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Clinic > Hip > Flashcards

Hip Flashcards

1
Q

Fx anatomy of the hip

A
  • Articulation between the head of the femur and the pelvic acetabulum
  • 1° Weight-bearing synovial joint
  • Multi-axial ball and socket joint
  • Promotes mobility
  • Surrounded by a strong fibrous capsule
  • Re-inforced by strong ligaments
  • Promotes stability
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2
Q

Muscles of the hip

A 
•  Muscles
–  Flexors:
•  Iliopsoas
•  Rectus Femoris
•  Sartorius
•  Pec2neus
–  Extensors:
•  Gluteus maximus
•  Hamstrings –  Adductors:
•  Adductor Magnus, longus and brevis
•  Gracilis
•  Pec2neus
–  Abductors
•  Gluteus maximus, medius and
minimus
•  Tensor fascia lata (TFL)
–  Medial rotators
•  Gluteus medius, minimus
•  Psoas major
•  Iliacus
–  Lateral rotators
•  Gluteus maximus
•  Pirformis
•  Obturator internus, externus
•  Gemelllus superior, inferior
•  Quadratus femoris
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3
Q

PE

A

• Observation
– Not just the ‘hip’ but the ‘person’ too
– Don’t always assume that ‘abnormal’ observations are relevant
• Baseline functional test
– E.g.Kicking a ball ,squating, walking
– Very useful for evaluating any subsequent progress
• Active Movement
– ROM; quantity, and quality (and what limits ,e.g. pain ,caution, insufficiency ,etc.)
• Passive Movement
– Range of movement (ROM) ;quantity ,and quality (and what limits ,e.g.pain,
caution, etc.). Some clinicians value ‘end-feel’.
• Resisted tests
– Isometric ,Isotonic ,Functional; pain and weakness
• Consider appropriate start position and sequencing: – Lying, sitting, standing?
• For example, in lying:
– Active hip flexion, passive hip flexion, resisted hip flexion and repeat for abduction, external rotation, internal rotation and adduction before moving the patient into side lying for examination of extension
• ‘Special’ orthopaedic tests
– Multiple tests exist (e.g.FABER)
– Serious questions exist in relation to what most of these tests add to the clinical reasoning process

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4
Q

FNSF

A

primarily in endurance athletes
• ocen in thin amenorrheic women
• loss of shock absorption with muscle fatigue?
• Associated risk factors – training errors
– inadequate footwear
– poor surface shock absorp2on – coxa vara

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5
Q

FNSF symptoms

A
  • hip/groin/thigh pain/ache

* relieved with activity cessation • Night-time pain if chronic

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6
Q

FNSF signs

A
  • antalgic gait
  • limitation of hip ROM – esp. internal rotation
  • axial compression – hop test
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7
Q

FNSF confirmation

A 
•  plane film
–  tension side (superior)
•  periosteal callus or fracture line
–  compression side •  (Osteo)sclerosis
•  bone scan
–  posi2ve 2-8 days post symptoms
•  MRI
•  CT scan
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8
Q

Legg-Calve-Perthes disease

A

• self-limiting noninflammatory condition
• flattening of the weight bearing surface of the femoral head
• caused by disruption in the blood supply of the femoral head
– → avascular necrosis
• due to antecedent trauma
• usually in children 4-8 years old

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9
Q

LCP symptoms

A
  • pain in the groin, anterior thigh/knee • worsens with activity
  • relieved by rest
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10
Q

LCP signs

A
  • painful limp-worsens with activity
  • decreased hip ROM – especially internal rotation
  • chronic → flexion/adduction contraction
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11
Q

LCP confirmation

A

• Plane film
– irregular femoral head
– increased density epiphysis

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12
Q

Slipped captial femoral epiphysis

A 
•  progressive or acute
•  posteroinferior slip of femoral head
•  10-15 year old males
–  recent growth spurt
–  obese with delayed puberty
•  imbalance of sex & growth hormones
•  zone separation
–  hypertrophying & calcifying cells
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13
Q

SCFE symptoms and signs

A
  • insidious groin/hip/thigh/knee pain • painful limita2on of hip ROM
  • psoas spasm
  • antalgic/trendalenburg gait
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14
Q

SCFE confirmation

A

• Plane film
– widening of epiphyseal line
– grade 1-3 slip classifica2on

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15
Q

Acetabular labral tears

A 
•  previously undiagnosed injuries
•  mechanism trauma –  twis2ng/rota2on
–  running/falling
•  chronic
– acetabular dysplasia
– → ligamentous trac2on on labrum
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16
Q

