Hip Flashcards
Hip OA CPR
- Squatting as aggravating factor
- (+) Scour Test for groin or lateral hip pain
- Active hip flexion causing lateral hip pain
- Passve internal rotation < 25 degrees
- Active hip extension causing hip pain
Sartorius insertion point and possible pathology
ASIS
Avulsion fracture in adolescent athlete.
Muscles and ligaments that attach to pubic tubercle
Rectus abdominis
Adductor longus
Ilioinguinal ligament
Adductor magnus insertion and relevance to pathology
Inferior pubic ramus, inferior ischial ramus, and ischial tuberosity (medial portion)
Too broad to be a source of tendinopathy
Is predisposed to traumatic avulsion esp. at ischial tuberosity
Description of where hamstrings attach on ischial tuberosity
Lateral surface.
Semimembranosus inserts most laterally.
Shape of acetabulum/ changes with age
Starts more conical, transitions to spherical shape with weight bearing.
Faces ventral, lateral, caudal
Deeper acetabulum associated with more spherical femoral head.
Collodiaphyseal angle
Angle between femoral neck and diaphysis.
Starts at 150 deg, decreases to 120-130 by adulthood due to weight bearing.
<120 = coxa vara >130 = coxa valga
Center edge angle
Measures femoral head coverage by acetabulum
Normal = 30 deg.
<30 - dysplasia
Femoral angle of torsion
Normal ~15 deg anteversion in adulthood (Up to 40 deg in children)
Excessive anteversion -> Increased IR, decreased ER. Increases compression forces on hip cartilage, can predispose patient to tendinopathies. Best remedied with positional adaption before puberty
Decreased angle (Retroversion) -> Decreased IR, increased ER. Can lead to degenerative changes in anterior labrum. May be associated with instability. May be associated with pincer deformity.
Sometimes a complimentary acetabular torsion exists.
Area of acetabulum where cartilage is most developed
Posterior and anterior superior surfaces - greatest contact/ loading from femoral head during gait.
Acetabular dysplasia can lead to:
Ligament laxity
Instability
Early degenerative femoral head flattening and notching.
Labrum neurovascularization
- Has a variety of nerve endings > important in proprioception
- More vascularized on outer margins
- Superior labrum is less vascularized > susceptible to traumatic and degenerative tears
Plica folds in hip capsule
- At inferior edge of femoral head
- Can swell after trauma
- Trauma can lead to femoral head necrosis - recurrent blood supply from femoral artery courses deep to the plica on the way to the head
Ligamentum teres
Aids capsule in maintaing the reduction of femoral head
Conduit for neurovascular supply to femoral head.
High association rate between tears of ligamentum teres, labrum, and cartilage injury. Ligamentum teres rupture rare - 8%.
Can be a significant source of pain and mechanical sxs
Ligaments that are important in hip stability during quiet stance
Iliofemoral (Y), pubofemoral, ischofemoral ligaments. All taught in the upright position.
Which directions for dislocation are most likely
anterior inferior
posterior
Inguinal canal
Connects abdomen and scrotum/labia majora.
Males: Passageway for testes/ sperm cord
Females: Contains round ligament of uterus
Created by folding over of external oblique aponeurosis. This aponeurosis also creates a superficial inguinal ring, which can be the site of a direct inguinal hernia
Conjoint tendon
Posterior to the superficial inguinal ring. Created by fibers of internal oblique and TA muscles.
Hip joint innervation and location of referred pain
Anterior hip: Femoral, obturator nerves. Pain in groin
Posterior hip: Sacral plexus. Pain in buttock, trochanter
Rectus femoris insertion
AIIS
Predisposed to avulsion fx
Injury to reflected head can > superior labral lesion, similar to SLAP tear.
Prevalence of painless tears in glute med in individuals > 60 yo
10%
Pubic symphysis innervation and location of referred pain
Anterior: L2-L4 > Groin pain
Posterior: S3-S5> Genital pain
Movement of femoral head with cardinal plane motions
3 dimension movement due to oblique orientation of acetabulum.
Cardinal plane hip movement also creates movement in SIJ and lumbar spine.
