Hip Exam and Interventions Flashcards
What are the 3 classifications for hip
- Arthritis (OA)
- Non-arthritis
- Regional movement differentiation
Remote/medical referral hip diagnoses
- Femoral head & neck fractures
- Avascular necrosis femoral head & neck
- Colon cancer
- Inguinal hernia
- Visceral referral
Most likely diagnoses for the hip
- Labral tear
- Femoral acetabular impingement (FAI)
- Glute med tendinopathy
- Greater trochanter bursitis
Anterior hip pain possibilities
- Referred: intra-abdominal or intra-pelvic
- Extra-articular: flexor tendon
- Intra-articular: FAI, labral tear, femoral neck stress Fx, AVN, OA, hip Fx
Posterior hip pain possibilities
- Intra-abdominal
- Intra-pelvic
- Deep gluteal syndrome
- Ischiofemoral impingement
- Lumbar spine or muscle
- SIJ pain
- Proximal hamstring tendinopathy/tear
Later hip pain possibilities
- Greater trochanteric pain syndrrome
- Bursitis
- Glute med tendinopathy
- IT band: external snapping
AVN illness script
- Trauma: dislocation, femoral head Fx, Cancer
- Non-traumatic: ETOH (alcohol), steroid abuse, obesity, smoking
- Gait abnormalities with loading
- ROM limitations
- Testing: any WB, possibly with hip compression (Scour)
Femoral neck stress Fx illness script
- Females more affected than males
- Athletes or those with poor nutrition & lifestyle activities
- Gait: loading more than AVN
- May not have ROM limitations but point tenderness to palpation
- Testing: Fulcrum, Hop, Full extension
Outcome measures for hip pathology
- Harris Hip Score: Pain, Gait, ADLs, Sport sub scales, ROM
- WOMAC (Western Ontario & McMaster Universities Arthritis Index): more OA specific, physical function, pain, stiffness; higher scores indicate worse Sx
- International hip outcome tool (i-HOT): for younger active populations, uses VAS, appropriate for activity level ≥4 on modified Tegnar Activity Scale
- Patient Specific Functional Scale
- FABQ
- LEFS
- Ostwestry
Differentiation sequence before testing the hip
- After SERIOUS pathology clear AND after clear for femoral Fx/stress Fx
- Rule out lumbar spine: repeated motions & neurodynamicis (SLR/Slump)
- Rule out pelvic girdle pain: Thigh thrust
- Finally the HIP TESTS
Differential diagnosis of the hip
- Lumbosacral spine pathology
- Nerve entrapment (lateral femoral cutaneous, obturator)
- Hip osteoarthrosis
- Iliopsoas tendinitis/bursitis
- Adductor strain
- Obturator internus strain
- Inguinal hernia
- Athletic pubalgia (sports hernia)
- Osteonecrosis of femoral head
- Stress fracture (proximal femur or pelvic)
- Avulsion injury (sartorius or rectus femoris tendon)
- Myositis ossificans
- Heterotopic ossification of hip joint
- Neoplasm (benign or malignant)
- Legg-Calvé-Perthes disease
- Slipped capital femoral epiphysis
- Osteomyelitis
- Psoas abscess
- Septic arthritis
- Rheumatoid arthritis
- Prostatitis
- Metabolic bone disease
- Urogenital disorders
Occurs age 30-50 from extra loading or Non-Trauma like ETOH (alcohol) or steroids (illness script)
- AVN (Avascular Necrosis)
Occurs in Pre-Teen and Teenagers especially those with obesity (illness script)
- Slipped capital femoral epiphysis
Skinny Jeans, Tool Belt or a Gun Belt (illness script)
- Peripheral nerve entrapments (Lateral cutaneous nerve); Meralgia Peresthetica AKA Skinny Jeans Syndrome
Occurs in childhood age 4-10 usually male (illness script)
- Legg-Calve-Perthes disease
Occurs during childbirth – noted shortly after (child not the mom) (illness script)
- Congenital Hip Dislocation
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What does glute minimus referral pattern mimic
- Mimics Sciatica
- Trigger points can also cause paresthesia
What does TFL mimic
- Mimics hip joint pain AKA “psuedotrrochanteric bursitis”
- Pain worse with movement
What are the 4 ways the sciatic nerve can exit the pelvis (in order of most common to least common)
