Hip Flashcards
primary roles of the hip
1: support weight of head, arms, trunk during upright postures and dynamic weight bearing activities
2: provides a pathway for transmission of forces between the lower extremities and pelvis
2 angular relationships
1: angle of inclination of femoral head
1: angle of torsion
normal angle of inclination
125-135 degrees
angle of inclination
the angle formed by the meeting of the axis of the shaft of the femur with the long axis of the femoral neck and head
coxa valga
> 135 degrees
clinically abducts
coxa vara
<120 degrees
clinically adducts to get femoral head back in position in the acetabulum
angle of torsion
projection of the long axis of the femoral head and the transverse axis of femoral condyles
normal angle of torsion
10-15 degrees
35 degrees at birth
- think about alignment of knee axis during gait
- think about compensations at the subtalar joint
excessive anteversion
> 15 degrees
clinically toes in
excessive retroversion
cannot change bony alignment but can change activation of muscle groups and ROM to help
ligaments of the hip
iliofemoral ligament
ischiofemoral ligament
pubofemoral ligament
hip flexors
iliopsoas tensor fascia lata rectus femoris sartorius adductor magnus, longus, brevis pectineus gracilis
hip extensors
gluteus maximus
hamstrings
posterior fibers of gluteus medius
piriformis
hip abductors
*typically the most impacted glut med TFL superior glut max glut min
hip adductors
adductor magnus, longus, brevis quadratus femoris pectineus obturators gracilis medial hamstrings
hip medial rotators
TFL glut min anterior fibers of glut med adductor magnus, longus semimembranosus/tendinosis
hip lateral rotators
piriformis obturator interior/exterior gemelli quadratus femoris glut max posterior fibers of glut med biceps femoris
nerve supply to the hip
lumbar plexus (L1-L4) sacral plexus (L4-S3)
blood supply for head of femur
artery of ligamentum trees
medium and lateral circumflex arteries
ROM
- varies with age, sex
- flexion 120-135 degrees with knee flexed 90
- extension: 0-15 degrees
- abduction 0-30 degrees
- rotation generally 45 deg in each direction (more LR with males, more MR with females
lateral pelvic tilt
the hip on the high iliac crest side is in relative ADDUCTION while the hip on the low iliac crest side is in relative ABDUCTION
rotation of pelvis and hip
rotation of the pelvis in a clockwise direction results in left hip ER and right hip IR
single limb stance components of gait
normal: adduction torque on the standing hip counterbalanced by sufficient abduction torque
compensation by lateral trunk flexion
Trendelenberg: contralateral iliac crest tends to drop bc of glut med insufficiency
leg length discrepancy (LLD)
=unilateral difference in the total length of one leg compared with another
anatomic LLD
=actual osseous length difference between the hemipelvis, femur, tibia
measured from umbilicus (fixed point)
anything greater than 3/8 of an inch would require modification of the shoe
functional LLD
position of osseous structures as they relate to each other and to the environment during WBing function
hip exam and eval
- history
- lumbar spine clearing
- other clearing tests (visceral involvement
- balance
- joint mobility and integrity
- muscle performance
- pain and inflammation
- posture and movement
- range of motion and muscle length
- work, community, and leisure integration or reintegration
- special tests
hip questions
sudden injury? gradual? pathology? "developing hip"? coxa valga/varus? something gradual w/ age? degeneration? trauma? over correction? visceral pain?
standing force on the hip
=0.3 times body weight
unilateral standing force on the hip
=2.4-2.6 times BW
walking- force on the hip
=1.3-5.8 times BW
walking up stairs- force on the hip
=3 times BW
running- force on the hip
=4.5+ times BW
balance tests
often included in hip examinations due to high incidence of falls resulting in hip injury:
- Berg balance scale (not good for high performers)
- Mini BESTest of dynamic balance
- Dynamic gait index (similar to Berg but don’t hit ceiling as quickly)
- Balance self-perception test
- History of balance problems
- type of assistive device used for ambulation
gait evaluation
an important component of examination of a person with a hip dysfunction
- analysis of gait should include observation of the hip along all three planes of movement during each critical phase of gait
- *the relationships between the hip and the rest of the kinetic chain
-video analysis can assist in this complex examination procedure
joint mobility and integrity
quantity of motion, end feel and presence/location of pain should be noted during the following tests:
- lateral/medial translation
- distraction
- compression
- anteroposterior/posteroanterior glides
muscle performance
- MMT of hip musculature
- specialized tests looking at positional strength to determine length-associated changes
- selective tissue tension tests to diagnose noncontractile versus contractile lesions
- resisted tests to determine severity of the tissue lesion- weak and painful?
