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OCS prep (TQ) > Hip APTA > Flashcards

Hip APTA Flashcards

1
Q

In general which directions does the acetabulum face?

A
  • ventrally, laterally, and caudally
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2
Q

What does the collodiaphyseal (CD) angle of the femur refer to?

A
  • the superior medial orientation of the femoral neck.
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3
Q

What is the normal CD angle in children, and what does it develop to?

A
  • 150, decreasing to ~120-130 in adulthood from weight bearing
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4
Q

Coxa vara refers to a CD angle of: _____?

A
  • <120*
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5
Q

What does the center edge angle (CE) refer to?

What is normal?

What is abnormal?

What can influence the angle?

A
  • angle between the acetabulum and femoral head in the frontal plane.
  • normal would be ~30*
  • angle < 30* signifies dysplastic changes in the joint
  • can be influenced by variations in shape of the superior lateral acetabular edge
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6
Q

How does the orientation of the femoral head/neck in the transverse plane change during development?

A
  • Starts with ~40* anterior orientation, decreasing to ~9*; relative to the line between the distal epicondyles
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7
Q

What is considered an anteverted hip? What are the consequences?

What is considered a retroverted hip? What are the consequences?

A
  • excessive anterior rotation is anteversion. Hip ER is decreased to maintain the 90-100* total rotational ROM in the transverse plane. Increases compressive forces on cartilage and may result in tendinopathies
  • decreased anterior rotation is retroversion. Hip IR is limited, with increased ER. Could produce early degenerative changes in the anterior superior acetabular labrum
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8
Q

What is the distribution of cartilage in the acetabulum?

A
  • hyaline cartilage covers ~2/3rds
  • no cartilage in the center where the ligamentum teres comes through
  • thinner in the superior dome and anterior/inferior region
  • thicker in the posterior and anterior/superior portion of the acetabulum, where the femoral head has the most contact during the gait cycle
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9
Q

A dysplastic hip has a more ______ head. What is the converse?

A
  • dysplastics hips have more elliptical heads, while those with deeper acetabulums typically have more spherical heads
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10
Q

What is the role of the labrum?

A
  • increases depth of acetabulum
  • maintains articular seal
  • load support
  • joint lubrication
  • proprioception; many sensory receptors are located in labral tissue
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11
Q

How well is the acetabulum vascularized?

A
  • similar to the meniscus; outer portions are better vascularized than the inner portions.
  • Additionally, the superior portion of the labrum is less well vascularized
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12
Q

What are the 3 different fiber systems of the capsuloligamentous structures of the hip?

A
  • longitudinal: proximal to distal fibers. Creates tensile restraint to capsule
  • transverse: encircles the diameter of the capsule around the neck, creating Zona Orbicularis
  • arcuate: create loops at the proximal insertion of the labrum, reinforcing that insertion
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13
Q

T or F;

The ligamentum teres can be a significant source of hip pain or mechanical symptoms.

A

T

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14
Q

What are the two branches of the iliofemoral ligament, their connections, and what do they restrict?

A
  • pars inferioris: constrains hip extension. Iliac outer wall of acetabulum to the attachment on the intertrochanteric line on the anterior proximal femur.
  • pars superioris: constrains hip extension, adduction, and external rotation. Same proximal attachment, but courses inferolaterally to the intertrochanteric line just anterior to the greater troch.
  • in flexion, limits ER
  • in extension, limits ER and IR
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15
Q

What is the course of the pubofemoral ligament and what does it restrict?

A
  • constrains extension, abduction, and ER
  • from the pubic outer wall of the acetabulum to the same attachment as the pars interarticularis of the iliofemoral ligament
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16
Q

What are the differences in what the iliofemoral ligament limits in flexion and extension?

A
  • in general limits extension.
  • however, in flexion, limits ER
  • in extension, limits ER and IR
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17
Q

What is the course of the ischiofemoral ligament, what ligament does it assist, and what is it’s general function?

A
  • ischial outer wall of acetabulum to the posterior capsule.
  • assists the arcuate ligament (courses from lesser to greater trochanter on the posterior joint capsule)
  • generally, these both support the posterior capsule and add stability in quiet standing, as they are taut in the upright position
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18
Q

T or F;

You can have a Hill Sachs lesion on a hip.