ALT symptoms

A
  • unilateral groin pain • +/- anterior thigh
  • +/- low back pain
  • occasional clunk
  • “giving way”
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17
Q

ALT signs

A
    • hip quadrant
    • Faber test
  • “snapping” with ext/int rot
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18
Q

ALT confirmation

A
  • MRI

* Arthrography • Arthroscopy

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19
Q

• Iliopec2neal bursi2s

A
  • anterior hip pain +/- limp

* iliopsoas tendon/iliopec2neal eminence

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20
Q

Trochanteric bursitis

A

• pain localised lateral aspect of hip – +/- lateral thigh

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21
Q

Snapping hip syndrome

A

• audible/palpable “snapping”
• Extra-ar2cular
– ITB/TFL over GT
– iliopsoas over Iliopec2neal eminence – biceps femoris over ischial tuberosity
• Intra-ar2cular
– iliofemoral ligt over femoral head – subluxa2on of hip
– loose bodies in hip

22
Q

Avulsion # about the hip

A
  • skeletally immature athletes
  • occur at secondary growth areas/ apophysis
  • local pain swelling/ecchymosis
  • asis/aiis/ischium
23
Q

Pubic rami stress #

A 
•  associated with runners
•  higher incidence in females
•  pain in inguinal, perineal, adductor region
•  antalgic gait is common
•  exquisite tenderness over
pubic ramus
•  posi2ve standing sign
24
Q

Osteitis pubis

A
  • Inflammatory lesion of the bone
  • adjacent to the symphysis pubis
  • ae2ology unknown
  • associated with twis2ng and turning sports – soccer, icehockey, AFL,distance running
  • pain in inguinal, perineal, thigh region
25
Q

osteitis pubis signs

A
  • pubic synthesis tender to palpate
  • passive abduc2on/extension
  • isometric adduc2on/flexion
  • ↓ pain by rectus abdominis contrac2on
  • confirma2on with scin2graphy
26
Q

Muscle strains

A

• Muscle strains – Adductor longus – Rectus femoris – Iliopsoas
– Sartorius – Gracilis

27
Q

muscle strain musculotendinous triad

A

• Musculotendinous triad – tenderness to palpa2on

– pain with resisted muscle ac2on – pain with passive stretching

28
Q

OA of the hip

A

• Typically c/o anterior groin pain
– Referral to anterior shin with increasing severity
• More prevalent with advancing age
• Pain provoked when walking/ weight-bearing
– Usually also c/o difficulty with ac2vi2es associated with requirement for end-range hip movements, e.g. ge]ng in and out of a car
• Sleep might be disturbed, par2cularly when lying on the right side
• X-rays might/ might not be reported as showing degenera2ve change
• Gait typically antalgic
• Ac2ve = Passive ROM – End range pain
– Medial rota2on and flexion painfully limited (1°)
• Resisted tests typically nega2ve

29
Q

ligaments of the hip

A

External
• Iliofemoral, ischiofemoral, pubofemoral
– Two “i’s” are the most consistent and strongest
• Internal Ligamentum teres & transverse acetabular ligament
– Assist with blood supply

30
Q

hip joint capsule

A
  • Extends bony rim of acetabulum to intertrochanteric line and crest of femur
  • Fibres mostly longitudinal (parallel) fibres + circumferen)al band around femoral neck centre (femoral arcuate ligament)
  • Capsule covers femoral head and most of neck
31
Q

blood supply of the hips

A

• Blood supply
– Femoral neck – medial & lateral circumflex arteries
– Superior gluteal
– Inferior gluteal
– Artery to head – branch of obturator artery
• Essential blood supply travels from femoral neck
– Important in #NOF

32
Q

nerves of the hips

A

• Branches from
– Femoral nerve
– Obturator nerve
– Superior gluteal nerve – Sciatic nerve
• Hilton’s Law
“The same trunks of nerves whose branches supply the groups of muscles moving a joint furnish also a distribution of nerves to the skin and over the insertions of the same muscles and…..the interior of the joint receives its nerves from the same source”