Epiphysiolysis demographics
Females 11-13
Males 13-15
Articular osteochondritis dissecans demographics
Age 15-25
Ischemic femoral necrosis demographics
Age 35-50
Labral lesion demographics
Age 18-40
Identifying osteoid osteoma
Pain can be temporarily resolved with aspirin.
ASLR test metrics
Sensitive and specific
Testing for hip abduction flexibility with knee flexed and extended
Assesses the influence of gracilis
Testing for hip adduction strength in various levels of hip flexion
0 deg: Adductor longus/ gracilis
45 deg: Pubic sphysis provocation
90 deg: pectineus
Hip capsular pattern
Internal rotation is most limited. Variable combination of limits in flexion, extension, and abduction after that (inconsistent pattern)
Treatment for hip arthritis
- Early mobilization (traction)
- Exercise
- Surgery
Contraindications for hip mobilizations
- Joint instability
- Degenerative bone disorders
- Presently on anticoagulants
- Nontraumatic synovitis e.g. systemic disorder, or Legg-Calve-Perthes
Transient synovitis
Males age 4-10, viral or autimmune response. 40% have history of preceding illness.
Antalgic gait
Often spontaneously recover in 2-3 weeks, but at increased risk for progressing to LCPD. Routine periodic imaging studies indicated.
Treatment: 2-4 days bed rest with cuff traction, then progressive WBAT.
Hip arthritis age of onset
Primary: >40 yo
Secondary: > 25 yo
More common and severe in women
Minimally invasive THA
PReserves muscle, tendon, and trochanteric structures
Evidence for pre-THA PT
Decreases post-acute care services
PRe-op hip abd and knee ext strength are predictors of ambulation ability following THA
THA rehab
- Pain and mobility improve with early AROM and isometrics. No improvement in long term function with these.
- Weight bearing strength program > better postural stability and strength after 4-12 months after THA compared to NWB exercises.
SCFE
- Variable limits in IR and flex
- During puberty, males > females
- Pt rests with hip abducted, limb shortened
- Pts are often overweight and underdeveloped
- Acute: significant groin pain limiting weight bearing tolerance.
- Gradual: Mild groin or anterior knee pain, can eventually have Drehmann sign, Trendelenberg
Treated surgically
PWB with AD for 4-6 weeks
Drehmann sign
Limited IR, increased ER
Obligatory abd + ER during passive flexion
Legg-Calve-Perthes disease
- Self limiting
- Imperfect vascularization
- Age 3-8
- Groin, anterior thigh, anterior knee pain. Antalgic gait
- Capsular joint mobility limitation
- Plain films in “frog leg” position shows femoral head collapse.
- Drehmann sign.
Legg-Calve-Perthes treatment
Depends on stage of disease
Conservative: Bed rest with traction, serial casting, functional orthoses that allow for weight bearing while maintaining hip abd and IR, exercises to increase hip abd to promote containment.
Surgical: Osteotomy to improve containment. Post-op: PROM initially, no flex, abd AROM for 40 days. PWB for 3-6 months.
Adult femoral head necrosis
Can be acute or months-years after a vascular compromise.
Gradual onset of groin pain, possible ROM limitation.
Conservative: Meds, ESWT, electromagnetic therapy, hyperbaric oxygen
Surgical : Rotation osteotomies or core decompression. PWB for 3-6 months, AROM as tolerated.
End stage: THA or hip resurfacing
Clinical triad for loose body in hip
- Pathological end feel
- Noncapsular limitation. Often limited in add and ER.
- Sharp pain + giving way of LE following pain.
Gold standard for diagnosis of intraarticular loose body
Hip arthroscopy
myositis ossificans
- Can develop in iliopsoas or adductors in response to trauma.
- Results in groin pain, hip flexion contracture, abdominal tenderness, paresthesias in femoral nerve distribution
Sign of the buttock
Pain with hip flexion PROM both with knee extended and flexed. Indicates non-MSK pain generator.