A
  • T
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19
Q

What nerve is found in the inguinal canal?

A
  • ilioinguinal nerve

- can become entraped in the canal

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20
Q

T or F;

The iliopsoas passes over the ilioinguinal ligament.

A
  • F

- Ilioinguinal ligament passes lateral to medial from the ASIS, and is pretty superficial

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21
Q

The anterior coxafemoral joint is innervated by which two nerves?

A
  • sensory branches of the femoral and obturator nn.
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22
Q

The posterior CFJ is innervated by which nerve?

A
  • innervated by branches of the sacral plexus
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23
Q

The origin of which muscles are prone to avulsion fractures in adolescents?

A
  • rectus femoris (AIIS)

- sartorius (ASIS)

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24
Q

What landmarks can help palpation of the pectinius?

A
  • it lies distal to the ilioinguinal ligament and medial to the femoral artery.
  • attaches to the pectin pubis and femoral pectineal line
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25
Q

What is the orientation of the adductor longus w/ connections?

A
  • emerges from the caudal surface of the pubic tubercle, running down the medial thigh to the mid posterior medial femur
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26
Q

What is the orientation of the gracilis w/ connections?

A
  • originates medial and posterior to the adductor longus on the inferior pubic ramus, attaching to the pes anserine.
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27
Q

T or F;

The adductor brevis cannot be palpated.

A
  • T
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28
Q

What is the orientation of the adductor brevis with connections?

A
  • anterior pubis just deep to the adductor longus and gracilis.
  • covered by those muscles and can’t be palpated
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29
Q

What is the orientation of the adductor magnus with connections?

A
  • emerges from the inferior pubic and ischial rami with multiple connects along the length of the femur below the neck
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30
Q

What are the connections of the glute max?

A
  • proximally from the iliac crest, PSIS, dorsal sacrum and coccyx to the posterior IT band and gluteal tuberosity running in a line distally, which is just distal to the greater troch
  • proximal attachment intertwines with the thoracolumbar fascia and the dorsal sacroiliac ligament
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31
Q

What is the orientation/connections of the piriformis?

A
  • deep to the glute max.
  • anterior sacrum to the posterior greater troch
  • ER that extends and abducts the flexed thigh
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32
Q

What are the hip ERs? Other than the piriformis, where do they attach distally?

What is their likely function?

A
  • piriformis, superior/inferior gemelli, obturator interus/externus, and quadratus femoris
  • they all insert just inferior to the piriformis on the greater troch. Quad femoris more significantly lower, along a line
  • ER; but likely also improve load bearing through the CFJ; kind of like the RC?
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33
Q

The insertion of the glute med/minimus is prone to what degenerative development?

A
  • calcification, with chronic tendinopathy and mechanical deficiency with potential to tear
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34
Q

What % of adults over the age of ____ may have painless glute med tears?

A
  • 10% of adults over the age of 60
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35
Q

Where is the trochanteric bursa found?

A
  • in proximity of the posterior greater troch.

- several layers of synovial-lined bursa

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36
Q

Where is the ischiogluteal bursa found?

A
  • under the glute max, just posterior to the ischial tuberosity
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37
Q

Where can the iliopectineal bursa be found?

A
  • deep to the iliopsoas tendon, just anterior to the iliopectineal eminence.
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38
Q

The anterior pubic symphysis sends sensory information back through which spinal levels?

The posterior pubic ramus sends sensory information back through which spinal levels?

What are the implications?

A
  • anterior pubic symphysis: L2-4. thus can have referred groin pain when those levels are irritated.
  • posterior pubic ramus: S3-5. can produce genital pain with pathology
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39
Q

What motions occur in the CFJ relative to the acetabular plane with anatomical flexion? Extension? Abduction?

A
  • Flexion: flexion, abduction, and internal rotation
  • Extension: extension, adduction, external rotation
  • Abduction: abduction, extension, external rotation
  • Adduction: adduction, flexion, external rotation
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40
Q

Peak force at the acetabulum during gait is ____ to ____ x body weight.

A
  • 1.8 to 3.8 times body weight

- this is increased with increased anteversion

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41
Q

In general, what regions are loaded in the acetabulum during the gait cycle?