33
Q

coxa vara

A

• Decreased frontal plane angle
– Distance between greater trochanter to joint is decr
– incr bending moment to medial and increased tensile forces lateral NOF
• Incr shear forces – Incr risk of slipped capital femoral epiphysis
• Hip abductor moment arm increased
– May perform osteotomy to position hip with pathology, post # or in
design of THR
– Can incr joint stability BUT incr risk of gluteal tendinopathy (GT)
• ITB compression force=997N for 115o (vs 656N in 128o)(Grimaldietal,2015)
– AND incr medial pull on femur into acetabulum
• Potential for acetabular erosion…

BUT ALSO
• Functional length of hip abd decreased
– decr force generating capacity of glut med – offsets above incr in torque

34
Q

coxa valga

A

• Increased frontal plane angle
– decr bending moment – decr shear forces

• Joint centre to trochanter distance decreased
– Moment arm to hip abd decr
• decr MA of hip abds
• Larger contractile forces req’d to support hip joint BUT
– incr functional length of hip abductors
•Greater force generating capacity

  • Increased joint reaction forces – incr risk of joint degeneration
  • Extreme – alignment may incr risk of joint dislocation
35
Q

transverse plane alignment

A

• Changes – 32-40o at birth, gradually decreases to 15o (approx 16 yo)

36
Q

excessive anteversion

A
  • HOF further anteriorly in acetabulum
  • IR hip to compensate – in toed position
  • Evidence of incr IR ROM + decr ER ROM
  • Postural modification of in- toed position
  • Development of 2o lateral tibial torsion (no longer in- toed)
37
Q

excessive retroversion

A

• Less common
• NOF rotated posteriorly to frontal plane
• Evidence of incr ER ROM+ decr IR ROM
• Postural modification of toe-outposition
• May increase risk of slipped capital femoral epiphysis in adolescents
– SCFE = gradual or sudden inferior and posterior displacement of epiphysis at base of femoral head

38
Q

effect of OA or #NOF

A

• Results in mechanical instability
– # NOF - Can experience significant loss of func)on
• Often given walking stick as aid
– Remember walking aids from last year..
– In opp hand – studies demonstrated 36% decr in joint reaction force

39
Q

Normal ROM

A

• Review normative ROMs and be aware that there is quite extensive variations in literature
• Slightly influenced by sex – > IR in females
– > adduction in males
• Clinically – aging has insignificant effect on ROM until > 80 yo
– Significant decreases in ROM suggest joint impairment

40
Q

Hip joint stability

A

• Combination of
– Bony configuration – congruence – Strong capsule
– Reinforcing ligaments
• Longitudinal and circumferential fibres
• Hip extends – fibres of capsule clamp and firmly hold HOF in acetabulum
• Hip flexion – joint capsule slackens
– Additional stability from intra-articular pressure
• Close packed position
– Full hip ext (approx 20o > neutral) + slight IR – Spirals most of capsular ligaments ‘taut’ – Passive tension reduces accessory mo)on – NOT position of greatest congruency
– Congruency greatest at approx 90o flex + mod abd + sl ER
• Most of capsule and ligs have ‘unravelled’ so minimal passive tension present

41
Q

maximum torque generated in

A

Sagittal plane
• Hip extensors > hip flexors
Frontal plane
• Hip abductors & adductors
Transverse plane (considerably less) • IRs & ERs
• Why??
– Consider functional movement requirements and which
movements don’t have to act against gravity… • For all muscles around the hip consider
– Pelvis on femur & femur on pelvis + influence on Lx spine

42
Q

impact of pelvis on hip motion

A

• ROM – usually open chain with femur moving on pelvis
• Functionally – usually pelvis on femur (closed chain)
– Anterior pelvic rotation – flexes hip
– Posterior pelvic rotation – extends hip
– Elevation of pelvis – ipsilateral hip adduction + contralateral hip abduction
– Both femurs fixed – anterior rotation of pelvis in transverse plane on one side = ER of ipsilateral hip + IR of contralateral hip

43
Q

link with the pelvis and Lx spine

A

• Pelvis on hip
– Important to realise that hip movers also tilt the pelvis & further on
the Lx spine
– Anterior pelvic tilt – e.g. psoas
• incr Lx lordosis
– Posterior pelvis tilt – e.g. hamstrings
• decr Lx lordosis
– Lateral tilt of trunk and pelvis can substitute for hip abduction
• Clinically
– Care when testing ROM and analysing movement
– Impact of tight muscles on the Lx spine & lumbopelvic rhythm
– Correct positioning for stretching hip muscles • E.g. Hip flexor stretch vs hamstring stretch
• Hip on pelvis
– Power of hip muscles, esp flex/ext requires good co- contraction of abdominal muscles
• Controls Lx spine
• Clinically
– SLR – need good abdominals (esp TrA & RA) to neutralise ant tilt from hip flexor action
• Prevent excessive Lx lordosis
– Patients with lack of abdominal control may incr compressive forces on Lx
z-joints – LBP link?
• This is how we assess abdominal strength and control
• Again – need to address all areas when we prescribe exercises

