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
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
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
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
5
Q
FNSF symptoms
A
- hip/groin/thigh pain/ache
* relieved with activity cessation • Night-time pain if chronic
6
Q
FNSF signs
A
- antalgic gait
- limitation of hip ROM – esp. internal rotation
- axial compression – hop test
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
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
9
Q
LCP symptoms
A
- pain in the groin, anterior thigh/knee • worsens with activity
- relieved by rest
10
Q
LCP signs
A
- painful limp-worsens with activity
- decreased hip ROM – especially internal rotation
- chronic → flexion/adduction contraction
11
Q
LCP confirmation
A
• Plane film
– irregular femoral head
– increased density epiphysis
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
13
Q
SCFE symptoms and signs
A
- insidious groin/hip/thigh/knee pain • painful limita2on of hip ROM
- psoas spasm
- antalgic/trendalenburg gait
14
Q
SCFE confirmation
A
• Plane film
– widening of epiphyseal line
– grade 1-3 slip classifica2on
15
Q
Acetabular labral tears
A
• previously undiagnosed injuries • mechanism trauma – twis2ng/rota2on – running/falling • chronic – acetabular dysplasia – → ligamentous trac2on on labrum
16
Q
ALT symptoms
A
- unilateral groin pain • +/- anterior thigh
- +/- low back pain
- occasional clunk
- “giving way”
17
Q
ALT signs
A
- hip quadrant
- Faber test
- “snapping” with ext/int rot
18
Q
ALT confirmation
A
- MRI
* Arthrography • Arthroscopy
19
Q
• Iliopec2neal bursi2s
A
- anterior hip pain +/- limp
* iliopsoas tendon/iliopec2neal eminence
20
Q
Trochanteric bursitis
A
• pain localised lateral aspect of hip – +/- lateral thigh
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
osteitis pubis signs
* pubic synthesis tender to palpate
* passive abduc2on/extension
* isometric adduc2on/flexion
* ↓ pain by rectus abdominis contrac2on
* confirma2on with scin2graphy
26
Muscle strains
• Muscle strains – Adductor longus – Rectus femoris – Iliopsoas
– Sartorius – Gracilis
27
muscle strain musculotendinous triad
• Musculotendinous triad – tenderness to palpa2on
| – pain with resisted muscle ac2on – pain with passive stretching
28
OA of the hip
• 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
ligaments of the hip
External
• Iliofemoral, ischiofemoral, pubofemoral
– Two “i’s” are the most consistent and strongest
• Internal Ligamentum teres & transverse acetabular ligament
– Assist with blood supply
30
hip joint capsule
* 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
blood supply of the hips
• 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
nerves of the hips
• 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
coxa vara
• 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
coxa valga
• 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
transverse plane alignment
• Changes – 32-40o at birth, gradually decreases to 15o (approx 16 yo)
36
excessive anteversion
* 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
excessive retroversion
• 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
effect of OA or #NOF
• 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
Normal ROM
• 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
Hip joint stability
• 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
maximum torque generated in
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
impact of pelvis on hip motion
• 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
link with the pelvis and Lx spine
• 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
Trunk control
• 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
Hip flexor dysfunction
• 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
Hip extensors
• 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
Glute max vs hamstring functionally
• Leaning forward
– ES controls spine
– Hip exts control pelvis on femur • HS >> 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
Hip extensor weakness and tightness
• 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
hip abductors
• 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
Hip adductors
• Don’t just function as adductors
• Adductor longus
– Also hip flexor & etensor
• > 70 hip flex – extensor moment armègenerates extensor torque
• Full hip ext – flexor moment armègenerates 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
Hip IR's and ERs
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
