Hip, Groin And Thigh Flashcards
The anterior tilt of the hip is controlled by:
Contraction of hip flexors
Posterior tilt of Hip, is controlled by:
Contraction of the lumbar spine extensors, hip extensors or trunk flexors.
Lateral tilt of hip, groin ans thigh is controlled by:
Contraction of the hip abductors
Flexion of the hip, groin and thigh is accomplished by:
Rectums fermoirs and psoas contraction of the hip abductors. (L1, L2 and L3)
Extension of the H, G and T is controlled by:
Gluteus Maximus and the hamstrings (L5, S1, S2 and S3)
Internal rotation and abduction of H, G & T is accomplished by:
Gluteus medius, gluteus minimums and TFL contraction. (L4, L5 and S1)
External rotation of H, G & T is controlled by:
Piriformis, gemellus and obturator contraction (L3, L4, L5, S1 and S2)
Adduction is controlled by:
the adductor group and the gracilis muscle (L3, L4, L5 and S1)
Normal ROM of H, G and T:
Flex: 120 if knee is flexed at 90
Ext: up to 20 Abd: 45 Add: 20-30 Inward rotation: 40 Outward rotation: 45
What is the normal femoral angle?
120-130 degree = normal
What is coxa valga:
Greater than 130 femoral angle
What is considered coxa vara:
Decreased angle (less than 120)
Common disorder of the H, G and T:
1- Hip Fx 2- Dislocation 3- Dysplasia 4- RA, OA 5- Pages 6- MO 7- Slipped Capital Epiphysis 8- AVN 9- Bursitis 10- Snapping hip syndrome
Which type of Hip fx are the most common?
Intracapsular (2x as likely) to occur than extracapsular
Which type of Hip fox are most likely to lead to serious complications for example osteonecrosis and osteomyelitis.
Intracapsular Fx.
Su-capital or trans cervical are __________ Fx, basicervical, trochanteric and sub-trochanteric are ___________ Fx.
1- intracapsular
2- extracapsular
Associated, with hip fracture. What is the most common predisposing factor in the elderly and more likely to be seen in women.
Osteoporosis
Besides Osteoporosis what are the DDx or other consideration to rule out with hip fracture?
Paget’s Dx, MM, Kidney related bone pathologies
Besides major trauma, what are the most common pathologies associated with hip fx in younger patients?
Benign or malignant tumors:
Benign - unicameral bone cysts or fibrous dysplasia
Malignant tumors - Ewing’s or osteogenic carcinoma
Percentage of Elderly patient who fracture their hip never make it back home.
10-15% Death Rate.
Due to pneumonia or pulmonary embolism
Most conclusive assessment for Hip FX =
Plain film xray, AP and lat.
Stress fix are typically found in ______ who participate in activities such as:
Young and active
Marathon running, gymnastics, dancing, and even marching.
Stress fix present as:
Insidious pain, feels worse upon weight bearing and located most often ANTERIOR AND DEEP
Structure involved in Stress fracture of the Hip:
Femoral neck micro-fractures
Stress fracture of the hip:
Damage takes place at the _________ level as _______________________________ and weakened bone is the result.
Cellular level
ostéoclastic activity exceeds osteoblastic activity
Stress FX (Hip); X-ray (plain film) Findings:
X-rays will be mostly unremarkable
What type of imaging is helpful when assessing stress fractures?
MRI and bone scan will be helpful, can rule out tumor. If suspected.
When is a stress fracture considered unstable:
If a Transverse fracture presents, considered UNSTABLE with serious complications - refer out immediately
Who long will it take for a stable compression FX to heal? What is the proper management?
4-6 weeks
Rest, follow up with a program of non-weight bearing exercises like swimming or cycling.
Congenital Hip Dislocation and Hip Dysplasia - Anatomy involved:
Acetabular deformities and capsular tightness results in dislocation
Patient presents with a limp on weight bearing and decreased and or diminished active abduction.
