Hip APTA Flashcards
In general which directions does the acetabulum face?
- ventrally, laterally, and caudally
What does the collodiaphyseal (CD) angle of the femur refer to?
- the superior medial orientation of the femoral neck.
What is the normal CD angle in children, and what does it develop to?
- 150, decreasing to ~120-130 in adulthood from weight bearing
Coxa vara refers to a CD angle of: _____?
- <120*
What does the center edge angle (CE) refer to?
What is normal?
What is abnormal?
What can influence the angle?
- 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
How does the orientation of the femoral head/neck in the transverse plane change during development?
- Starts with ~40* anterior orientation, decreasing to ~9*; relative to the line between the distal epicondyles
What is considered an anteverted hip? What are the consequences?
What is considered a retroverted hip? What are the consequences?
- 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
What is the distribution of cartilage in the acetabulum?
- 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
A dysplastic hip has a more ______ head. What is the converse?
- dysplastics hips have more elliptical heads, while those with deeper acetabulums typically have more spherical heads
What is the role of the labrum?
- increases depth of acetabulum
- maintains articular seal
- load support
- joint lubrication
- proprioception; many sensory receptors are located in labral tissue
How well is the acetabulum vascularized?
- similar to the meniscus; outer portions are better vascularized than the inner portions.
- Additionally, the superior portion of the labrum is less well vascularized
What are the 3 different fiber systems of the capsuloligamentous structures of the hip?
- 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
T or F;
The ligamentum teres can be a significant source of hip pain or mechanical symptoms.
T
What are the two branches of the iliofemoral ligament, their connections, and what do they restrict?
- 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
What is the course of the pubofemoral ligament and what does it restrict?
- 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
What are the differences in what the iliofemoral ligament limits in flexion and extension?
- in general limits extension.
- however, in flexion, limits ER
- in extension, limits ER and IR
What is the course of the ischiofemoral ligament, what ligament does it assist, and what is it’s general function?
- 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
T or F;
You can have a Hill Sachs lesion on a hip.
- T
What nerve is found in the inguinal canal?
- ilioinguinal nerve
- can become entraped in the canal
T or F;
The iliopsoas passes over the ilioinguinal ligament.
- F
- Ilioinguinal ligament passes lateral to medial from the ASIS, and is pretty superficial
The anterior coxafemoral joint is innervated by which two nerves?
- sensory branches of the femoral and obturator nn.
The posterior CFJ is innervated by which nerve?
- innervated by branches of the sacral plexus
The origin of which muscles are prone to avulsion fractures in adolescents?
- rectus femoris (AIIS)
- sartorius (ASIS)
What landmarks can help palpation of the pectinius?
- it lies distal to the ilioinguinal ligament and medial to the femoral artery.
- attaches to the pectin pubis and femoral pectineal line
What is the orientation of the adductor longus w/ connections?
- emerges from the caudal surface of the pubic tubercle, running down the medial thigh to the mid posterior medial femur
What is the orientation of the gracilis w/ connections?
- originates medial and posterior to the adductor longus on the inferior pubic ramus, attaching to the pes anserine.
T or F;
The adductor brevis cannot be palpated.
- T
What is the orientation of the adductor brevis with connections?
- anterior pubis just deep to the adductor longus and gracilis.
- covered by those muscles and can’t be palpated
What is the orientation of the adductor magnus with connections?
- emerges from the inferior pubic and ischial rami with multiple connects along the length of the femur below the neck
What are the connections of the glute max?
- 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
What is the orientation/connections of the piriformis?
- deep to the glute max.
- anterior sacrum to the posterior greater troch
- ER that extends and abducts the flexed thigh
What are the hip ERs? Other than the piriformis, where do they attach distally?
What is their likely function?
- 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?
The insertion of the glute med/minimus is prone to what degenerative development?
- calcification, with chronic tendinopathy and mechanical deficiency with potential to tear
What % of adults over the age of ____ may have painless glute med tears?
- 10% of adults over the age of 60
Where is the trochanteric bursa found?
- in proximity of the posterior greater troch.
- several layers of synovial-lined bursa
Where is the ischiogluteal bursa found?
- under the glute max, just posterior to the ischial tuberosity
Where can the iliopectineal bursa be found?
- deep to the iliopsoas tendon, just anterior to the iliopectineal eminence.
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?