- resisted tests can also screen neurologic cause of muscle performance impairment
pain and inflammation
- examination is done in conjunction with other tests to determine source (if possible) and cause of pain
- source diagnosis often requires additional tests that are beyond the scope of physical therapy
posture and movement
- specific lumbopelvic and lower quadrant alignment should be examined about all three planes
- hypothesis can be developed regarding the contribution of faulty alignments at the ankle, foot, knee, and lumbopelvic regions to the alignment of the hip
- hypothesis can be generated regarding muscle lengths related to posture alignment
- initial screening for LLD can be performed
range of motion and muscle length
- Quick tests: placing foot on standard step, forward bending, squatting, sitting with leg crossed
- stand to sit; willingness to move, ROM, strength
-AROM/PROM in open kinetic chain
Muscle length tests:
- medial/lateral hamstrings
- individual hip flexor lengths
- hip adductors/abductors
- hip rotators
work, community and leisure, integration or reintegration
- functional ability can be measured directly through observation of functional tasks
- self-report measures can also be used
-Harris hip function scale is another self report measure that is specific to degenerative joint conditions
functional tests of the hip
- squatting
- reciprocal stairs (how do they ambulate stairs? 1 at a time? every other?)
- ankle to opposite knee in sitting
- stairs 2 at a time
- running: straight plane, decelerating
- one legged hop
- jumping
impaired muscle performance
RESULT OF:
- neurologic pathology
- muscle strain
- altered length-tension relationships
- general weakness from disuse
- pain and inflammation
neurologic pathology
-neuromusculoskeletal or neuromuscular in origin
Neuromusculoskeletal- pathology at nerve root or peripheral nerve
-treat origin of pathology to positively affect muscle force/torque production
muscle strain
- hamstring strains/overuse are common
- underused synergists
Overstretch
- ex: glut med on high iliac crest side
- strengthen glut med in short range
- taping in short range
- correct posture habits and movement patterns that maintain muscle in lengthened state
treatment of muscle strain focuses on..
CAUSE of strain
treatment of underused synergist in hamstring strain
improving motor control and muscle performance of underused synergists (ex: glut max and hip lateral rotators- prime moves that tend to get underused)
-correct biomechanical factors contributing to underused synergists
PRONE HIP EXTENSIONS
walk stance progression
Step up and overs
glut med strength progression
purpose: to strengthen the hip muscles that keep your hip and pelvis in good alignment when you walk
1: prone hip abduction
2: w/ TB
hypermobility
- often associated with impairment in the developing hip
- with increasing use of arthroscopy, diagnosis of acetabular labral tears is more common
- labral tears are a possible precursor to OA
- treatment for developing hip consists of positioning, bracing or surgery
- treatment for adult hypermobile hip consists of specific therapeutic exercise, posture education, movement training
- children- bracing`
- adults- dynamic stabilizers
primary objective of treatment
- promote joint stability
- prevent continuous stress to overstretched or torn tissues
- posture and movement pattern training
- strengthen lengthened muscles in short range
- improve muscle performance of deep musculature to enhance core stability
anteversion
- whenever excessive medial rotation ROM is measured, screen for ante version (trochanteric prominence angle test)
- focus on strengthening deep hip LRs
- educate regarding postural habits and movement patterns
strengthen abductors
prone –> sidelying
functional approach to treating medial hip rotation tendencies
“standing knees over toes”
isn’t a limit of motion but often don’t have motor control to keep it there- need to be re-educated
- wt distributed evenly
- pelvis level
- knees aligned with feet; if bent should be over midline of your feet
- shoulder width apart and slightly outward
- arch slightly elevated with big toe down
walking knee over toes:
- don’t let knee lock back as weight comes over your foot. knee slightly bent when heel contacts floor and should slightly straighten as BW moves over
- at heel strike think of squeezing butt to prevent your knee from turning in as your BW moves over your foot
- think of using you foot muscles to prevent your arch from dropping too low as your BW moves over
- keep inner core activated to prevent pelvis from tilting forward
hypomobility: established capsular pattern
50-55 degrees of limitation of femoral abduction
0 degrees of femoral MR from neutral
90 deg of limitation of femoral flexion
10-30 deg of limitation of femoral extension
femoral LR and adduction are fully maintained
limitation of MR: thinking capsular shortening or OA
but if hip flexion is no more than 90, thinking capsular
either way mobilizing the joint based on patient response model!!
