Hip Clinical Presentations Flashcards
List common clinical presentations at the hip
- Osteoporosis
- Fractures
- Avulsion
- Stress
- AVN
- Osteoarthropathy
- Labral Tear
- FAI
- Loose Bodies
- Snapping Hip Syndrome
- Tendinopathy
- Muscle Strain
- Bursitis
- Greater Trochanteric Pain Syndrome (GTPS)
- Nerve Entrapments
Fractures of the Hip and mortality and prognostic indicators
- >/= 90% of hip fractures are sustained by individuals >65 y/o
- 1 year mortality rate 14-36%
- increases 5-10 years post-fracture
- Survivors have shortened life expectancy
- Positive prognostic indicators
- surgery within 48 hours
Negative Prognostic indicators for hip fractures
- Male gender
- age >86 y/o
- >/=2 comorbidities
- anemia
- mini mental test score = 6/10
Fractures of the hip general info
- Proximal 1/3 of the femur
- Prognosis
- displaced vs nondisplaced
- comminution
- vascular integrity
- reduction
- fixation
- High risk for thrombosis/embolism
categories for hip fractures
- Intertrochanteric → between greater and lesser trochanters
- Subtrochanteric → refer to common surgery procedures
- Femoral neck
- monitor for AVN and non-union
- Compression frx more stable than tension frx
Hx and Symptomlogy of hip fractures
- Hx
- older adult
- trauma (fall) vs. spontaneous
- Symptomology
- severe groin and anterior thigh pain more likely than severe lateral hip pain
Physical Exam Findings for Fractures of the Hip
- Shortening of the LE
- Limited/painful squat in LQS
- Painful/limited hip AROM/PROM
- Painful/weakness with strength testing
- +Fulcrum and pubic percussion tests
Common Surgical procedures for fractures of the hip
- Arthroplasty
- External fixation (rare and temporary)
- Open reduction internal fixation (ORIF)
- full w/b 8-12 weeks post op (commonly)
- Intramedullary fixation
what is AVN?
Avascular Necrosis of Femoral Head
- progressive ischemia with secondary bone cell death
- collapsing of bone
- leads to degenerative arthropathy
- possibly conservative management, many managed surgically
Hx and risk factors for Osteonecrosis
- Risk Factors
- trauma
- corticosteroid use
- excessive alcohol consumption
- coagulation disorders
- hemoglobinopathies
- Dysbaric phenomena
- Autoimmune disease
- storage disease
- smoking
- hyperlipidemia
Symptomology and Hx for AVN of the femoral head
- Hx
- 3-5th decade
- risk factors
- Symptomology
- deep groin, buttock, knee pain
Physical Exam findings for AVN of femoral head
- limited squat LQS
- limited/painful AROM and PROM (IR)
- pain/weakness with resistive testing
prognostic indicators for AVN
- Extent of lesion
- location
- bone marrow edema presence
Hx for osteoarthropathy
- Insidious onset
- Hx trauma
- family Hx
- obesity
- hypermobility
- joint shape abnormality
- physical activity level
- Age > 50 years
Osteoarthropathy symptomology
- Dull vs sharp buttock, groin, thigh, knee pain
- C-Sign
- Hip stiffness (greater following prolonged sitting/inactivity)
- Difficulty with donning pants/socks/shoes
- Stair ambulation limitations
physical examination findings for osteoarthropathies
- limited AROM and PROM, painful at end-range (greatest IR, flexion, abduction)
- >1 plane
- +Scower test
- +/- weakness or pain with resistive testing
- joint hypomobility
CPR for hip OA
- Self-report squatting as aggravating activity
- Lateral pain with active hip flexion
- Passive hip IR = 25
- Pain with active hip extension
- Postive Scower test with adduction
Acetabular labral tears are assocaited with what?
- Degenerative osteoarthropathy
- Developmental hip dysplasia
- Aspherical femoral head
- Slipped Captial Epiphysis
- Legg-Calve-Perthes disease
- Hip trauma
- Athletics involving repetitive pivoting/flexion
- FAI
what is FAI?