A
  • at initial loading, the dorsolateral aspect of the acetabulum, with the ventrolateral aspect taking most of the load during the propulsive end of the gait cycle
  • that said, there’s a fair amount of variation between individuals
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42
Q

Any force > than ___x body weight increases the risk of early joint degeneration.

A
  • 3x body weight.
43
Q

Describe the consequences of acetabular or femoral head dysplasia.

A
  • reduces femoral head coverage, altering loading and joint congruency.
  • increases risk for joint laxity/instability, increasing risk for degeneration that could produce femoral head flattening or notching
44
Q

A 9 year old pt is scheduled for a hip pain eval. What is immediately in the differential?

A
  • transient synovitis
  • Legg-Calve-Perthes disease
  • juvenile rheumatoid arthritis
  • all of the above are most commonly occurring between 4-10 yo
45
Q

A 12 year old girl is scheduled for a hip pain eval. What is immediately in the differential?

A
  • Epiphysiolysis
  • most often in females between 11-13
  • most often in males between 13-15
46
Q

Articular osteochondritis dissecans occurs most often in what age range?

A
  • 15-25
47
Q

Ischemic femoral necrosis and synovial osteochondromatosis most often occurs in what age range?

A
  • 35-50
48
Q

Labral lesions are most common between what age ranges?

A
  • 18-40
49
Q

What pathologies are more likely for males > 40 yo?

A
  • labral cysts
  • sacral pathologies
  • stress fractures of the femur and pelvis (in younger females, often associated with the triad)
50
Q

T or F;

Pain location and type are helpful to specifically identify type/presence of hip pathology.

A
  • F; not on their own. Too much referral.
51
Q

While not cleanly diagnostic, an aching pain is more often associated with which diagnoses? Sharp pain? Burning pain?

A
  • aching: bursitis, tendinopathy, arthritis, arthrosis
  • sharp: labral tears, articular loose bodies (often accompanied by clicking, giving way, catching, locking)
  • burning: nerve entrapments
52
Q

A pt has c/o burning pain with some hair loss and foot/nail changes. What is a potential ortho dx?

A
  • nerve entrapment with sympathetic involvement. May produce sweating, hair loss, and/or foot and nail changes
53
Q

A pt is complaining of groin pain. Barring lumbar/SIJ referral, what is generally in the hip differential?

A
  • CFJ/labral injury
  • symphasis pubis lesion
  • adductor tendinopathy
  • iliopectineal bursitis
  • incompetent abdominal wall
  • other urological, gynecological, neurovascular, or organic lesions of the abdominal cavity and pelvic region
54
Q

A pt is complaining of posterior hip/buttock pain. What is generally in the differential?

A
  • SIJ dysfunction
  • lumbar spine or nerve root referral
  • gluteal bursitis
  • hamstring tendinopathy
  • hamstring syndrome
55
Q

A pt is complaining of posterolateral hip pain? What is in the differential?

A
  • trochanteric bursitis
  • gluteal insertion tendinopathy or disruption
  • component loosening in pts w/ hip arthroplasty
  • lumbar spine pathology
  • nerve root involvement, including potential contribution from the dorsal ramus from the T12 segmental nerve
56
Q

A pt reports increased groin pain with coughing, sneezing, or straining. Another reports of provocation of buttock pain. What are these more concerning for?

A
  • groin pain w/ coughing: hernia, pubic symphyseal affliction, tendinopathy of the adductor longus or rectus abdominis
  • buttock pain with coughing: lumbar disc prolapse or extrusion
57
Q

A pt presents with swelling in the groin region. Can this be caused by swelling in the CFJ?

A
  • not really. Swelling in the CFJ is not typically observable.
  • Groin swelling would be concerning for inguinal hernia, lymphangitis, or other serious pathology. Should probably refer.
58
Q

Observed atrophy in the gluteal muscles may suggest involvement of which nerve roots?

A
  • S1 and/or S2
59
Q

A pt presents with some nodular formations over the sacrum. What is this indicative of?

A
  • typically benign lipomas that can be removed if cosmetically unwanted or produce patient discomfort
60
Q

How can the lumbar spine be screened during a hip exam?

A
  • active movements in standing (flexion, extension, lateral flexion)
  • looking for provocation or significant abnormalities
61
Q

What two tests are recommended to screen for lumbosacral root involvement, via dural tension?

