Hip Injuries and Conditions--week 10 QUIZ Flashcards
Hip Anatomy
Boney landmarks
________________= SARTORIUS and tensor fasciae latae
Iliac crest – Gluteal muscle attachment
___________=Rectus femoris attachment
Greater trochanter – Vastus lateralis and gluteal muscles
Posterior superior iliac spine (PSIS)
_____________Hamstring muscles
Pubic ramus – Adductors
Anterior superior iliac spine (ASIS)
Anterior inferior iliac spine (AIIS)
Ischial tuberosity
Hip Anatomy
Flexors:
- Iliopsoas
- ______ _____
- Sartorius, Pectineus, TFL
Extensors:
- ________ __________
- Long head of Biceps Femoris,Semitendinosis
- Semimembranosis, Adductor Magnus
Abductors/internal rotators:
1. Gluteus Medius/Minimus, _________
Rectus Femoris
Gluteus Maximus
TFL
Hip Anatomy
Adductors:
- Adductor longus, brevis & magnus
- Gracilis, Pectineus
External rotators:
- ________ ________
- Piriformis
- Quadratus Femoris
No pure internal rotators
Gluteus maximus
Hip Pain
Common complaint
• Etiology can be numerous
Note: patients often claim “hip pain” when in fact the pain is in ________, groin, pelvis etc.
low back
Hip Pain
Appropriate History
• Rule out more _______ _________
– ask about night sweats, fevers, weight loss
– history of menstrual irregularities, amenorrhea
• To help r/o ______ _____ of the hip pain – ask about nausea, vomiting, diarrhea, changes in stools, or presence of blood in stools
• To help r/o _______ _________
– ask about LBP; radiation of pain down the leg into the calf, foot, or toes
– numbness, tingling, or weakness in the leg or foot
dangerous pathologies
abdominal sources
spinal causes
Differential Diagnoses of Hip/Groin Pain
Metabolic bone diseases – e.g. Paget’s • Neoplasms – e.g. Osteoid osteoma, metastatic disease • \_\_\_\_\_\_\_\_\_ condition – e.g. Osteomyelitis • Referred pain – e.g. L/S, pelvic viscera: prostatitis, UTI, GYN disorders • \_\_\_\_\_\_\_\_\_ conditions – e.g. AS, Reactive Arthritis (Reiter’s) • Hernia
Infectious
Inflammatory
Hip Examination
Exam of the ____ and __________ _______
Important – > establishes if the patient’s hip pain is referred pain from these sites
knee
lumbosacral spine
General NMS Diagnosis
What is the source of the patient’s problem?
• Is it vascular? _____ ________
• Is it neural? Neural tension tests
• Is it muscular? Muscle tests
• Is it ligamentous? Stretch tests
• Is it joint? ___________ tests
• Is it disc? Patient position/compression tests
Check pulses
Compression
Allis Test
Positive Finding: femur protrudes farther caudally and/or tibia protrudes higher
• Indication: femoral length discrepancy and /or tibial length discrepancy
Know
Ortolani’s Test
Positive Finding: A palpable or audible click or clunking sensation (as the head of the femur slips back into the socket)
• Indication: Displacement of the femoral head in or out of the acetabular cavity
Know
Muscle Strains/Ruptures
• Most common athletic injury of the hip
Mechanism of injury:
– Violent contraction OR forceful stretching
– May also occur from sudden stopping, rapid __________ & _________
• Increased chance w/muscles that move 2 joints (ie: hamstrings, quadriceps)
deceleration & acceleration
Risk Factors for Hip Injury
• Inadequate flexibility&warm-up
• Muscle strength imbalances
• Weakened by previous injury (_____ ______) & lack of rehab or faulty rehab & Muscle weakness.