- All fibers pass anterior to piriformis b/w the muscle & the rim of the greater sciatic foramen (usual route)
- Peroneal portion passes through piriformis muscle & the tibial portion travels anterior to muscle
- Peroneal portion loops above & then posterior to muscle & the tibial portion passes anterior to it; both portions lie b/w the muscle and the upper for lower rim of the greater sciatic foramen
- Undivided sciatic nerve penetrates the piriformis muscle
Trigger points in what muscle is the most common cause of groin pain
- Adductor longus
Adductor Magnus trigger points can be a source of what problems
- Pelvic pain syndromes
- Menstrual problems
- Painful intercourse
- Stress incontinence or anal/genital/perineal pain
How are pectinous trigger points described as
- A deep seated aching pain in the groin immediately distal to the inguinal ligament
How are gracilis trigger points described as
- A local, hot, stinging, superficial pain that travels along the medial aspect of the thigh
How are semitendiosus, semimembranosus, & biceps femurs trigger points described as
- Sx described as buttock, thigh, knee pain, & sciatica
- SemiT and SemiM trigger points have more proximal referral pain
- Biceps femoris trigger points have more knee pain
Intra-articular tests for hip
- FABER
- Grind/Scour
- Resisted SLR
- McCarthy sign
Impingement tests for hip
- FADIR
- Anterior & posterior labral
Laxity tests for hip
- Log roll
- Dial
- Long axis distraction
Pediatrics tests for hip
- Ortolani & Barlow
General hip tests
- Thomas test
- Trendelenburg
- Step-down test
- Craig test
- Ober test
What is the open and closed packed position of the hip
- Open: 30º flexion, ABD, & slight ER
- Closed: Max extension, IR, & ABD
Normal ROM of the hip
- Flexion: 120º
- Extension: 20º
- ABD: 40º
- ADD: 20º
- IR/ER: 45º
What do the hip ligaments limit
- Iliofemoral Lig (Y-Lig of Bigelow): Anterior Superior; Limits ER & ADD
- Pubofemoral Lig: Anterior Inferior; Limits ABD
- Ischiofemoral Lig: Posterior; Limits Ext, IR & ADD when hip is flexed
What is the non-arthritic CPG
- Diagnoses: FAI, Labral tear, Osteochondral lesion, Loose bodies, Ligamentum teres rupture
- Hip Dysplasia
- Femoral neck abnormalities
- FAI
- Hip instability
What is the arthritic CPG
- Diagnoses: OA is most common cause of hip pain in older adults
- Age > 50
- Pain with WB (anterior or lateral)
- Morning stiffness <1 hr after wakening
- Hip IR <24º
- Hip IR and hip flexion 15º less than the non-painful side
FAI illness script
- Pain is aching or sharp
- Pain with sitting
- Positive FADIR test
- Limited IRR <20º at 90º flexion
- Mechanical symptoms of pops, clicks, locking, & snapping
Describe the 2 types of FAI
- Symptoms: classic “C” to show where the pain is around the hip
- Cam: beard on the femoral neck, younger teens to 20’s, Males 2x (femoral neck)
- Pincer: more common in middle age active females (acetabulum)
What typical age gets labral tears
- Age >30
- Most prevalent is anterior superior
What are the 4 phases of post-op hip FAI scope
- Phase I: protective phase
- Phase II: post-op guidelines (linear 4-8 wks/complex 6-12 wks, goal is ADLs
- Phase III: post-op guidelines (linear 8-12 wks/complex 12-20 wks), goal is recreational asymptomatic
- Phase IV: post-op guidelines (near 12-16 wks/complex 20-28 wks), goal is pain free competitive state
What is the updated hip OA criteria
- Age >50
- Moderate anterior or lateral hip pain during WB activities
- Morning stiffness less than 1hr
- Hip IR <24º or IR & hip flexion 15º < the non-painful side
- And/or increased hip pain with passive IR
What is the hip OA PT CPG
- Unilateral hip pain
- Age ≤ 58
- Pain ≥ 6/10
- 40m SPWT score of ≤25.9 sec
- Duration of symptoms of ≤1 yr
Lower quarter hip interventions
- Multimodal interventions
- Therapeutic exercise
- Manual therapy (Alone)
- Neuromuscular Re-education
- Manual therapy
- Flexibility, Strengthening & Endurance