A
  • Slump test (distal initiation)

- SLR (distal initiation)

62
Q

What is the sequencing for the SLR, with distal initiation?

A
  • all movements passive
  • with the knee bent, dorsiflex the ankle
  • then extend the knee
  • then flex the hip
  • then have the pt come into cervical flexion
63
Q

A pt has c/o groin pain that is increased by sitting. What is a potential dx?

A
  • anterosuperior acetabular labral tear
64
Q

A pt has c/o buttock pain that increases in sitting. What are potential dx?

A
  • discogenic pain
  • ischial bursitis
  • hamstring syndrome
  • gluteal bursitis
65
Q

What is the proposed mechanism for “hamstring syndrome”?

A
  • entrapment of the sciatic nerve in the fascial envelope that emerges form the proximal insertion of the biceps femoris as it inserts into the tuberosity.
66
Q

What SIJ screen tests are appropriate? (5)

A
  • dorsolateral provocation test
  • thigh thrust test
  • Gaenslen in supine
  • ventromedial provocation test in sidelying
  • sacral thrust test in prone
  • 3 or more positives is highly suspicious for SIJ involvement
67
Q

What is another appropriate sensitive/specific test for SIJ screening? How is it performed?

A
  • Active SLR
  • Pt in supine, lifts heel ~20cm off the mat with knee extended.
  • positive when the pt feels weakness and/or pain that limits his/her ability to adequately complete the maneuver.
  • maneuver repeated with therapist compressing innominates. If performance improved (pain reduced, weakness reduced), then more indicative of SIJ involvement
68
Q

Limitations noted during passive joint assessment are more indicative of: _______

A
  • joint/articular involvement; labral lesions
69
Q

What movements/assessments are appropriate to screen for tendinopathy in the hip?

A
  • manual resistance in the directions of hip flexion, abduction, adduction; w/ hip position of 0, 45, and 90* of flexion. Emphasizes adductor longus/gracilis, symphysis pubis, and pectineus tendons respectively
  • manual resistance in prone for ER/IR
  • manual resistance in prone for knee flexion/extension for hamstrings and rectus femoris respectively
  • manual resistance for glute med in sidelying
70
Q

Manual resistance is provided in flexion, adduction, abduction for a pt in supine with their leg in 0, 45, and 90*. What tendons/structures are emphasized in these positions?

A
  • 0*: adductor longus/gracilis
  • 45*: symphysis pubis
  • 90*: pectineus
71
Q

What type of imaging is best for:

  • labral lesions
  • bursitis
  • occult hip fx
  • acetabular fx
A
  • labral lesions: MRI
  • bursitis: MRI
  • occult hip fx: CT
  • acetabular fx: CT
72
Q

A pt presents with intact PROM but an isolated active ROM limitation. What is this concerning for?

A
  • typically, an isolated active limitation is associated with neurological disorder
73
Q

Capsular limitations are typical of what diagnoses?

A
  • hip arthritis (synovitis) or arthrosis
74
Q

Repetitive motion/loading that results in arthritis would be considered traumatic or nontraumatic arthritis?

A
  • traumatic; repetitive microtrauma
75
Q

Traumatic arthritis more often occurs in people > than ____ yo, as a result of forceful or repetitive _________, __________, or combinations of those movements.

A
  • > 20 yo

- hyperextension and rotation

76
Q

What patterns/descriptions of pain and aggravating factors are often associated with arthritis?

A
  • groin and/or anterior thigh pain

- aggravated with sitting, walking, and ascending stairs

77
Q

Is ascending or descending stairs more associated with hip OA?

A
  • ascending
78
Q

What is the capsular pattern of limitation at the hip?

A
  • not super consistent, however IR is the most limited, followed by varied degrees of flexion/extension/abduction
79
Q

What is a predictor pattern for diagnosing hip OA? (5)

How many variables should be present?

A
  • self-reported squatting as an aggravating factor
  • active hip flexion causing lateral hip pain
  • Scour test with adduction causing lateral hip or groin pain
  • active hip extension causing pain
  • passive IR of = 25*
  • 3 of 5
80
Q

T or F;

ER and/or adduction limitations are rarely found with hip OA.