Congenital Hip dislocation / hip dysplasia.
Would of been discovered upon examination of the neonate or infant. Left undetected the patient would present with the aforementioned characteristics.
Ortho test for Congenital hip dislocation/ hip dysplasia:
Ortolani’s and Barlow’s maneuver
Imaging of choice for Congenital hip dislocation / hip dysplasia.
MRI and diagnostic Ultrasound best for early detection of dysplasia changes.
What is a Pavlik Harness and what is it for?
Keeps hips in abduction to strengthen adduction.
For Hip dysplasia
About 90 % of sports related dislocation of the hip are _______ in nature.
Posterior
Presentation:
normally acute injury following a major force being applied to a FLEXED, ADDUCTED hip. Following the impact, the attitude of the hip will be in FLEXION, ADDUCTION and INTERNAL ROTATION.
Very severe pain down the posterior leg, might accompany hip pain indicating sciatic nerve injury.
Posterior Traumatic Hip dislocation
10% of Traumatic Hip Dislocation - follows a blow/injury to an extended, externally rotated leg. Following the injury the leg will present FLEXED, ABDUCTED and INTERNALLY ROTATED.
Anterior
Anatomy structures involved with traumatic hip dislocation:
Femoral head dislocates from acetabulum (ant. Or post)
Iliofemoral lig Ligamentum capitus, Transverse-acetabular ligament Articular capsule Zona orbicularis Acetabular labrum (Will be involved)
Traumatic hip dislocation management:
Orthopedic/ ER intervation
- Following relocation, rehab is recommended
- Chiropractic management would include adjustments to improve functional ROM of all structures and relief of compensatory spasm or misalignment.
The patient is a 14 years old, male. He presents in your office with chronic and gradual worsening right hip pain. He displays a left antalgique lean. The patient is overweight.
Slipped capital epiphysis
______% of the time slipped capital epiphysis follows a traumatic incident.
50%
The most common hip condition in adolescents.
Slipped capital epiphysis
Anatomy of slipped capital epiphysis.
Coxa Vara of the femoral head with soft tissue damage.
Slipped capital Epiphysis: If acute ___________________fx, is noted.
A salter-Harris type 1 fracture is noted
Cause of SCFE: Hormones can play a part in overweight (SCFE) , what is the name of the syndrome?
Frohlich syndrome
Imaging of choice for SCFE
X-ray, especially lateral view where the posterior/inferior slippage is seen.
** film should be bilateral due to the incidence of opposite hip involvement in some 10-20% of the cases.
Management for SCFE
Surgical pinning, traction and screw fixation
MANIPULATION WOULD BE CONTRAINDICATED!!!!!!!!!!!
Avascular necrosis of the hip -
Leg-calve-perthes disease.
The patient is a 6 years old male, he walk into the office with a noticeable limp. He doesn’t recall any incident.
AVN - Legg-calves-perthes disease.
Leg-calves-perthes is predominantly seen in:
Male (80%) between 4 and 9 years old.
Bilateral pain (10%) Knee pain (15%) Trauma (17%)
Metabolic disease is a common concomitant with:
Legg-Calves-Perthes
Anatomy involved in AVN of hip
Disruption of the blood supply to the femoral head. (Mostly circumflex artery)
Causes of AVN of the hip
1- vascular supply disruption to the femoral head. 2- secondary to sub capital fracture 3- posterior hip dislocations 4- long term STEROID use 5- hyperlipidemia 6- alcoholism 7- pancreatitis 8- hemoglobinopathies
Evaluation of AVN of the hip:
Muscle spasm with limited hip abduction and internal rotation
+ Trendelenburg test (weak gluteus medius)
X-ray findings associated with AVN of the hip:
Crescent sign
Fragmentation
Re ossification
Remodeling and deformities of the femoral head.
Femoral nucleus will appear small but opaque.
Management of AVN of the hip.