Femoral-Acetabular Impingement (FAI)
- bony abnormality with decreased femoral-acetabular clearance
- Cam → increased size of femoral head, irregular junction with the neck
- leads to anteriosuperior labral and cartilage damage
- Pincer → increased protrusion of acetabular rim
- Cam → increased size of femoral head, irregular junction with the neck
- Most common is a mixture of Cam and Pincer
- Hip pain and degeneration
Hx and Symptomology of FAI
- Hx
- hockey players, golfers, dancers, football, soccer players
- Symptomology
- sharp, deep anterior hip pain
- pain/limitation with deep squat, cutting, lateral movements, painful ER
Physcial Exam findings for FAI
- Cam → hip flexion/adduction/IR ROM painful/limited (potentially bony end-feel)
- +FABER Test described
what are loose bodies
- free-floating body (cartilage/bone) within joint
- vary in size
- often secondary to degenerative changes in hip
- may cause muscle inhibition (weakness/discoordination)
Hx and symptomology of loose bodies
- Hx
- chronic hip pain
- advanced OA
- prior traumatic hip dislocation
- prior AVN
- Symptomology
- anterior hip/groin pain
- catching, locking, clicking, giving way of LE
- sudden pain w/b activities
clinical implications of loose bodies
ID, refer, likely managed with arthroscopy
Snapping hip syndrome can be classifed in what 3 ways?
- Intra-articular
- Internal
- External
causes of intra-articular snapping hip syndrome
- synovial chondromatosis
- loose bodies
- labral tears
- long head of biceps over ischium and iliofemoral ligament over femoral head
describe internal snapping hip syndrome
- causes:
- iliopsoas over femoral head, lesser trochanter, pectineus fascia, iliopectineal eminenc e
- fibrosis/tenosynovitis of iliopsoas tendon
- snapping/painful anterior hip (especially extending from flexed position)
- pain/snap with movement from FABER position to extension, adduction, IR
describe external snapping hip syndrome
- ITB/glut max over greater trochanter
- lateral hip pain/snapping
- aggravated by running on slanting surfaces, directional change on planted LE
- ITB contracture vs weak glut med and hip ERs
- Painful Ober Test
- can lead to greater trochanteric bursitis
external snapping hip syndrome may be observed at ____
- Hip
- increased compression on soft tissue structures between greater trochanter and ITB
- Knee
- increased compression on soft tissue structures between lateral femoral condyle and ITB
external snapping hip syndrome is also known as ___________
IT Band Friction Syndrome
tendinopathy at the hip commonly includes what structures?
rectus femoris
iliopsoas
glutes
Hx and symptomology of tendinopathy at the hip
- Hx
- internal snapping hip syndrome
- Symptomology
- anterior thigh/groin pain
Physical exam findings for tendinopathy at the hip
- painful/weak resisted hip flexion
- painful/limited hip extension and IR ROM
- guarded or empty end feel
general physical exam findings for muscle strains
- TTP muscle bellies with possible palpable defect
- antalgic gait
- on-going ecchymosis/edema several day
- painful/weak resistance testing of involved musculotendinous unit
- limited/painful AROM w/concentric contraction
- Painful/limited A/PROM placing stretch on musculotendinous unit
Hamstring muscle strain Hx and risk factors
- risk factors
- prior history
- hamstring weakness
- older adults
- Hx
- distinct injury/audible pop
- common MOI → sprinting with trunk flexion and fast running
Adductors mucle strain
- risk factors
- prior history
- decreased ROM
- clinical correlations
- soccer, hockey
- common MOI
- directional change while running
- symptomology
- groin pain (worse quick stops/starts)
Iliopsoas muscle strains
- Common MOI
- forced hip extension during active hip flexion
- Symptomology
- anterior hip/groin pain
- painful high stepping
T/F: rectus femoris strains have great prognosis
FALSE
worse (rectus central lesions) and also have longer recovery durations
risk factors and common MOI for quad strains
- Risk factors
- older athletes
- dry playing field
- shorter height
- dominant LE strength/flexibility
- MOI
- kicking while running
- sprinting (during acceleration and deceleration)
Hx and symptomology for glute med/min strains
- Hx
- fall, increased duration/frequency of loading sport-related injury
- middle-aged women
- Symptomology
- buttock/lateral hip/groin pain
two types of bursitis at the hip
- Trochanteric
- Iliopsoas/Iliopectineal
Trochanteric Bursitis demographics
- greater risk 40-60 year olds
- females > males
