligament, strongest ligament
**limits IR and EXT
Pubofemoral-limits abduction
Posterior hip joint
Ischiofemoral- limits IR and Adduction
Acetabulum
made up of fusion of:
Ilium
Ischium
Pubic Bones
concave
deepened by ring of fibrocartilage labrum
- -hyaline cartilage decreases the forces of friction
- -Thicker on lateral aspects b/c forces more on lateral side
Open Pack of hip
30 flex
30 abd
slight ER-10-15 degrees
close pack of hip
full ext
slight abd
slight IR
Arthrokinematic motion of FEMUR on ACETABULUM
Flex: posterior Ext: Anterior Abduction: inferior Adduction: superior IR: posterior ER: anterior
Normal end feels of hip
flexion: soft
Ext: abduction, adduction, ER, IR- firm
Angle of inclincation
angle between axis of femoral neck and shaft of femur
NORMAL: 125 degrees
Coxa Valga
greater than 135 degree angle and results in long leg on that side and genu varum
- -longer leg on coxa valga
- -leg will bow out–>varum @ knee
Coxa Vara
less than 120 degrees angle and results in short leg on that side and genu valgum
- -shorter leg on coxa vara side
- -valgum at knee
angle of torsion
–angle formed by transverse axis through the formal condyles and axis of neck of the femur
–normal 10-15 degrees
Anteversion
Increased angle of torsion
femoral shaft is rotated medially
RESULTS IN:
genu valgum
pes planus
**internally rotated and foot pronated
Retroversion
Decreased angle of torsion
femoral shaft rotated laterally
RESULTS IN:
long leg
genu varum
**externally rotated and femoral head rotates more in line w/ condyles
Hip flexor muscles
psoas major
iliacus
rectus femoris
Hip extension muscles
gluteus maxiums-attaches to ITband
hamstrings
hip abductors
gluteus medius
gluteus minimus
TFL/IT band
Hip adductors
pectinus
gracilis
adductor magnus, brevis, longus
External rotators
piriformis
quadratus femoris
obturator externus, internus
gemellus superior, inferior
internal rotators
gluteus minimus, medius
Tensor Fascia Latae
Active insufficciency
hamstrings in prone knee flexion
Passive insufficiency
Hamstrings in supine with straight leg raise
Anterior Pevlic Tilt
ASIS moves downwardly and anteriorly
Hip Flexors (iliopsoas and Sartorius) pull down anteriorly
Erector Spinae pull up posteriorly
POSITION: increased hip flexion and lumbar spine extension
OBSERVE: hip flexors, back extensors, abdominals and hip extensors
-excessive femoral IR
Compensations for Anterior Pelvic Tilt
Femur IR
genu valgum
lateral tibial torsion
pes planus
Posterior Pelvic Tilt
ASIS moves upwardly and posteriorly
Rectus Abdominus pulls up anteriorly
Gluteus Maximus and hamstrings pull down posteriorly
POSITION:
-increased hip extension and trunk flexion
OBSERVE:
- hip flexors, back extensors, stability form Y ligaments
- people rest on Y ligaments
Compensastions for Posterior Pelvic Tilt
hip extension Femur ER genu recurvatum genu varum pes valgus
Lateral Pelvic Movement
pelvic drop of less than 5 degrees on swing leg side
gluteus medius on stance side ccontracts to hold up pelvis on swing leg side
IF glute med weak= Trendelenburg Gait
Pelvic Rotation movement
keeps body’s center of gravity within its base of support
forward motion of pelvis
femur opposite side is rotated internally
Common sources of pelvic/hip pain
sciatic nerve-passes under piriformis SI joint lumbar and lumbar/sacral joint bursae OA-groin pain
Acetabular Labral Tear or Femero Acetabular Impingement
groint pain
usually people younger than 40 y.o
athletes-soccer and gymnastics
Faber’s Test
figure 4 test
identifies arthritis of hip, SI joint involvement, iliopsoas problem
Patient supine w/ knee flexed
What to do:
- Therapist Flexes, Abducts, ER hip and rests lateral malleolus on opposite knee above patella
- Therapist applies downward force
- will feel pain in general hip
- SI=back pain
- iliopsoas= more groin pain
Thomas Test
Identifies hip flexor tightness
What to do:
- patient supine with non-test limb in full hip and knee flexion held by patient
- limb to be tested is off of exercise surface
Normal:
*thigh level with exercise surface
knee flexion of 80 degrees or greater
1 Joint Muscle tight- Thomas Test
hip in flexion
knee can flex to 80 degrees
**Psoas and iliacus
2 Joint muscle tight: Thomas test
thigh level with exercise surface- 0 degrees of hip flex
knee flexion less than 80 degrees
**Sartorius, TFL, rectus femoris
1 & 2 Joint tightness -Thomas Test
hip in flexion