hypomobility
-look at relationships to other regions in the kinetic chain to treat hip hypo mobility
Examples:
- lumbar spine relative flexibility during forward bending with associated stiff hips in the direction of flexion)
- knee flexion relative flexibility during standing knee bends with associated stiff hips in direction of flexion
-hip extension stiffness is often associated with anterior pelvic tilt and lumbar extension relative flexibility
- specific muscle length tests are necessary to prescribe accurate exercises to address muscle length impairments
- train proper movement patterns to utilize specific exercise (late stance phase of gait)
hypomobility- improving ROM
slide 53
balance
- falls are the leading cause of morbidity and mortality in persons older than 65
- Tai Chi has been shown to be valuable in promoting posture stability and balance control in the well elderly
- force-platform biofeedback is another mode used to improve balance
- clinical trials have not demonstrated a reduction in falls among older persons using force-platform biofeedback systems
risk of falls adjusts how much care and direction (living situations, surgeries)
pain
differential diagnosis of etiology and cause of pain
- pain can be referred to the groin, laterally or posteriorly radiate down the anterior and medial thigh or to the knee
- tx must focus on alleviating impairments related to the underlying cause of symptoms
do they belong here??
guidelines for pain relief
- activity modification
- physical agents or electrotherpeutic modalities
- manual therapy
- therapeutic exercise
- assistive devices
- weight loss
- biomechanical support (orthotics)
posture and movement impairment
- optimize kinetics and kinematics at the hip and other joints in the kinetic chain
- ALL patients should be educated on details of posture and movement that contribute to the cause of symptoms
- hip alignment- influenced by other joint angles (knee and pelvis), hypo/hyper mobilities, length-tension relationships, muscle performance, etc
check posture w/o telling pt., try different positions to see if it alleviates any pain
- changes in posture and movement require basic skills in mobility, muscle performance, and motor control
- these skills must be at functional levels to intervene at the level of posture and movement
- initially, the goal is to improve all associated impairments to functional levels
- gradual transition to functional activities with emphasis on optimal posture and movement
leg length discrepancy (LLD)
3 categories:
- mild (0-30 mm)
- moderate (30-60 mm)
- severe (>60 mm)
treatment ranges from shoe inserts, posture training, and movement training to various surgical techniques
functional LLD
ex: femoral and tibial medial rotation
- lengthened or weak post glut med and deep hip lateral rotators
- lengthened or weak foot supinators
- postural foot pronation or supination
therapeutic exercise interventions for osteoarthritis
ROM and mobility:
1: passive stretch
2: active stretch
3: active exercises
osteoarthritis-muscle performance
- functional exercises should be included whenever possible
- use of adjuncts may be necessary to reduce joint reaction forces
- always include core activation
- step up activities stimulate hip extensor recruitment, facilitate hip flexion mobility
- alter step height and resistance (adding weight) to ensure proper technique
OA- balance
after establishing muscle balance in single limb stance, progress to balance activities
OA posture and movement
educate pts on positioning, core training, and Ads during functional activities
OA adjunctive interventions
NWBing activities (aquatics, etc) are recommended
ITB related diagnoses
- ITB fascitis (inflammation from overuse)
- trochanteric bursitis (bursa becomes inflamed)
- ITB friction syndrome (pain localized to lateral femoral condyle)
- patellofemoral dysfunction
- TFL strain (overuse of short or stretched TFL/ITB)
- faulty movement patterns
synergistic relationships associated with ITB/TFL overuse
- anteromedial TFL dominates in hip flexion force couple= underuse of iliopsoas
- posterolateral TFL dominates in hip abductor and IR force couple = underuse of glut med, upper fibers of glut max and min
overuse of ITB may contribute to underuse of quads
signs of nerve entrapment syndrome (piriformis syndrome)
- hip flexion with IR
- lordosis and ant pelvic tilt
- high iliac crest on involved side
- ER and ABD reduces symptoms
key tests for nerve entrapment syndrome
- standing alignment
- tissue tension tests
- ROM
- palpation
- positional strength
- functional tests
- lumbar clearing exam
strengthening piriformis in shortened range
prone, knees flexed to 90. pt positions hip in abduction and ER. pushes heels together with submax contraction
hip is designed for:
stability and transmission of kinetic forces
angles of inclination and torsion are:
critical for ideal functioning
hip osteokinematic ROM is closely linked to:
lumbopelvic region
thorough hip exam is necessary to understand:
anatomic/physiologic impairments in hip and related regions
*impairments in muscle performance, gait, balance, posture and movement, ROM and mobility commonly occur together
primary focus of treating OA is:
to improve joint loading
restoring mobility and force are often prerequisites to:
restoring endurance and improving posture
stretched piriformis syndrome can mimic:
lumbar radiculopathy
disuse and deconditioning
results from injury, pathology, acquired movement patterns contributing to disuse and deconditioning of specific synergists
consider acquired postures and movement habits
optimize length-associated relationships and restore motor control and force/torgue contributions from underused synergists
cam lesion
lesion of femoral neck
in some developing hips there isn’t a concave neck
decreases excursion of hip movements and causes acetabulum impingement possibly causing a future labral tear
pincer lesion
extra lip of labrum