criteria for diagnosing trochanteric bursitis
- lateral hip pain
- distinct tenderness about the greater trochanter
- pain at the extreme of rotation, abduction, or adduction, especially positive FABERE test
- pain on hip abduction MMT
- Pseudoradiculopathy-pain radiating down the lateral aspect of thigh
Iliopsoas/Iliopectineal bursitis info
- frequency un-recognized
- anterior hip pain
- painful/limited hip flexion ROM
- painful/limited hip extension and ER
- Local TTP
- between anterior hip joint and iliopsoas
Greater Trochanteric Pain Syndrome Info
- TTP over greater trochanter w/pt in side-lying
- may involve glut max/med/min bursae, muscle attachments, and/or other overlying soft tissue structures
- Clinical correlations
- hip/lumbar/knee OA
- tendinopathy
- ER strain
- Prevalence
- 20-35% for individuals w/mechanical LBP
- 17.6% older adults at high risk for knee OA
Hx for GTPS
- Female
- Obesity
- LBP/Chronic arthropathy of hip/knee
- Middle-age/older adults
conditions associated with GTPS
- Ipsilateral and/or contralateral hip arthritis
- L/S degenerative OA
- L/S degenerative disc disease
- Chronic mechanical LBP
- RA
- LLD
- Post-op lumbar disc disease
- Radiculopathy or other neuro sequalae
- Obesity
- Fibromyalgia
- ITB syndrome
- Totatl hip arthroplasty
- lower limb amputation
- pes planus
symptomolgy for GTPS
- Pain greater at night
- aggravted w/standing >/= 15 min
- radiating symptoms (paresthesia, pain, etc)
- limitation/pain with donning/doffing socks/shoes
- symptoms may radiate to the knee or below the knee
Physical exam findings for GTPS
- excessive hip ABD vs adduction during gait
- TTP lateral hip
- ITB tightness
- +FABER (lateral hip pain)
- +Resisted External Derotation Test
- Pain/limitations with hip adduction ROM (possibly hip IR as well)
- Pain/weakness with hip abduction and ER resistance testing and AROM
Sciatic nerve entrapments
- Potential areas of compression
- piriformis, ischial tuberosity/GT long head BF
- Motor distribution
- hamstrings, fibular and tibial distributions
- Sensory distribution
- lower leg tibial and fibular dist
- Other clinical indicators
- achilles and hamstring DTR diminished
Obturator nerve entrapments
- Potential areas for compression
- overlying fascia
- Motor distributions
- adductors/IR
- Sensory distributions
- med thigh and knee joint
- other clinical indicators
- Hx pelvis frx, THA pelvic operation, prolonged labor
Femoral nerve entrapments
- Potential areas of compression
- inguinal canal
- Motor distribution
- knee extensors
- Sensory distribution
- anterior thigh/lower leg
- Other clinical indicators
- diminished patellar reflex
- aggravated w/hip extension
- 50% compound action potential (EMG) good prognostic indicator for recovery within a year
Lateral femoral cutaneous nerve entrapment
- Potential areas of compression
- inguinal canal
- Sensory Distribution
- anterio-lateral thigh
- Other clinical indicators
- latrogenic, compression from tool belts, seat belts, or tight waist bands
- obesity
- pregnancy
- improves with hip flexion/sitting
- worsens with standing/walking
avulsion fractures info
- males > females
- commonly 2nd decade
- may mimic apophysitis
- common involving:
- ischial tuberosity
- AIIS
- ASIS
- Pubic symphysis
- Iliac Crest
- Other: lesser and greater trochanters
Hx and symptomology of avulsion fractures
- Hx
- vigorous activites
- Symptomology
- known trauma
- local pain (worse with activity, improves with rest)
physical exam findings for avulsion fractures
- TTP
- antalgic gait/limping
- hematoma
- crepitus
- muscle guarding
- limited/painful hip ROM (stretching involved contractile unit)
- painful/weak resistance testing (of action that unit is responsible for)
Stress fractures info
- femoral head and neck
- inferior surface → subject to compression
- superior surface → tensile loading (more likely to become unstable)
- 5% of all stress fractures
- fatigue fractures
- normal bone, abnormal stress
- insufficiency fractures
- normal stress, abnormal bone
Hx and symptomology of stress fractures
- Hx
- risk factors → female and amenorrhea
- change in exercise program/training intensity
- smoking
- prolonged steroids use
- Symptomology
- exercise-induced pain
- hip, groin, thigh, or referred to knee
- night pain
- aggravated by w/b activities (pending stage in progression)
Physical exam findings for stress fractures
- possible diffuse groin/hip pain with testing procedures
- +Patellar-Pubic percussion test
- +Fulcrum test
- MRI, bone scan findings