knee in flexion less than 80 degrees
Ober Test
Identifies tightness in ITB or TFL
Patient sidelying w/ test limb up
Passively abducts and extends limb and allow limb to lower
If limb does not drop to 10 degrees below horizontal the IT/TFL is tight
Ober test: knee flexed to 90 degrees
Modified Ober: knee straight
True Leg Length Discrepancy Test
identifies leg length asymmetry
Patient supine
measure from ASIS to Medial Malleolus
If knee projects anteriorly: femur is longer
If knee projects superiorly: tibia is longer
Legg-Calve_Perthes Disease
- affects children between 2-12 y/o
- noninflammatory, self-limiting syndrome
- femoral head becomes flattened at WB surfaces= disruption of blood supply
- abductor orthosis
TREATMENT GUIDELINES
-must keep hip abducted during ROM and strengthening exercises
Slipped Capital Femoral Epiphysis
The neck of the femur slips upwardly and anteriorly at epiphysis
ETIOLOGY
- epiphyseal plate is at risk of displacement before it fuses in adolescent years
- can be idiopathic or due to trauma
- occurs btw. 10-15 y/o
- occurs in males more than female: 2 to 1
Clinical Signs of slipped capital femoral epiphysis
present with mild to moderate pain at hip and sometimes knee
Dx on x-ray
surgical fixation
Total HIP-THA/THR Indications
decreased functional ability to ambulate or perform ADLs/Functional Roles
hip instability
avascular necrosis
previous hip surgery failure
Cemented THR
prosthesis is cemented to existing bone usually older patient usually immediate WBAT Disadvantage -has higher incidence of loosening
Non-cemented THR
prosthesis allows for bony in-growth
usually for younger pts.
usually more stable and lasts longer
TTWB or PWB for 6 weeks up to 3 months
THR anterolateral approach
older approach glute med is cut other muscles disturbed: glute min TFL Iliopsoas rectus femoris
Hip Precautions for anteriorlat approach
no hip flexion > 90
no hip extension
no adduction past neutral
no ER past neutral
ADL reminders for Anteriorlat approach
no prone lying
no bending forward in sitting position-putting on socks
no tailor sitting
no pivoting on involved leg
THR anterior approach
TFL is divided longitudinally
1/2 of glute med is released
Vastus Lateralis is divided longitudinally
HIP PRECAUTIONS
- check w/ MD
- Sometimes hip extension and ER limitations
- sometimes no hip precautions
Posteriorlateral Approach THR
- most common
- glute max is divided in line with muscle fiber alignment
- glute med and vastus lateralis not cut-> strong ability to abduct
- Highest percentage of post-surgical dislocations
Hip Precautions for posteriorlateral THR
no hip flexion > 90
no IR past neutral
No adduction past neutral
ADL reminders: no sitting on low chairs no bending of waist > 80 no crossing legs no pivoting on involved side no laying on involved side for 8-12 weeks
Minamaly invasive surgical THR
can be lateral, posterior or anterior
smaller incision: 1 or 2
check with MD protocol
evidence base practice
-presently no evidence to support quicker recover times with minimally invasive THR
0all approaches achieve similar outcomes at 6 months and 1 year post-op
Treatment considerations for all THR
ensure no hip dislocation bed mobility with precautions prevent DVT early rehab management: -open chain exercise -transfer training -initiate ambulation w. appropriate AD -initiate ambulation with typical environmental home barriers
Hip hemiarthroplasty surgical procedure
surgical procedure where only priximal femur is replaced
follow MD protocol
hip resurfacing surgical procedure
similar to THA but removes less bone
cap placed within femur with matching Cup placed within acetabulum
Precautions for Hip resurfacing
prone lying alllowed to decrease contractures
active hip abduction allowed
strengthening exercises for hip abduction and extension begun early in rehab
keep hip in neutral IR/ER for first 6 weeks
Hip fractures
70% occur in people older than 70
90% occur from falls
Most common fracture: intertrochanteric Fracture
*proximal femur fracture
complications from hip fractures
compromised blood supply to the head of the femur fracture is displaced delayed healing or non-healing fracture avascular necrosis of head of femur often results in THA
ORIF following hip fracture: rehab management
similar to THA program usually no hip precautions follow MD WB precautions -DVT -non-union/ failed surgical intervention
Tendonitis/ Muscle Strain
