Hip and SI Joint Assessment

Question 1

What are the most common isometric tests for hip assessment?

Answer 1

1. Abduction (can be a glute medius test)
2. Flexion

Question 2

If people have hip pain where will they usually point?

Answer 2

If it is an anterior capsule problem (90% of the time it is) they will point to their groin. Posterior capsule they will point to glute area.

Question 3

What things are you looking for with history for hip pathology?

Answer 3

• Insidious (more likely) vs traumatic
• Where is the pain?
• Ask about snapping (internal vs external)

Question 4

When thinking about snapping of muscles in the hip joint what are we referring to? External vs Internal

Answer 4

External snapping: Iliopsoas may snap over trochanter or head of femur. Rectus femorus crosses over and may snap as well. These will create superficial clicking that does not hurt too much.

Internal snapping: be more suspicious of labral issues. Deep and painful. People have to grab onto something as they feel their hip is going to give out. A lot of people have labral pathology that is not too much of a problem.

Question 5

What are we observing when it comes to hip pathologies?

Answer 5

Posture

• pelvis
• lumbar
• knees
• ankles
  Stance
• Foot position (rotation of the hips or tibia?)
• Weight bearing ability

Q angle
Leg length discrepancy

Question 6

When we are looking at posture what are we looking for?

Answer 6

Pelvis - anteriorly or posteriorly rotated, upslips and downslips

Lumbar - check if they are standing in hyperlordosis are hip flexors torquing on back? Or maybe lordosis decreased, posteriorly rotated, with hamstrings really tight?

Knee angle, are they valgus (knees coming in) or varus (knees going out). Or one more than the other.

Foot rotation: often see interiorly rotated hip, valgus knee and pronated foot. If foot is pronated, is it because of internal rotation at tibia, does it stop at knee? Or does it go all the way to the hip?

Question 7

What are we looking at when it comes to weight bearing?

Answer 7

With hip issues people will often stand off to one side and not want to bear weight on that side (will eventually cause Trendellenburg gait)

Question 8

What is the Q angle? What does it mean for hip problems?

Answer 8

Q angle: Angle between patella and ASIS. If there is no angle: the patella will sit straight underneath ASIS (uncommon). Women often have a wider Q angle, usually have wider hips, innominate more outflared. More Q angle means more pressure at hip joint. Usually you will have larger glutes if you have wider hips. But if you get a weak glute med on top of a wider Q angle that will start to cause pain.

Question 9

If you get a springy end feel for hip flexion what could this mean? What about a bony block?

Answer 9

Springy: could be a torn labrum

Bony block: thinking more OA

Question 10

What is the most important sinew channel for the hip?

Answer 10

Stomach sinew

Question 11

What are some special tests for intra-articular hip pathology? (Tests for femoroacetabular impingment or labral tears)

Answer 11

1. Hip Quadrants
2. Hip Scour
3. FABER (Figure four position with gentle pressure)
4. FADDIR
5. Impingement Provocation Test (Patient supine and leg and hip off edge of plinth, hip into hyperextension, abduction and external rotation HABER)

Question 12

Which of the tests for intraarticular hip pathology will also pick up SI joint pathology?

Answer 12

FABER

Impingement Provocation test

Question 13

Which of the tests for intrarticular hip pathology test the posterior-inferior labrum?

Answer 13

Impingement Provocation Test (HABER)

Question 14

What type of hip impingement problems will catch during internal rotation and adduction?

Answer 14

• Labral tears
• Osteoarthrits
• Cam and Pincer Lesions

Question 15

Which tests will pick up anterior capsule problems?

Answer 15

Any of the intrarticular pathology tests performed with the patient supine such as:

• Quadrants
• Hip scour
• FABER
• FADDIR

Question 16

What is a test for generalized capsular laxity?

Answer 16

Log roll test

Can also help pick up hip anterior impingement pathology.

Question 17

What are 4 test for muscular imbalance of the hip? What does each of them test?

Answer 17

1. Thomas Test (ITB, hip flexors, quads)
2. 90/90 test (hamstring tightness)
3. Noble’s Compression Test (ITB tightness, snapping)
4. Trendelenburg’s sign (Glute med weakness of stance leg if other hip sags)

Question 18

Describe the Thomas test

Answer 18

1. Patient sits at edge of plinth, lies back and pulls both knees in.
2. Asymptomatic leg held to chest and other leg lowered into extension of hip and knee relaxed
3. Patient can be asked to pull pelvis into greater posterior rotation.
4. Can use a goniometer to measure extension angle of hip and or knee

Hip flexor tightness: The leg should be in line with the plinth. If it goes up at an angle you might be looking at hip flexor tightness.

Quad tightness: Knee should be relaxed and dangling about 90 degrees. If it is sticking out into gerater extension there maybe quad tightness.

Glute or deep lateral rotator tightness: leg is externally rotated

IT band problems: leg is going out to the side

Question 19

What are the clinical prediction rules for hip osteoarthritis?

Answer 19

1. Self report of squatting as an aggravating factor
2. Active hip flexion causing lateral pain
3. Passive internal rotation less than or equal to 25 degrees
4. Active hip extension causing pain
5. Positive scour or FABER test.

Question 20

What should one ask in terms of history for SI joint pathology?

Answer 20

a. MOI: Insidious or Traumatic

Really insidious one is during pregnancy as the hormone relaxin can cause shifting and problems.

b. Where is the pain?

Fortin’s finger test: they point asymmetrically to an SI joint.

SI joint problems you will usually see pain above the knee. Does not completely exclude the disc but less likely. Pain all the way down the foot, this is NOT your SI joint.

SI joint problems can often involve the anterior hip. Anterior hip pain may radiate down the back of leg or laterally and occasionally into the calf. More often than not it still stays above the knee.

c. What movements aggravate it?