Cancer in pelvic bones and proximal femur
Pelvis: Primary tumors are usually malignant
Proximal femur: Primary tumors are usually benign
Avulsion fracture
Complete: Presents with initial severe pain during the trauma, reduced pain and possible weakness afterwards
Incomplete: Persistent pain and weakness after injury.
4-6 weeks of rest with gradual resumption of activity.
Most common cause of pain in the pubic and medial thigh regions
Tendonopathies
Purported benefits of friction massage
Stimulate fibroblast proliferation
Promte tissue healing
Temporary analgesia
Review “specific test outcomes for establishing a diagnosis for a patient’s buttock pain.”
Review “specific test outcomes for establishing a diagnosis for a patient’s buttock pain.”
Hamstring syndrome
Entrapment of sciatic nerve as it courses around sichial tuberosity and through a fibrous band projecting from biceps femoris as it inserts into tuberosity.
Frequently preceded by episodic hamstring injury or injury to low back that predisposes sciatic nerve to injury
Frequently seen in runners, jumping athletes
Pain localized to ischial tuberosity, worsens with persistent physical activity.
CPR for hamstring syndrome
Pain with sitting
Pain with resisted knee flexion with the hip is flexed to 90 but not when hip is neutral
Pain with palpation over lateral ischial tuberosity
Treatment of hamstring syndrome
Stretching often aggravates sxs Sitting on a wedge Neural mobilization Iontophoresis (authors recommendation) May require surgical release
Piriformis syndrome
Increased pain in buttock with walking
Sitting can decrease pain
If axons of inferior gluteal nerve are compressed, can see glute max atrophy with glute med sparing.
FAIR test positive (flexion, abd, IR).
Treatment: Avoid stretching, sitting on hard surfaces. Nerve glides. Injections to reduce pain and piriformis muscle activity.
Hamstring tendinopathy
- No pain with sitting or nerve tension testing
- Pain with resisted knee flexion both with hip flexed and in neutral
Loosened prosthesis or greater trochanteric stress fracture
Lateral buttock pain
Rely on subjective history, will have absence of clinical exam findings
Periotrochanteric abnormality findings on MRI
Sensitive, not specific. Common to find in patients without pain.
Hip lag sign
Indicates damage to hip abductors Pt not able to keep leg in abducted and internally rotated position High sensitivity (89%) and specificity (96%)
Pudendal nerve entrapment
Terminal branches of S2-4 getting entrapped between sacrotuberal/spinous ligaments.
Lower inner gluteal quadrant pain, worse with sitting. May be elicited during bicycling.
Treatment: Relaxation of pelvic floor muscles, sacral sitting pad (perineal cutout), avoiding deep squatting and sustained hip flexion postures.
Neural mobilization not possible
Bilateral resisted adduction test
Provocation of pain with this test is sensitive and specific for sports-related groin pain, frequently accompanied by bone marrow edema.
Clinical exam for iliopectineal bursitis
Pain with passive hip ext, flex, ER+flex
Reasons pubic symphysis instability can develop
- Trauma
- Athletic microtrauma and overuse
- Hip joint limitations
- Pregnancy
- RA, gout
Pubic symphysis hypermobility/irritation sxs
Pain with weight bearing activities (walking, running, hopping, landing from jump)
+ASLR
Pain improves with stabilization belt
Treatment for pubic symphysis conditions
Belt and exercises to restore TA and pelvic floor muscles
Belt should be positioned just superior to greater trochanters
Where is there a high prevalence of secondary osteomyelitis?
Pubic bone
Pubic bone stress injury
AKA osteitis pubis.
Often associated with athletic trauma
Conservative treatment typically fails
Treatment: Prolotherapy, monthly injections of dextrose+lidocaine, surgical stabilization
Sport’s hernia
- Weakening of transversalis fascia, conjoined tendon, and/or internal oblique fibers
- Unilateral or bilateral
- Exacerbated with exertion or valsalva
- No change in pain with resisted adduction with use of belt
Diagnostic ultrasound = best support for diagnosis.