can be one specific event or occur secondary to overuse
CLinical findings:
- localized pain at muscle belly, insertion or origin
- pain reproduce with an active contraction or stretching of the involved muscle
- most common in hamstrings, adductor longus, iliopsoas or rectus femoris
Initial rehab: Acute/protection Phase
- RICE
- protect muscle during healing process
Hip Pointer
direct trauma to subcutaneous tissues of iliac crest
Acute/Protection Phase:
-RICE
Bursitis
Inflammation of Bursa
aggravated when muscle over bursa is stretched or contracts
CLINICAL SIGNS:
- pain in area of inflammation
- pain with muscle stretching or resisted testing
- gait deviations
- decreased muscle endurance
Greater Trochanteric Bursitis
inflammation of bursa located between glute med/ IT band and greated trochanter
often due to compression and friction from tight ITBAND
usually there is a pelvic asymmetry
–check lumbar and SI joints
Clinical SIGNS:
- pain over lateral hip, lateral thigh to knee
- pain aggravated by stair climbing
- pain may awaken patient at night
Psoas Bursitis
inflammation of bursa that is below Iliopsoas near anterior capsule of hip
often due to activities that require excessive/reptative hip flexion=running,swimming
CLINICAL SIGNS:
- pain in groin area, can go to patella
- pain with resisted hip flexion
Ischiogluteal Bursitis
-inflammation of bursa located near ischial tuberosity
often due to sitting on hard surface and/or excessive -hamstring contraction-running, jumping
-slow to heal, difficult to treat
CLINICAL SIGNS:
- pain at Ischial Tuberosity
- pain with palpation of ischial tuberosity
- pain increases with walking, climbing stair
- may present with sciatica
Maximum Protection Phase
limit aggravating activities alter lifestyle STM, joint mob for pain relief-improve motion control WB forces posture well joint mechanics progressive ROM flexibility stationary biking, pool multi-plane isometrics supplemental modalities for inflammation control
Controlled motion phase
CRITERIA:
- decreased pain
- improve pain-free ROM
- ability to full WB
return to full WB w/ minimizing gait devviations gain maximal ROM increase strength-function patter muscle flexiblity and strength balance balance strategies begin to return to funcitonal acitivites
Return to Function Phase
CRITERIA:
- max ROM and strength
- Appropriate balance strategies
- no gait deviations
gain max strength
max functional acitivities
plyometrics
sports related activities if appropriate
Hip Flexor tightness
stresses back-increase lumbar extension as thigh extends into gait
stresses knee-if during gait hip cant move into full extension
the femur cant move as far posteriorly and lock the knee as it should
TFL tightness
IF IT band is not long enough
to slide easily over hip which may result in trochanteric bursitis
slide easily over knee which may result in lateral knee pain
may pull the patella laterally which may result in patellafemoral impairment
pelvic may anteriorly tilt which rotates femur internally stressing medial knee too
Hip Abdcutor, ER and/or extensor tightness
increase femoral IR and adduction w/ knee valgum increasing
results in:
- piriformis syndrome-over use from ER of femur compresses sciatic nerve
- patellofemoral impairment
- anterior cruciate strain-valgus increases anterior shear of tibia
Total Hip phase 1
post op
0-3 days after
gaosl:
- bed mobility
- minimal assistance
- maintain precautions
- ambulation
- regain 80 degrees of PROM and AROM of hip flexion
Criteria to move to phase 2
hip flexion 0-90 degrees
hip abduction 0-30 degrees
independt transfers and abmulation w/ AD
Phase 2 rehab
day 3- 6 weeks
motion phase
goals:
- strenghten entire hip
- begin proprioceptive training
- continue gait and endurance
Week 1-4:
- AROM hip abduction, quad, hamstring, glute isometris
Week 4-6:
-continue/progress above exercises with resistance
Criteria to move to phase 3
AROM of hip motion 0-110
good quad control
independently ambulate 800 ft. w/o AD or gait deviations
Phase 3
7-12 weeks
adequate strength of all LE muscles
return to functional activities
Criteria to move to phase 4
4+/5 of all LE muscle
minimal to no pain or swelling
Phase 4 rehab
return to appropriate sports/rereational activities
increase endurance and strength
Criteria for DC
AROM
4+/5 strength
normal age-appropriate balance and proprioception
independent in HEP