Under 4 yoa: ultra conservative
4-5 yoa: (with good motion) will probably not require surgery or bracing. Hampered ROM will require medical consultation. Chiropractic assessment includes full spine and extremity evaluation for subluxations to determine functionality and improve recovery time.
Non-surgical treatment: children with Legg-Calves-Perthes in a special brace or cast combined with rehab is what is needed to resolve LCP (pelvis brace)
Legg-Calves-Perthes Occurs: Children tend to be: \_\_\_\_\_ of the femoral \_\_\_\_\_\_ Treatment primarily : Surgery, when indicated, may involve \_\_\_\_\_\_\_\_\_\_\_\_.
Slipped capital Femoral Epiphysis Occurs: Children tend to be: \_\_\_\_\_\_\_ of the femoral \_\_\_\_\_\_ Treatment is primarily: Surgery usually involves \_\_\_\_\_\_\_\_\_\_\_\_\_\_ with a single cannulated screw.
Legg-Calves-Perthes Occurs: B/W 4-8 Children tend to be: SHORTER DEFORMITY of the femoral HEAD Treatment primarily : CONSERVATIVE Surgery, when indicated, may involve FEMORAL OSTEOTOMY.
Slipped capital Femoral Epiphysis Occurs: B/W 10-15 Children tend to be: OVERWEIGHT DISPLACEMENT of the femoral NECK Treatment is primarily: OPERATIVE Surgery usually involves INTERNAL FIXATION with a single cannulated screw.
Patient is a 65 years old female, with hip, groin and knee pain. She doesn’t recall any trauma. She reports stiffening with certain movement. She’s had chronic LBP for the past 6 years.
OA
What is the “attitude of the hip” in patient with OA.
Commonly held in external rotation.
The low back pain in OA patients is a chronic compensation for:
Limited hip extension
The patient is a 44 years old women, with hip pain and surrounding tissue swelling, stiffness and decreased ROM. Her pain is bilateral. (Could be unilateral in other patients)
RA
Non-uniform loss of the joint space (femoral head and acetabular articular cartilage)
OA
The femoral head can protrude through the acetabulum (Protrusion acetabuli)
RA
Progressive degeneration of the joint space due to repetitive micro trauma.
OA
Secondary OA to the hip is more common and is due to many different articular problems/stresses:
Acromegaly, hemochromatosis,
Neuroarthropathy
Synovial inflammatory processes causing a destructive pannus.
RA
Evaluation of OA
Patrick and laguerre’s might be positive (compression of the femur into the acetabulum)
Restricted internal rotation and extension of the hip. Abductor and adductor restriction and contracture may develop. (Condition)
OA
X-ray findings of OA
Non-uniform joint loss, osteophytes formation with subchondral cysts apparent.
X-ray findings associated with RA.
there will be uniform loss of joint space. This is generally bilateral (one of the distinguishing factors from OA). Other findings would be peri-articular osteoporosis, sub- chondral cysts and general boney destruction. Later, ankylosis will most likely occur.
Lab test associated with RA
Elevated ESR
Positive Rh factor.
Management of OA
Joint and associated musculature strengthening will be very beneficial. Stretching is also helpful, especially the PNF technique.
• Use of a cane should be limited to severe patients.
• Chiropractic adjustments to maintain joint integrity, use caution however to
not thrust into inflamed or ankylosed joints.
Management of RA
NSAID’s prescribed by MD’s during inflammatory phases will be indicated.
• Mild and gentle joint mobilization will be helpful being careful not to thrust aggressively into inflamed joints.
• Drop or light force techniques will be best to restore mechanoreceptor and
proprioceptor integrity while assisting in improving motion in joints.
Usually asymptomatic (90%) of the time. The typical Paget’s type signs are often detected on X-Ray without the patient reporting an associated complaint. (Condition)
Paget’s
The presenting patient might also report an increase in hat or shoe size and low back and
hip pain without an initiating event that is becoming increasingly uncomfortable.