Increasedage
• Muscle fatigue
• Poor technique with sport
• Muscles subjected to prolonged exposure to cold
• Sports demanding maximum muscular work
scar tissue
Classification of Muscle Strains
Grade I Strain:
• Mild injury
• Overstretching w/ rupture of NONE or
pull
structural
Classification of Muscle Strains
Grade II Strain:
• Moderate injury
• ________ _______ of muscle- tendon unit–partial rupture
Incomplete rupture
Pop
Classification of Muscle Strains
Grade III Strain: • Severe injury; possible \_\_\_\_\_\_\_ • Complete rupture • Moderate to severe functional loss • Palpable defect across entire belly • Muscle may ‘bunch up’ & form a lump • Unable to contract muscle • Tenderness & swelling • After 24 hrs: bruising • X-ray to r/o avulsion fx
avulsion
Hamstring Strain
Classic Presentation
• Athlete or weekend warrior, sudden pull or pop
• Onset of pain following forceful knee ________
– Over contraction while in position of stretch
• Strength imbalance hamstrings
– Strength imbalance of _____% or more between right & left hams OR
– Flexor-extensor strength ratio of
extension
10
Hip Adductor Strain (Groin Pull)
Classic Presentation
• Athlete,sudden I ncapacitating pulling in groin
– Kicking, sprinting, sideways kicks in soccer, hard track running, ice hockey, skiing, hurdlers, high-jumpers
• MC site = _______ ________
• Pain at pubic attachment or w/in adductors itself
– PN with _________ and resisted adduction
• Contributing factors:
– Inadequate warm-up
– Poor flexibility, endurance
– Leg length discrepancy
adductor magnus
abduction
Hip Adductor Strain
DDX
• _______ muscle injury,osteitis pubis,hernia, disorder of bowel, bladder, testicles, kidneys
Abdominal
Rectus Femoris Strain
Classic Presentation
• Pain just above hip joint or ant thigh
• Sudden contraction of _____
• Sudden stopping
Physical Examination
• Palpable tenderness
• Pain w/active knee extension
• Pain with resisted hip flexion/knee extension
• Pain w/isometric quad contraction w/ leg ext
• Possible defect on resisted extension
• Strength imbalance w/hamstring
quads
Treatment of Muscle Strain
GOAL:
Restore strength, stability & fxn
1. Decrease _______
2. Promote ST healing
3. _______ muscle
4. Regain muscle power, strength and flexibility
5. Regain endurance and aerobic conditioning
pain
Stretch
“R.I.C.E.”
Rest:
–
Crutches
Hemorrhage
“M.I.C.E”
“Addition of a talocrural _________] to the RICE protocol in the management of ankle inversion injuries necessitated fewer treatments to achieve pain-free dorsiflexion and to improve stride speed more than RICE alone.”
- Early mobilization within pain-free range of motion
mobilization
M.E.T.H.–End of the ice age?
Mobilization Elevation Traction Heat
“These data suggest that topical cooling, a commonly used clinical intervention, seems to not improve but rather delay recovery from
________ exercise–induced muscle damage”.
eccentric
Treatment
Conservative Treatment:
– Massage
– Ultrasound
– Electrical muscle stimulation
– Rehabilitation
• Sign and symptoms of injury resolve but ________ deficits persist;
TX / REHAB GOAL: restore ______] function
– CMT
– Stretch: gentle w/ caution as early as possible when tolerable – Re-strengthen: begin when ___% of normal ROM available – Nutritional advice, anti-inflammatory diet
functional
normal
75
Treatment
Early: Initiate ____ _____ to prevent atrophy & promote healing
– Stationary bike, pool therapy, proprioceptive exercises
Conventional Treatment
– NSAIDs, muscle relaxants, etc.
muscle action
Return to Activity • When strength is within \_\_\_\_% of uninjured side – Guided by symptoms & objective signs • Coordination • Strength balance • Speed, endurance • Painless athletic participation • Full flexibility • Grade1:w/ncoupleweeks • Grade2:w/n4-6weeks • Grade3 (full rupture):w/n3-4months
10
Hip Fracture Classic Presentation • Elderly \_\_\_\_\_\_ patient • Hip pain,unable to bear weight(?) • Possible fall on to hip – \_\_\_\_\_\_\_ trauma - such as a stumble or fall from standing height
Causes
• Elderly:MC = ___________
• Young:(other than major trauma or stress fracture if active) r/o tumor
– Benign: fibrous dysplasia, unicameral bone cyst – malignant: Osteogenic sarcoma, Ewing’s sarcoma
female
Minimal
osteoporosis
Hip Fracture
• Relatively common in older adults,often lead to devastating consequences.
Disability frequently results from persistent pain and limited physical mobility
• Associated w/substantial morbidity & mortality.
Approximately ____-____% of patients die within 1-year of hip fracture
Complications of surgery and/or immobilization: including development of deep vein thrombosis, pulmonary embolism, pneumonia, congestive heart failure, muscular deconditioning (loss of _______)
15-20
function
Slipped Capital Epiphysis (Adolescent Coxa Vara)
Classic Presentation
• MC hip condition in _______
– Ball at upper end of the femur slips off in a ________ direction - cause unknown
• Overweight child or young, tall rapidly growing adolescent (8-17 yoa)
• Trauma, but may be minor
– ___% have no obvious traumatic HX
–Occurs due to weakness of the growth plate.Often develops during periods of accelerated growth, shortly after the onset of puberty.