Surgery: Return to sport in 1-2 months
Obturator nerve pain
- Deep, vague pain in groin
- Provoked with reisted hip adduction
- Caused by fx, postsurgical fibrosis, overuse, anatomical variation
- Pts have post exercise add weakness and paresthesia in medial thigh
- Treatment: Surgical neurolysis
Traumatic vs. atraumatic lesions in labrum
Traumatic 46%
Atraumatic 49%
Labral tears
- Most often in superior anterior or superior posterior margins
- Very common, one study found present in 88% of patients >30 yo
- Can be related to dysplasia or FAI
- Promote instability
- Precursor to arthrosis
- Pain with sitting, climbing stairs
- Clicking, locking, giving way with WB activities
- Pain with FADIR, scour
- Appropriately selected patients benefit from surgery
FAI
- Can result in labral pathology
- Cam - nonspherical femoral head/neck
- Pincer - overgrowth on acetabulum
Stress fractures in hip
- Immediate onset of pain with WB, relief with NWB
- Negative clinical exam except for pain with unipodal hop
- Impact activity should be reduced/ eliminated until fx is healed
Rectus femoris tendinopathy
- Groin pain
- Reproduced most with resisted knee extension with hip neutral (prone). Mild pain with resisted hip flexion or ER.
- Can occur following THA
- Females> males, younger
Meralgia paresthetica
Lateral femoral cutaneous nerve entrapment
- Pain and sensory changes in lateral thigh and lateral knee.
- May respond better to injection or surgical management.
Testing position for lateral femoral cutaneous nerve tension
Sidelying, hip extended, adducted, IR, knee extended, ankle everted and plantar flexed.
Hip OA risk factors
Age History of hip developmental disorders (especially cam) or injury Reduced hip IR ROM Lower socioeconomic status Higher bone mass Higher BMI
Criteria for classification of hip OA recommended by CPG
- Moderate anterior or lateral hip pain with weight bearing activities
- Morning stiffness < 1 hour
- Hip IR ROM <24 deg, or flex+IR limited by >15 deg compared to other side
- Pain with passive IR
Most important hip OA exam components
Passive hip ROM (especially IR, flex)
Hip muscle strength (especially abd)
FABER test
NSAIDs and hip pain with mobility deficit
effectivef or relief of symptoms. Be aware of GI effects.
Hip pain with mobility deficit and supplements
Insufficient evidence
Hip pain with mobility deficit and patient education
Should be combined with exercise and manual therapy
Hip pain with mobility deficit and manual therapy
A level evidence supporting manual therapy including thrust, nonthrust, soft tissue
Add exercises as mobility improves
Hip pain with mobility deficit and exercise
A level evidence supporting use of individualized exercises to address impairments
Hip pain with mobility deficit and modalities
B level evidence for use of ultrasound + hot packs + exercise in short-term management of pain
Hip pain with mobility deficit and bracing
Should not be used as first line treatment (grade F evidence)
Hip pain with mobility deficit and weight loss counseling
C grade evidence, PTs should work with other HCPs to support weight reduction in pts who are overweight/obese and have OA
Diagnosis of FAI per CPG
- Anterior or lateral hip/ groin pain
- Achey or sharp pain
- Aggravated by sitting
- FADIR
- Limited IR in flexion ROM (less than 20 deg) (hip flexion and abd also limited)
- Mechanical sxs present
- Radiographic findings
Diagnosis of structural instability per CPG
- Anterior, lateral, or general hip pain
- FADIR or FABER
- Apprehension sign
- Hip IR ROM >30 in flexion
- Mechanical sxs present
- Radiographic findings: Increased acetabular inclination, tonnis nagle, or femoral head coverage
Nonsurgical management of nonarthritic hip pain per CPG
Trial of 8-12 weeks before considering surgery.
Manual therapy and nonarthritic hip pain
“F” grade evidence that it may be used when indicated.
Therapeutic exercise and nonarthritic hip pain
“F” grade evidence that it should be used for impairments. Particular attention should be placed on strength of abductors and rotators in patients with structural instability.
NMR and nonarthritic hip pain
“F” grade evidence it may be used to diminish movement coordination impairments when identified.
Hip pain with mobility deficit and functional gait and balance exercises
“C” level evidence