44
Q

Trunk control

A

• Consider again the impact of theses strong flexors on the pelvis
– Need RA (core abdominals esp TrA) to control trunk & Lx spine
• Clinically - when we give exercises for hip pa)ents, we always include the core and trunk muscles
• *need to consider interactions between lower limb, pelvis & trunk - make exercises functionally relevant
• We will come back to this when we do axial skeleton…

45
Q

Hip flexor dysfunction

A

• Weakness - difficulty with ADLs
– Stairs
– In and out of bath tub – Diminished balance
• Tightness
– Restricts hip ext & LF
– Increased Lx lordosis or potential forward trunk tilt

46
Q

Hip extensors

A

• Primarily – glut max and hamstrings
– Most adductors assist when hip > 70o flexion • Glut max – extends & ERs
– Powerful hip extensor
• Hamstring – hip extensor & knee flexor
– Consider why it is less powerful?
– Consider why it is more susceptible to injury risk?
– Clinically – link with lumbo pelvic rhythm again informs why abdominal stability exercises vital part of rehab from strain

47
Q

Glute max vs hamstring functionally

A

• Leaning forward
– ES controls spine
– Hip exts control pelvis on femur • HS&raquo_space; glut max
– HS = incr ext moment arm + elongation at both hip & knee incr passive tension
– Glut max = decr ext moment arm
• Climbing stairs, hills, sprinting
– Glut max more effective to move femur on stable pelvis
– Leaning into flexed position – incr effectiveness

48
Q

Hip extensor weakness and tightness

A

• Weakness
– Impact on gait – glut maximus lurch (hyperextension of trunk prior to and thru heel contact)
• Tightness
– Reduced ROM – flex + IR
– May impact on LBP as bending requires excessive trunk flexion

49
Q

hip abductors

A

• 1o – glut med, glut min, TFL
• 2o – piriformis & sartorius
• Super important as pelvic stabilisers
– Produce greatest compressive force between HOF + acetabulum
– 2xBW force required to stabilise pelvis on femur in SL stance
• Clinically
– Consider their role in gait
– Consider impact of weakness on lower extremity and Lx spine
– What is clinical sign of weakness?
• Maximum hip abd torque – at 0o or sl add – Point of greatest functional demand
– Clever body!!!
• Min hip abd torque – approx 40o hip abd
– Ironically = where we test hip abd strength in MMT
• Adducted position –incr passive tension in ITB
– Clinically – gluteal tendinopathy (GT)
• Linked to excessive hip add in functional activities
• Patients demonstrate lower hip abduction torque – Both symptomatic and asymptomatic hip
• Strengthen BUT also stretch!
– Clinically – also consider dual TFL func)on when performing Ober’s

50
Q

Hip adductors

A

• Don’t just function as adductors
• Adductor longus
– Also hip flexor & etensor
• > 70 hip flex – extensor moment armègenerates extensor torque
• Full hip ext – flexor moment armègenerates flexor torque
– Clinically – may impact on susceptibility to injury
• Quick ac)vi)es (run, jump) esp with change of direction
• Adductor magnus
– Ant head similar to other
adductors
– Post head is extensor head
• Location, innervation & action similar to HS
• Clinically – different position for stretching (length testing)
– Add long – hip neutral
• Add trunk contralat rotn
(ER hip)
– Add magn – hip flexed
• Clam posi)on…
• Both femur-on-pelvic & pelvic-on-femur mo)on consecutively
• E.g. soccer kick
– Stance = pelvis on femur
– Kick = femur on pelvis
– Consider the link to adductor strains & osteitis pubis..

51
Q

Hip IR’s and ERs

A

Hip IRs
• No 1o IRs
• Torque greatly incr at 90 hip flexion – 50% strength incr
– Clincally – test muscle strength in this position
• Adductors also work as IRs
– Why ER hip position included in add stretch..
Hip ERs
• Lots of 1o & 2o
• Most common function is to change direction & shift pelvis on femur
– “cutting” = glut max both ERs AND extends
– Adductors must eccentrically control these movements
• Sports & movements where strains common

Clinic (17 decks)

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