• Acute: Salter-Harris type 1 epiphyseal FX
• Chronic: gradual hip pain with antalgia
• May only have knee pain
Management
• Surgical pinning is often used
• Manipulation of slippage is contraindicated: may result in dire consequences including avascular necrosis
adolescents
backward
50%
Bilateral slipped capital femoral epiphysis
- Chronic: evidence of remodeling of the neck and an _______ bone bump that restricts flexion
- Acute: absence of any evidence of __________
anterior
remodeling
Avascular Necrosis (AVN)
Cellular death of bone components due to ____________ of the blood supply
– Bone structures then collapse, resulting in bone destruction, pain, and loss of joint function
interruption
Avascular Necrosis of Hip
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Disease One form of AVN Classic Presentation • Male, MC 4---9yoa • Mild hip pain,limp,insidious onset • 15%have knee pain only • HX of trauma or metabolic disease NOTE: The younger the age of onset the \_\_\_\_\_\_\_\_\_ the prognosis- Children >10 yoa have a very high risk of developing OA. Cause • Believed to be due to disruption of vascular supply to \_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_.
Legg Calve-Perthes
better
femoral head
AVN of Hip
***NOTE: May be asymptomatic and occasionally discovered incidentally on radiographs!
Classic Presentation
• _____ is typically the presenting symptom
• Patients with AVN of the femoral head often report ______ pain that is exacerbated by weight bearing.
• The pain may initially be mild but progressively worsens over time and with use.
• Eventually, pain is present at rest and may be present at night.
Pain
groin
Avascular Necrosis
Management
• Definitive DX: Radiographs
• Under ____ yoa or with minor involvement no TX is required – observation only
• ________ may be indicated - Bed rest and ___________ stretching exercises are often recommended.
• Surgery required only in severe cases
• Healing takes ~____ months
• NOTE: LCPD may result in femoral head deformity and degenerative joint disease
4
Bracing
abduction
18
Hip Bursitis, Tendinitis, Tendinosis
• Occur commonly in active individuals:
– Runners, cyclists, cutting sports such as football, hockey, soccer, etc.
• Can occur after an ____ injury,such as an adductor strain from soccer, OR
• Present as a chronic pain,such as a hamstring
tendinosis from repetitive activities such as running
• Training errors,biomechanical issues,and sudden increases in activity levels are risk factors
• In adolescents:traction Injures such as ____ _______ can occur
acute
avulsion fracture
TendonITIS vs. TendinOSIS
Tendinitis
• Inflammation
• Involve _______ injuries accompanied by inflammation
• Typically resolve with rest, ice, rehab, and anti-inflammatory modalities, anti-inflammatory meds
acute
TendonITIS vs. TendinOSIS
Tendinosis
• Chronic degeneration without ___________
• Main problem is failed ________, not inflammation
– Accumulation of microscopic Injuries that don’t heal properly
– Inflammation can be involved in initial stages of injury,but inability of tendon to heal perpetuates the pain & disability
•____________ medication may actually impair tendon recovery
• Tx designed to designed to stimulate healing – Graston, ART, laser
inflammation
healing
Anti-inflammatory
2003 more than 3.5 million children under 15 suffered a sports related injury requiring medical treatment. Estimated ____% are overuse injuries. 1990’s it was 20%.
75
Hip Bursitis
Bursae
– flattened synovial-lined sacs
– Serve as a protective buffer between bones & overlapping
muscles OR b/w bones & tendons/skin
– Filled with minimal amounts of fluid to facilitate movement during muscle contraction
• Inflammation caused by ________ use,trauma, _________
• Inflammation causes synovial cells to multiply, increases collagen formation and fluid production
repetitive
infection
Hip Bursitis
Locations
• Ischial tuberosity
• Iliopsoas region
• Greater trochanter
Causes
• Friction from ______ OR trauma from direct blow
overuse
Subtrochanteric Bursitis
Classic Presentation
• 40-60yoa
• Painful inflammation of the bursa under ITB & gluteus tendon
– subgluteus medius and maximus
• Local pain at greater trochanteric region of the lateral hip - May radiate to low back, lateral thigh and knee; not all the way to ______
• PN worse when the patient ______ on the affected bursa; may wake pt at night when rolls onto affected bursa
foot
lies
Subtrochanteric Bursitis
Causes
• Acute ________
– Contusions from falls, contact sports, and other sources of impact
• Repetitive, cumulative irritation
– Often occurs in runners but can also be seen in less active individuals
trauma
Subtrochanteric Bursitis
Evaluation • Some loss of internal rotation • Tenderness and swelling over greater trochanter, pain with FABERE’s Management • Reduce inflammation • Correction of abnormal \_\_\_\_\_\_\_\_ – leg length discrepancy
biomechanics
Iliopsoas Bursitis
Classic Presentation
• Anterior hip pain w/antalgic gait
– May radiate into ant. leg (pressure on ________ nerve)
Cause
• Hip flexor tightness, repetitive activity
– Constant friction from overlying psoas tendon
Management
• Rest, stretching of hip flexors
• MRT of psoas with caution
femoral
Ischial Bursitis
Classic Presentation
• Pt reports sitting for long periods of time,fall on buttocks, horse-back riding
• Athlete,sprinter-excessive hamstring contraction
• Referral down leg mimicking ________
sciatica
Osteoarthritis
Classic Presentation
• Primary OA:Middle aged or elderly
• Secondary OA: may have HX of trauma or other joint involvement, i.e.. _____
• Hip,possible buttocks,groin or knee pain
• Insidious onset
• Slow stiffening (especially _________ rotation)
– Pt may walk with hip in external rotation
• May c/o LBP
Gout
internal
Osteoarthritis
• Restricted passive Internal rotation and extension of hip
• Radiographs: _________ joint space narrowing with subchondral cysts and osteophytes - Hallmark of OA
Management
• Weight loss if indicated
• Non-wt bearing exercise:pool,bicycle
• Strengthening joint,helps relieve pain
• Stretching of hip contractures PNF or Myofascial Release
• Use of cane only if pain is severe
Superior
Contusions and Myositis Ossificans
Classic Presentation & Cause
• MC area is _________
• Direct blow to ______
– Damages underlying muscle, subsequent hematoma formation
• Swelling,___________,decreased ability to flex knee
quadriceps
knee
discoloration
Contusions and Myositis Ossificans
Myositis Ossificans can develop if _____ is
encouraged to remain.
