Hip Lecture Flashcards
what are some potential causes of hip pain?
articular cartilage
childhood disorders (dysplasia, LCP, epiphysis)
inflammation (bursitis, tendonitis, synovitis)
infection
labral tears
neoplasm
neurologic (entrapment)
overuse (sprain, strain, hernia)
referred (disc, piriformis, SI, genitourinary)
systemic (RA, Chron’s, lupus, cancer)
trauma (fx, DL, avulsion, MO)
vascular (necrosis)
what are some anterior hip/groin pathologies?
labral tears 2nd FAI
labral tears 2nd hypermobility
DJD/arthritis
femoral stress fx
SCFE
avascular necrosis
adductor strain
athletic pubalgia/sports hernia
avulsion fx of ASIS
what are some posterior hip pathologies?
referred pain from L spine, SI jt dysfxn
sciatic nerve entrapment
pudendal nerve entrapment
HS strain
ischiofemoral impingement
what are some lateral hip pathologies?
external snapping hip
ITBS
glut med/min pathology
greater trochanter bursitis
what are the 3 general MOI for pain and/or disability?
overuse situation
chronic degeneration
acute trauma
what things are a part of a pt’s PMH?
cardiac
surgery
meds
cancer
asthma
diabetes
what are the components of the examination?
sensation
DTRs
AROM
PROM
accessory motion
MMTs
palpation
clinical tests
functional tasks
what are radiographs used for?
fx
dislocations
arthritis
what are MRIs used for?
best choice for injuries to acetabular labrum and articular cartilage
femoroacetabular impingment
avascular necrosis of femoral head
what are CTs used for?
to distinguish fx in the acetabulum
localizing position of fx fragments
what are musculoskeletal USs used for?
primary choice to detect DDH in neonatal hips
guide aspiration procedure
what are current s/s of hip pathology?
tasks that are challenging
snapping, catching, locking
magnitude of pain
location of pain (C-sign)
referral patterns
t/f: leg length discrepancies always have a great impact on the treatment and pathology
false
what is the clinical presentation of pediatric hip pathology?
assymetry of the thighs or gluteal folds
limitation of hip abd
unequal femoral length
abnormal gait pattern
(+) Ortolani test
(+) Barlow test
what are abnormal gait patterns that may be seen in pediatric hip pathologies?
toe walking
in-toeing gait
out-toeing gait
t/f: the success of the Pavlik harness decreased in pts older than 4 months
true
what does a Pavlik harness do?
holds the hip at 90-100 degrees of flexion
what are some long term effects of DDH?
gait dysfxn
hip pain
DJD of hip
early onset THA
what is avascular necrosis (Legg-Calve-Perthes Disease)?
damage to vascular supply that may occur at birth
trauma resulting in ischemia
what % of avascular necrosis progresses to lead to collapse of the femoral head?
70-80%
what population is avascular necrosis most common in?
boys aged 3-13 yo (average 5-7 yo)
what are the s/s of avascular necrosis (Legg-Calve-Perthes disease)?
pain in the groin, buttock, proximal thigh
pain exacerbated by weight bearing
decreased ROM
antalgic gait
what are some interventions for avascular necrosis (Legg-Calve-Perthes disease)?
emphasis on containment of the femoral head and avoiding collapse
Scottish Rite brace to hold the femur in abd w/the ability to flex
surgical intervention (hip resurfacing vs THA)
what is slipped capital femoral epiphysis (SCFE)?
the femoral head slips down and back off the femoral neck
what is the initial symptom of 45% of pts with a SCFE?
knee or lower thigh pain
t/f: fx screening of a SCFE can manifest as a compression or tension rxn
true
if a pt with a SCFE has a compression rxn, what should be done?
reduce WB
therapy
if a pt with a SCFE has a tension rxn, what should be done?