(Condition)
Paget’s
Hip involvement of the femoral head, show changes. (Condition)
Paget‘ si
Cause is unknown, but there’s evidence of a viral etiology. (Condition)
Piaget’s
X-ray findings:
Cross-hatching of the femoral head trabeculae,
Later: remodeling and increased opacity, and deformity. Bowing occurs eventually.
(Condition)
Paget’s
Management of Paget’s patients.
Most asymptomatic patients will not receive treatment. Drug therapy is common for symptomatic patients.
• Chiropractic management involves…anything to help function
The patient is a 59 years old who presents with deep bone pain. The pain is worse at night and not relieved by rest. He has a past history of lung cancer.
50 + (deep bone pain 75%) Might have past history of cancer: TUMOR
Etiology of Hip tumor:
Mets or MM
Patient with MM lab results:
Bence- Jones protéinuria
Elevated ESR.
Lab test for tumor: (bone tumor) -
Elevated ESR, serum calcium,
Alkaline phosphatase
PSA
Tumor X-ray findings:
2 différents:
Breast and Kidney cancer and MM = lytic changes
Prostate cancer = blastic changes
Management of Tumor:
Refer to oncologist
Trauma/blow or injury to the knee or quadriceps with swelling and then
inability to bend or flex the knee.
Myosotis Ossificans
Structures involved in Myositis Ossificans
Usually the quadriceps muscles. Severe damage leads to hematoma and if
the hematoma does not resolve, myositis ossificans results.
When hematoma is unable to resolve, __________ might occur.
Myositis ossificans
Diffuse swelling and bleeding. Active and passive flexion is difficult and painful. If the injury took place some-time before presentation, a lump might be evident, indicating possible MO.
Myositis ossificans
X-Rays will show the degree of development of the calcification within the muscle
tissue.
Myositis ossificans
Proper management for Myositis ossificans
Ice and tensor bandage with the knee in a flexed attitude immediately following impact can help stop/reduce blood accumulation in the injured tissue. - Mild stretching can begin a few days following the injury. - In severe cases, surgery might be necessary to excise the calcified mass.
Chiro - to ensure functional gait is maintained
Well defined hip pain with a minor limp, usually between 40-60 years of age. There may be
reports of pain radiating to the low back, lateral thigh and knee. It’s common for patients to report inability to sleep on the affected hip.
Subtrochanteric Bursitis
Structures involved in Subtrochanteric Bursitis
The two major bursae involved are the subgluteus medius and the subgluteus maximus.
Subtrochanteric Bursitis
Causes:
Biomechanical in nature, so any condition that alters hip mechanics such as surgery,
neurological conditions, subluxation, arthritis/degenerative conditions or low back pain are common causes.
• There will be leg length differences and loss of internal rotation. Typically, the more active the
person, the worse the pain.
Extreme tenderness with a “jump” sign elicited on palpation of the lower region
of the trochanter with the knee and hip flexed. Patrick’s and Ober’s tests will often be positive as hip motion is tested.
Subtrochanteric Bursitis
Management of Subtrochanteric Bursitis
Adjustment of the hip and pelvis will be most effective to re-align altered biomechanics.
- Stretching of the hip abductors using PNF will be indicated.
- Use caution when doing side posture so as not to irritate the inflamed bursa. • Running shoe and exercise modification is helpful.
Acute anterior hip pain with antalgia. There will often be an associated radiating
pain down the front of the thigh from pressure on the femoral nerve. A typical position of flexion and external rotation is evident as the patient attempts to find a comfortable body attitude.
Iliopectineal and Psoas Bursitis
Iliopectineal and Psoas Bursitis structures involved.
The Iliopectineal bursa is located typically 1 to 2 cm’s below the middle third of
the inguinal ligament.
Generally due to hip flexor spasm and hypertonicity as a result of over exertion
or repetitive activity.
(Condition)
Iliopectineal and Psoas Bursitis
Evaluation of Iliopectineal and Psoas Bursitis
Deep anterior tenderness at the hip.