A
  • T
81
Q

According to the authors, what is the best intervention for treating micro or macrotraumatic arthritis?

A
  • early mobilization; joint mobs
82
Q

In general, what direction should traction be applied during joint mobs to the hip?

A
  • perpendicular to the concavity of the acetabulum

- or, ventrally, laterally, and caudally

83
Q

Joint-specific mobilization/manipulation is contraindicated for what conditions?

A
  • synovitis with associated instability
  • degenerative bone disorders
  • present use of anticoagulant therapy
84
Q

In general, how are joint mobs used to restore ROM?

A
  • put the joint at the end ROM, then apply traction in that position
85
Q

What is the general positioning to improve abduction ROM with joint mobs?

A
  • abduction to limit, then submaximal extension and ER
86
Q

What systemic (nontraumatic) reasons can create a capsular presentation at the hip? (6)

A
  • RA
  • gout
  • Reiter syndrome
  • psoriasis
  • ankylosing spondylitis
87
Q

T or F;

Legg-Calve-Perthes will not present with a capsular pattern.

A
  • F, it can
88
Q

A n 8yo male presents with hip pain without known MOI, with notable IR limitation and general limitations in hip flx/abduction. What is on the differential of primary concern?

A
  • Legg-Calve-Perthes; necrosis of the femoral head
89
Q

What are the common demographics for LCP disease?

A
  • male
  • age 4-10
  • in response to viral or autoimmune response
90
Q

The 8yo male pt with hip pain of unknown MOI with capsular restriction developed a transient synovitis. What is the likelihood that this will not progress to LCPD?

A
  • fairly good. Most will spontaneously recover, but 15-20% will be at risk to progress to LCPD
91
Q

What is the expected course for adhesive capsulitis of the hip; i.e., an idiopathic synovial reaction that results in ROM limitations

A
  • typically resolves in 1-2 years; considered self-limiting
92
Q

Primary coxarthritis occurs most often in pts older than _____, while secondary coxarthritis most often occurs in pts older than ________.

A
  • primary more likely in pts over 40 yo

- secondary more likely in pts over 25 yo

93
Q

What are some dx that can cause secondary coxarthritis? (5)

A
  • joint instability
  • dysplasia
  • previous intraarticular fx
  • long-standing loose body
  • other disease process
94
Q

For hip OA, what is the most appropriate short-term intervention for pain? For function?

A
  • pain: joint mobs

- function: exercise

95
Q

What preoperative factors can predict ambulatory ability post-op for a THA?

A
  • abductor and knee strength
96
Q

Is preoperative PT for THA appropriate?

A
  • yes; has been shown to decrease use of post-acute care services and inpatient rehab
97
Q

What is the current philosophy regarding hip precautions?

A
  • meh, variable. Some evidence for anterolateral approaches shows that those without precautions had earlier returns of function and overall increased satisfaction of their progress
98
Q

T or F;

Traditional NWB therex for post THA is effective even in the longer term after surgery to improve outcomes.

A
  • F. Those who progress to WB exercise will do better in strength and postural control
99
Q

Transient synovitis is most common with what demographic?

A
  • males under 6 yo

- rare in adults. Can be viral, autoimmune, or microtraumatic in origin

100
Q

What is the standard presentation surrounding a transient synovitis?

A
  • male under 6 yo, following preceding illness (40% of the time)
  • antalgic gait with slight capsular pattern of limitations
101
Q

What must transient synovitis be differentiated from?

A
  • septic arthritis
102
Q

What is the typical expectation for prognosis with a transient synovitis?

A
  • usually resolves in 2-3 weeks

- initial treatment of 2-4 days of bedrest with cuff traction, following by progressive WB as tolerated

103
Q

If doing a joint mob to improve hip flexion, what position should the joint be placed in to maximize ROM improvements?

A
  • flexion, abduction and IR
104
Q

What of the following can be treated with a HVLA mob/manip?

  • acetabular labral tear
  • arthritic loose body
  • idiopathic loose body
  • osteochondritis dessicans
A
  • all of them except for osteochondritis dessicans; it’d be contraindicated. Necrotic bone tissue leads to flaking/weakened tissue which may get worse with a mob

OCS prep (TQ) (25 decks)

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