Hip Flashcards
Conditions with painful resisted adduction
Adductor tendinopathy Rectus abdominis tendinopathy Obdurator nerve entrapment Osteitis pubis Ossifying myositis Symphysitis SIJD Sportsman hernia
Conditions with painless resisted adduction
Psoas tendinopathy Gynecological Urological Vascular Lymphatic Inguinal hernia Hip joint labrum Stress fracture Other nerve entrapment Incompetent abdominal wall Lumbar or thoracic spine referral
Hamstring syndrome (definition, clinical triad, management)
= sciatic nerve entrapment of potential irritation of epinerium at ischial tuberosity
Clinical triad:
1) pain with sitting
2) pain with resisted knee flexion with hip flex 90 and knee extended to limit with provocation by ankle DF
3) pain free resisted knee flexion in prone
Management = avoid stretching, sit on a wedge with thicker part dorsilly, gentle neural mobilization starting distally, iontophoresis, surgical release if non-responsive
Piriformis syndrome (definition, clinical signs, management)
= sciatic nerve compression and irritation at inferior edge of piriformis due to blunt trauma or overuse Clinical signs: Pain with walking Glute max atrophy Sitting with knee flex decreases pain Buttocks pain with FADIR test Positive SLR or slump test
Management = avoid stretching, hard surfaces; neural mobilization, cortisone or analgesics injection; botulinum injection suggested but not well studied; surgical release if non-responsive
Hamstring tendinopathy
= microtraumatic loading of tendon Clinical signs: Negative SLR and slump No pain with sitting Painful resisted knee flexion with hip flexed and extended
Management = transverse friction massage, gentle stretching of hamstrings with ankle and foot relaxed, reduced or unloaded activity, gradual eccentric activation/strengthening
Trochanteric bursitis and gluteus medius tendinopathy (clinical signs, management)
Bursitis = pain with full flexion, adduction, and ER/IR, no pain with SLR or slump, pain with palpation over greater trochanter
Tendinopathy = less pain with full flexion and ADD, tenderness over gluteal tendon, pain with resisted hip IR when hip positioned in flexion, ADD, and ER
MANAGEMENT:
Bursitis = not DTFM, rest, ice, NSAIDs, taping gluteus medius, endoscopic bursectomy
Tendinopathy = DTFM
Persistent bursitis (causes, clinical signs, management)
= persistent pain despite treatment, may indicate calcific tendonitis or gluteus medius tears
Clinical signs:
Women >50
Week resisted abduction
Pain can radiate from trochanter to lateral thigh and groin
Visible on MRI
Management = injections, heel lift on asymptomatic side, ambulation with cane, avoid crossing of legs, and often surgery
Ischiogluteal bursitis
Clinical signs: Increased gluteal mass Due to increase sitting, blunt trauma, or gluteus medius tear Pain near ischial tuberosity Confirmed with MRI
Similar treatment to other bursitis
Pudendal nerve entrapment (S2-4)
Pain or burning in perineal area
Worsened with sitting
Improved with standing
Can be elicited by bicycling with too narrow saddle pressing on pudendal nerve
Management = relaxation of pelvic floor muscles; sacral sitting pad with perineal cut out; avoid deep squatting; local steroid injection, radio frequency thermal coagulation, pulsed radio frequency, cryoneurolysis, or neuromodulation
Tendonopathies causing groin pain (and resisted movements causing pain)
Adductor longus and brevis = resisted ADD
Gracilis = ADD and knee flexion
Pectineus = hip flexion and ADD in 90 flexion
Rectus abdominis = hip ADD and trunk flexion
Iliopsoas = hip flexion
Treatment = transverse friction massage, stretching, and gradual strengthening; fluoroscopy guided injection at bony insertion
Myositis ossificans
Heterotophic changes of muscle, long standing symptoms after trauma not responsive to conservative measures
Of iliopsoas: Groin pain Hip flexion contracture Abdominal tenderness Femoral nerve pains of Requires surgical removal
Iliopectineal bursitis
Painful passive tests (hip extension, flexion, and external rotation)
Most painful is passive hip ER in fully flexed position (compresses bursa)
Pubic symphysis (causes, clinical signs, management)