• The psoas bursa can be palpated over the lesser trochanter on a supine
patient with hip flexed to 90 degrees.
• Psoas testing will elicit pain (resisted hip flexion).
Management of Iliopectineal and Psoas Bursitis
Deep anterior tenderness at the hip.
• The psoas bursa can be palpated over the lesser trochanter on a supine
patient with hip flexed to 90 degrees.
• Psoas testing will elicit pain (resisted hip flexion).
A history of prolonged sitting on cold hard surfaces (benchwarmer’s bursitis), and horseback
riding are common presentations. Possible mimicked sciatica with pain radiating down the posterior thigh. Pressing on the gas might relieve the pain due to extension of the knee which, Themed
by rotating the ischial tuberosity away from the sitting surface assists in decreasing pressure on 2
the bursa.
• Younger patients and athletes will often report discomfort following sprinting due to excessive hamstring contraction. This will directly irritate the bursa.
Ischial bursitis
Cause of Ischial bursitis
Acute trauma such as a blow to the ischial tube or chronic trauma such as
mentioned in the presentation.
Évaluation of Ischial bursitis
There might be a lean or list to the affected side with a shortened stride length on
that side. Toe push-off will be difficult and sore. There will be an obvious exquisite pain over the ischial tube/s. Performing the SLR and Patrick’s will reproduce pain symptoms.
Management of Ischial bursitis
Avoid the activity that initiates/irritates pain.
• Chiropractic adjustments to re-align biomechanical integrity following
compensatory changes.
Patients will often not report pain associated with the snapping. Following a
trauma, a labrum tear must be considered and ruled out.
Snapping hip syndrome
Structures involved with Snapping hip syndrome
Can be the ITB, IIiopsoas tendon, Iliofemoral ligaments or even the biceps
femoris tendon.
Snapping hip syndrome cause:
Generally tendons that snap over a bony prominence or bursae. Sometimes in
rare cases there can be a loose body found in the joint – this will be accompanied by mechanical blockage in ROM
Snapping hip syndrome EVALUATION (LAT,ANT & POST)
Lateral snapping: the hip is in adduction and the ITB is the offender at the greater
trochanter.
• Anterior snapping: with extension of the flexed, abducted and externally rotated
hip, the psoas tendon must be suspected (could also be the iliofemoral ligaments over the anterior joint capsule).
• Posterior snapping: in the buttocks area, the biceps femoris tendon will most likely
be snapping over the ischial tube.
Management of Snapping hip syndrome
Strengthening is indicated as opposed to stretching to increase stability.
• Chiropractic adjustments to restore pelvic and hip joint mechanoreceptor integrity.
Sudden forced adduction injury or
repetitive micro-trauma such as kicking or running. Pregnant women commonly suffer from OP especially during the latter stages of the term.
(Condition)
Osteitis Pubis
Cause of Osteitis Pubis
Direct or distractive
forces/injuries/traumas are
precipitating factors.
Groin pull involves:
Adductor longues and Gracilis
Évaluation of Osteitis Pubis
Tenderness at the pubic bone especially when the two ASIS’s are compressed together.
• Bone scan is definitive as X-ray might be unremarkable.
Management of osteitis pubis
Avoid initiating activity, rest and gradual increase of activity to
improve flexibility.
• Severe cases might require surgical repair.
• Chiropractic adjustments to restore pubic alignment.
Miscellaneous Iliac crest presentations: ASIS
Sartorius strain or in the younger patient, an avulsion or apophysitis.
Miscellaneous Iliac crest presentations: AIIS
Rectus femoris strain or again in younger patients, avulsion or apophysitis
Miscellaneous Iliac crest presentations: Lateral Crest
Hip pointer (following a trauma), iliac crest apophysitis, oblique abdominal, tensor fascia lata or gluteus-medius strain.
Miscellaneous Iliac crest presentations: Posterior iliac crest
Maigne’s syndrome from T12, gluteus-max strain or iliac fascia
strain. Referred pain from lower back.