Question 21

What do we want to observe during an SI joint assessment?

Answer 21

a) Posture: especially pelvis and lumbar
b) Pelvic alignment:

• Look at position of ASIS to PSIS
• Anterior innominate rotation - ASIS will be lower than PSIS
• Posterior innominate rotation - ASIS will be higher than PSIS
• Look at relative position of sacrum to innominate
• Look for inflare/outflare
• Look for upslip/downslip

c) Check for leg length discrepancy
* Is it structural or functional?

Question 22

Which is more common, an upslip or a downslip?

Answer 22

Upslips are more common. Could result from a fall onto the butt.

Downslips are very rare, would result from a very forceful pull on leg.

Question 23

What are the special tests for SI joint assessment?

Answer 23

1. Fortin’s Test
2. Straight Leg Raise
3. Active Straight Leg Raise
4. Laslett’s Cluster

Question 24

How is the straight leg raise performed? What other condition is this test used for?

Answer 24

1. Pateint lies supine
2. Examiner passively lifts leg maintaining knee extension and neutral ankle.
3. Raise to point of symptoms
4. Will usually see low back pain at 60/70 degrees if it is an SI joint problem

This test was also included in the tests for lumbar radiculopath or herniated nucleus pulposis. Nadine says it is more indicative of SI joint than disc problems

Question 25

How does one perform the Active Straight Leg Raise? When is it most commonlly used?

Answer 25

1. Patient positioned supine
2. Patient asked to raise affected leg 6 inches
3. If painful examiner stablizes pelvis by compressing ASIS medially or placing a belt around pelvis
4. Patient again asked to raise affected leg. If movement is no longer painful it is a posititve test.

Most commonly used to check for pregnancy related posterior pelvic pain.

Question 26

What test are involved in Laslett’s Cluster number two? How can you be sure it is an SI joint issue?

Answer 26

1. Thigh Thrust (4P, Ostaggard, Sacrotuberous, POSH test)
2. Distraction/Gapping Test
3. Compression Test
4. Gaenslen’s Test
5. Sacral Thrust

If you get 3/5 of these tests positive it is an SI joint issue.

Question 27

How do you perform the Thigh Thrust? (also known as Ostagaard, 4P, POSH, or Sacrotuberous Stress Test)

Answer 27

1. Patient supine. Resting symptoms assessed.
2. Examiner stands opposite painful side
3. Hip on painful side flexed to 90 degrees and knee flexed
4. Examiner places hand under sacrm to form a stable “bridge”
5. Downward pressure applied through the femur to force posterior translation of the innominate. Patient’s symptoms assessed.
6. Positive test is concordant pain that is posterioro to the hip or near the SI joint. Requires reproduction of pain on the thrust side.

Question 28

Describe the Distraction/Gapping Test

Answer 28

1. Patient supine. Resting symptoms assessed.
2. Medial aspect of both ASIS are palpated. Examiner crosses arms, creating an X and applies force in a lateral-posterior direction.
3. Examiner holds position for 30 seconds then appies a vigorous force repeatedly to see if concordant sign of pain is reproduced
4. Positive test is reproduction of concordant sign

Question 29

Describe the Compression Test

Answer 29

1. Patient lies on their side with painful side up superior to plinth. Resting symptoms assessed.
2. Examiner cups iliac crest of painful side and applies a downward force through the ilium. This position is held for 30 seconds. Considerable vigor is required to reproduce symtpoms and sometimes repeated force is necessary.
3. Positive test is reproduction of concordant sign.

Question 30

Describe Gaenslen’s Test

Answer 30

1. Patient positioned supine with painful leg resting very near end of treatment table
2. Examiner sagitally raises nonpainful side of hip with knee bent up to 90 degrees hip flexion.
3. Downward force is applied to lower leg (painful side) while flexion counterforce is applied to flexed leg. This causes a torque to the pelvis.
4. Test is positive if the torque reproduces pian of concordant sign.

Question 31

Describe the Sacral Thrust Test?

Answer 31

1. Patient lies in a prone position. Resting symptoms assessed.
2. Examiner palpates second or third spinous process of sacrum. Using pisiform examiner places downward pressure at S3
3. Positive test is reproduction of the concordant sign

Question 32

Approximately 80% of people have SI joint pain _____ the long dorsal ligament

Answer 32

ABOVE

Question 33

What is Sign of the Buttock? Two ways to perform it. What does it mean?

Answer 33

1. Patient lies supine
2. Examiner passively performs a straight leg raise to the point of pain or restriction
3. Examiner flexes knee while holding the thigh in the same angle at the hip
4. Examiner applies further flexion to the hip
5. If hip flexion is still restricted or results in the same pain as iwth SLR, the finding

This is passive knee flexion that causes extreme pain in your butt. Empty end feel –You do not feel anything yet but patient tells you to stop because it is so painful. Could be an abscess, tumor, sepsis. Very red flag, send them to doctor.

Question 34

What are 4 muscular test for SI joint assessment?

Answer 34

1. 90/90 Test (hamstrings)
2. Thomas Stretch Test
3. Prone knee bending for quads and femoral nerve (look at how pelvis rotates while doing this, looking for rec fem or hip flexor tightness)
4. FABERs

Question 35

What sinew channels are involved with the SI joint?

Answer 35

• Gallbladder
• Stomach
• Bladder

Question 36

What comprises the anterior oblique sling? What exercise can help stabilize?

Answer 36

Adductors, internal oblieques and external obliques

Dead Bug Exercise

Question 37

What is the posterior oblique sling? What exercise helps stabilize it?

Answer 37

Glutes across to lat

Bird dogs

Question 38

What is the posterior longitudinal system?

Answer 38

Glutes and spinal muscles

Bird dogs