- 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
What motions occur in the CFJ relative to the acetabular plane with anatomical flexion? Extension? Abduction?
- Flexion: flexion, abduction, and internal rotation
- Extension: extension, adduction, external rotation
- Abduction: abduction, extension, external rotation
- Adduction: adduction, flexion, external rotation
Peak force at the acetabulum during gait is ____ to ____ x body weight.
- 1.8 to 3.8 times body weight
- this is increased with increased anteversion
In general, what regions are loaded in the acetabulum during the gait cycle?
- 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
Any force > than ___x body weight increases the risk of early joint degeneration.
- 3x body weight.
Describe the consequences of acetabular or femoral head dysplasia.
- 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
A 9 year old pt is scheduled for a hip pain eval. What is immediately in the differential?
- transient synovitis
- Legg-Calve-Perthes disease
- juvenile rheumatoid arthritis
- all of the above are most commonly occurring between 4-10 yo
A 12 year old girl is scheduled for a hip pain eval. What is immediately in the differential?
- Epiphysiolysis
- most often in females between 11-13
- most often in males between 13-15
Articular osteochondritis dissecans occurs most often in what age range?
- 15-25
Ischemic femoral necrosis and synovial osteochondromatosis most often occurs in what age range?
- 35-50
Labral lesions are most common between what age ranges?
- 18-40
What pathologies are more likely for males > 40 yo?
- labral cysts
- sacral pathologies
- stress fractures of the femur and pelvis (in younger females, often associated with the triad)
T or F;
Pain location and type are helpful to specifically identify type/presence of hip pathology.
- F; not on their own. Too much referral.
While not cleanly diagnostic, an aching pain is more often associated with which diagnoses? Sharp pain? Burning pain?
- aching: bursitis, tendinopathy, arthritis, arthrosis
- sharp: labral tears, articular loose bodies (often accompanied by clicking, giving way, catching, locking)
- burning: nerve entrapments
A pt has c/o burning pain with some hair loss and foot/nail changes. What is a potential ortho dx?
- nerve entrapment with sympathetic involvement. May produce sweating, hair loss, and/or foot and nail changes
A pt is complaining of groin pain. Barring lumbar/SIJ referral, what is generally in the hip differential?
- 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
A pt is complaining of posterior hip/buttock pain. What is generally in the differential?
- SIJ dysfunction
- lumbar spine or nerve root referral
- gluteal bursitis
- hamstring tendinopathy
- hamstring syndrome
A pt is complaining of posterolateral hip pain? What is in the differential?
- 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
A pt reports increased groin pain with coughing, sneezing, or straining. Another reports of provocation of buttock pain. What are these more concerning for?
- 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
A pt presents with swelling in the groin region. Can this be caused by swelling in the CFJ?
- 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.
Observed atrophy in the gluteal muscles may suggest involvement of which nerve roots?
- S1 and/or S2
A pt presents with some nodular formations over the sacrum. What is this indicative of?
- typically benign lipomas that can be removed if cosmetically unwanted or produce patient discomfort
How can the lumbar spine be screened during a hip exam?
- active movements in standing (flexion, extension, lateral flexion)
- looking for provocation or significant abnormalities
What two tests are recommended to screen for lumbosacral root involvement, via dural tension?
- Slump test (distal initiation)
- SLR (distal initiation)
What is the sequencing for the SLR, with distal initiation?
- 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
A pt has c/o groin pain that is increased by sitting. What is a potential dx?
- anterosuperior acetabular labral tear
A pt has c/o buttock pain that increases in sitting. What are potential dx?
- discogenic pain
- ischial bursitis
- hamstring syndrome
- gluteal bursitis
What is the proposed mechanism for “hamstring syndrome”?
- 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.
What SIJ screen tests are appropriate? (5)
- 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
What is another appropriate sensitive/specific test for SIJ screening? How is it performed?
- 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
Limitations noted during passive joint assessment are more indicative of: _______
- joint/articular involvement; labral lesions
What movements/assessments are appropriate to screen for tendinopathy in the hip?
- 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
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?
- 0*: adductor longus/gracilis
- 45*: symphysis pubis
- 90*: pectineus
What type of imaging is best for:
- labral lesions
- bursitis
- occult hip fx
- acetabular fx
- labral lesions: MRI
- bursitis: MRI
- occult hip fx: CT
- acetabular fx: CT
A pt presents with intact PROM but an isolated active ROM limitation. What is this concerning for?