Causes = pelvic ring micro trauma and overuse, hip joint limitations, pelvic brain and stability associated with hormonal changes of pregnancy, RA, or gout
- Pain with weight bearing activities, resisted addiction with hip at 45 of flexion, and active straight leg raise
- Pain reduced with stabilization belt
Treatment = belt stabilization (wear as much as needed up to 23 hours per day), exercise for transverse abdominis and pelvic floor activation
Chronic pubic symphysis instability with synovial reaction in synovial cleft (causes, treatment)
= secondary osteomyelitis of pubic bone
Causes: Trauma Infection Systemic synovitis Infection due to female incontinence, surgery, sports Pelvic malignancy IV drug use
Treatment = corticosteroid or analgesic injection
Osteitis pubis
Clinical signs:
Persistent pain
Symphyseal tenderness
Reduced passive hip IR and ER
Usually fails conservative treatment and requires either proletherapy or surgical stabilization
Sportsman hernia (definition, cause, clinical signs, treatment)
= weakening or tearing of the transversalis fascia, conjoined tendon, and/or internal oblique fibers
Traumatic, due to twisting, turning, or directional changes and speed; ballistic movements causing sharing at the pubic synthesis and stress on above structures
Clinical signs: Unilateral or bilateral severe pain Lower adominal, inguinal, and groin regions Exaggerated by exertion or valsalva Painful resisted hip ADD Unchanged with stabilization belt Weak hip and obliques when hip an extension Unprovocative palpation of adductors
Surgical treatment (mesh repair may be better than laparoscopic; return to sport 1 to 2 months after surgery)
Operator nerve entrapment (causes, clinical signs, treatment)
Causes = pelvic ring or acetophylline fracture, post-surgical fibrosis, overuse
Clinical signs: Deep, vague groin pain Painful hip adduction post exercise adapter weakness and paresthesia and medial thigh Diagnosed with AMG or nerve block
Treatment = surgical neurolysis
Types of FAI
Cam = abnormal femoral head Pincer = acetabulum has too much coverage Mixed = coexisting cam and pincer
Clinical signs of labral lesions
Pain with sitting, climbing stairs
Clicking, locking, and/or giving way during weight bearing activities
Pain in groin, buttocks, truck intergration, thigh
Pain with IR with hip flexed but not extended
Pain with modified circumduction test
Confirmed with MRI
Treatment for labral lesions
Education about condition, changing seating surfaces to reduce it flexion, reducing sitting and use the stairs
Unloaded activities, ambulation with assistive device, cycling at low load
High velocity, low amplitude rotational mobilization / manipulation (as long as necrotic changes have been ruled out)
Intraarticular corticosteroid injection
Arthroscopy and conservative measures fail
Causes and most common location of labral lesions
Macro or microtrauma, degeneration, and developmental deficiencies
Traumatic vertical or degenerative horizontal tears
Most commonly an anterior superior or posterior superior margins of labrum (due to compromised mechanical properties, poor vascularity, and impact loading of memorial head neck junction)
Femoral and pubic stress fractures (location, clinical signs, treatment)
Proximal third of femur, femoral neck, or pubic ramus
Clinical signs:
Pain with weight bearing
Pain with unipedal hop
Pain with fulcrum test
Treatment = reduce loaded activity, address underlying condition (osteoporosis, osteomalacia, malignancy, metastasis)
Meralgia paresthetica
= entrapment of lateral femoral cutaneous nerve
Clinical signs:
Sensory changes at lateral thigh and knee
Positive neural tension in s/l, hip and knee extended, foot everted and plantar flexed, actively extending neck reproduces symptoms
Treatment = neural mobilization in supine, knee supported on pillows, flex and extend knee; injection or surgical management (neurolysis, excision, or release)
Hip nerve entrapments (nerves affected and distribution of paresthesias)
Ilioinguinal = medial proximal size Iliohypogastric = anterior and lateral proximal thigh Genitofemoral = anterior mid thigh, genital and groin
All best treated with neurolytic surgical release or excision