– Inflammation of muscle leading to bone formation
– ________ response, seen radiographically
– Contributing factors include: forceful stretching after injury, deep massage to area of injury, use of deep heat such as US
hematoma
Calcification
Contusions and Myositis Ossificans
Management
For Contusion:
• Application of tensor bandage,ice pack In ______ knee position
Alternate ice on 10 min / off 10-20 min Prevents accumulation of blood in area
• Moderate to severe contusion:crutches2-3d
For Myositis Ossificans:
• TX depends on degree of knee flexion restriction and deformity - _________ may be reabsorbed over time
• Surgical excision may be necessary
flexed
calcifications
Acetabular Labrum Tears
Classic Presentation
• Moderate to severe groin pain,limp – r/o genitourinary pathology
• Night pain
• Worse with activity
• _______ or locking,occasionally giving away
• No trauma or severe trauma
• Many causes/predisposing factors:
– repetitive trauma, hip dysplasia, ________ laxity
• Leads to early degeneration
Clicking
capsular
Acetabular Labrum Tears
Evaluation & Management
• Assess with FABERE,____________ Test,ROM
• __________ Is considered the“gold standard” for diagnosis and treatment
Radiographs not helpful, MRI limited: ant. tear visualized / post. tear is not
• Nodatacurrentlyonmanipulation
• Standardmedicalapproach
Impingement
Arthroscopy
The Impingement Test / Sign
With patient supine,the hip and knee of the affected limb are flexed to 90°
The leg is then adducted and ________ rotated in this position
• Occurrence of sudden exacerbation of pain, typically in the groin, is considered a positive test
***Positive impingement test/sign shown to be present in more than ____% of patients with FAI syndrome (femoral acetabular impingement syndrome)
internally
90
Snapping Hip Syndrome
Often no pain,just snapping
• Audible snap or click that occurs in or around the hip
• ______ of snapping Indicative of involved structure
• Traumatic:consider acetabular tear
• Intra-articular loose body
– will present w/ signs of mechanical blockage of movement
Location
Snapping Hip Syndrome
Cause
• Tendon snapping over boney prominence or bursa
– Lateral: ITB snapping over ________ trochanter
– Anterior: iliopsoas tendon involvement or iliofemoral ligament over ant. joint capsule
– Posterior: bicep femoris over ______ tuberosity
greater
ischial
Snapping Hip Syndrome
Management
• Benign,position dependant
• If painful or irritating,___________ rather than
stretching involved muscles is helpful
• Correct leg length inequalities,muscles imbalances – Overpronation
• ITB involvement: check for weakness of Glut Med. – ITB will substitute for weak Glut Med.
strengthening
Paget’s Disease (Osteitis Deformans)
Classic Presentation • 90% \_\_\_\_\_\_\_\_\_\_\_\_\_ • Increase in hat size • Insidious onset of LBP and/or hip pain IF \_\_\_\_\_\_\_\_\_\_\_\_\_\_ • Middle aged, elderly
asymptomatic
symptomatic
Paget’s Disease (Osteitis Deformans)
Cause: unknown, ______ etiology suspected
– metabolic disorder characterized by abnormal _________ remodeling
• Radiographs: bone is thickened, more apparent trabeculae (cross-hatching) eventual distortion of femoral neck or shaft
• TX: No medical treatment currently to prevent or cure
viral
osseous
**Patient with Paget disease > dense sclerosis involving the femoral head and neck