- typically, an isolated active limitation is associated with neurological disorder
Capsular limitations are typical of what diagnoses?
- hip arthritis (synovitis) or arthrosis
Repetitive motion/loading that results in arthritis would be considered traumatic or nontraumatic arthritis?
- traumatic; repetitive microtrauma
Traumatic arthritis more often occurs in people > than ____ yo, as a result of forceful or repetitive _________, __________, or combinations of those movements.
- > 20 yo
- hyperextension and rotation
What patterns/descriptions of pain and aggravating factors are often associated with arthritis?
- groin and/or anterior thigh pain
- aggravated with sitting, walking, and ascending stairs
Is ascending or descending stairs more associated with hip OA?
- ascending
What is the capsular pattern of limitation at the hip?
- not super consistent, however IR is the most limited, followed by varied degrees of flexion/extension/abduction
What is a predictor pattern for diagnosing hip OA? (5)
How many variables should be present?
- 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
T or F;
ER and/or adduction limitations are rarely found with hip OA.
- T
According to the authors, what is the best intervention for treating micro or macrotraumatic arthritis?
- early mobilization; joint mobs
In general, what direction should traction be applied during joint mobs to the hip?
- perpendicular to the concavity of the acetabulum
- or, ventrally, laterally, and caudally
Joint-specific mobilization/manipulation is contraindicated for what conditions?
- synovitis with associated instability
- degenerative bone disorders
- present use of anticoagulant therapy
In general, how are joint mobs used to restore ROM?
- put the joint at the end ROM, then apply traction in that position
What is the general positioning to improve abduction ROM with joint mobs?
- abduction to limit, then submaximal extension and ER
What systemic (nontraumatic) reasons can create a capsular presentation at the hip? (6)
- RA
- gout
- Reiter syndrome
- psoriasis
- ankylosing spondylitis
T or F;
Legg-Calve-Perthes will not present with a capsular pattern.
- F, it can
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?
- Legg-Calve-Perthes; necrosis of the femoral head
What are the common demographics for LCP disease?
- male
- age 4-10
- in response to viral or autoimmune response
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?
- fairly good. Most will spontaneously recover, but 15-20% will be at risk to progress to LCPD
What is the expected course for adhesive capsulitis of the hip; i.e., an idiopathic synovial reaction that results in ROM limitations
- typically resolves in 1-2 years; considered self-limiting
Primary coxarthritis occurs most often in pts older than _____, while secondary coxarthritis most often occurs in pts older than ________.
- primary more likely in pts over 40 yo
- secondary more likely in pts over 25 yo
What are some dx that can cause secondary coxarthritis? (5)
- joint instability
- dysplasia
- previous intraarticular fx
- long-standing loose body
- other disease process
For hip OA, what is the most appropriate short-term intervention for pain? For function?
- pain: joint mobs
- function: exercise
What preoperative factors can predict ambulatory ability post-op for a THA?
- abductor and knee strength
Is preoperative PT for THA appropriate?
- yes; has been shown to decrease use of post-acute care services and inpatient rehab
What is the current philosophy regarding hip precautions?
- meh, variable. Some evidence for anterolateral approaches shows that those without precautions had earlier returns of function and overall increased satisfaction of their progress
T or F;
Traditional NWB therex for post THA is effective even in the longer term after surgery to improve outcomes.
- F. Those who progress to WB exercise will do better in strength and postural control
Transient synovitis is most common with what demographic?
- males under 6 yo
- rare in adults. Can be viral, autoimmune, or microtraumatic in origin
What is the standard presentation surrounding a transient synovitis?
- male under 6 yo, following preceding illness (40% of the time)
- antalgic gait with slight capsular pattern of limitations
What must transient synovitis be differentiated from?
- septic arthritis
What is the typical expectation for prognosis with a transient synovitis?
- usually resolves in 2-3 weeks
- initial treatment of 2-4 days of bedrest with cuff traction, following by progressive WB as tolerated
If doing a joint mob to improve hip flexion, what position should the joint be placed in to maximize ROM improvements?
- flexion, abduction and IR
What of the following can be treated with a HVLA mob/manip?
- acetabular labral tear
- arthritic loose body
- idiopathic loose body
- osteochondritis dessicans
- 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