NWB often progresses to displacement and needs ORIF
what is the stress fx intervention for SCFE?
nutrition
metabolic panal
aquatics
aerobic conditioning
what is the purpose of the patella-pubic percussion test?
to assess for osseous pathology
what is the position for the patella-pubic percussion test?
supine w/the stethoscope on the pubic symphysis
what is the technique of the patella-pubic percussion test?
percuss or vibrate tuning fork on the patella and compare BL to hear for difference in sound
what would be a positive result of the patella-pubic percussion test?
decreased sound transmission when compared BL
what are the stats for the patella-pubic percussion test?
sensitivity=excellent
specificity=high-excellent
t/f: you should always ask WHERE the pain is when doing special tests
true
what is the purpose of the sign of the buttocks?
to assess for hip pathology, neoplasm, or abscess
what is the position for the sign of the buttocks?
supine
what is the technique for the sign of the buttocks?
performs passive SLR, note the angle of hip flexion that symptoms occur in
flex the hip and knee and compare the angle of hip flexion that symptoms occur at w/the SLR angle
what is a (+) test for the sign of the buttocks?
hip flexion angle isn’t greater than the SLR angle
what are the stats on the sign of the buttock?
no data
what is the purpose of the fulcrum test?
to assess for femoral shaft stress fxs
what is the position for the fulcrum test?
sitting, knees flexed, feet off the floor
what is the technique for the fulcrum test?
weave your arm under the involved femur to serve as a fulcrum
apply a posterior force to the distal femur
what is a (+) fulcrum test?
sharp pain with force
what are the stats on the fulcrum test?
sensitivity=excellent
specificity=high
t/f: we can always tell if the fall or the fx occurred first
false
t/f: the WB status of a pt depends on the type of fixation they have
true
what are some reasons for THA?
fx
trauma
dysplasia
JRA and RA
osteonecrosis
malignancy
what factors can make a person a poor candidate for THA?
systemic co-morbidities
gender
vascular supply
pre-op LEF score
walking speed and TUG
age
weight
dementia
with posterior approach THA, what muscles are involved?
violates the piriformis and short ER
preserves the glut med and min
what are the concerns with posterior approach THA?
problem w/hip flexion causing DL
what muscles are involved in posterio-lateral THA?
splits the glut med
what are the concerns with the posterio-lateral approach THA?
lurching gait
what muscles are involved in the lateral approach THA?
splits glut med and ITB
what are the concerns with the lateral approach THA?
lurching gait
what muscles are involved in the anterio-lateral approach THA?
detaches 1/3 glut med
what are the concerns with the anterio-lateral approach THA?
takes longer and increased risk of HO
what muscles are involved in the anterior approach THA?
splits the ITB and sartorius
what are the concerns with the anterior approach THA?
takes longer and higher femur fx rate
what are the precautions with the posterior approach THA?
no flexion >90 degrees (trunk on LE and LE on trunk)
no adduction past midline
clients shouldn’t sit in lower chairs for at least 6-8 weeks bc loads of 8x body weight can be produced at the hip jt when rising to stand
t/f: there is a reduced DL rate after hip arthroplasty for femoral neck fxs when changing from posteriolateral to anteriolateral approach
true
what are the risks of THA?
DL
HO
infection
leg length discrepancies
DVT
what are the 2 general categories of hip impingements?
femoroacetabular (FAI) - anterior
ischiofemoral (IFI) - posterior
is an FAI anterior or posterior impingement?
anterior
is an IFI anterior or posterior impingement?
posterior
does anterior or posterior hip impingement cause asynchronous patterns of movement w/end range ER?
posterior impingement
painful palpation of the external rotators may point to what syndrome?
deep glut syndrome (sciatic/piriformis)
painful palpation of the ischial tuberosity may point it what syndrome?
ischial tunnel syndrome
what are the s/s of posterior hip impingement?
peripheral nerve entrapment syndrome of the sciatic nerve
reproduction w/resisted ER
reproduction w/FAdIR
palpable MTrPs and/or hypertonic bands
radiating neurologic symptoms w/any of the above maneuvers
dull ache in buttocks that may radiate
tenderness to the deep palpation (92%)
pain with sitting (76%) and walking but decreased when in supine
pain with resisted hip extension and passive IR/add
what is the active piriformis test?
in SL on the involved LE up in a clamshell position, palpate the piriformis and resist ER and abd
what is a (+) active piriformis test?
reproduction of pain
what is the seated piriformis stretch test?
seated with the knee extended, palpate about 1 cm lateral to the ischium and passively lower the leg into hip add and IR
what is a (+) seated piriformis stretch test?
pain with passive motion
what are the clustered metrics for the active piriformis and passive seated stretch tests?
sensitivity=91%
specificity=80%
what is ischial tunnel syndrome?
thickening of the HS tendon
posterior thigh pain aggravated by running
what are the clinical tests for ischial tunnel syndrome?
active 30/90 and long stride
what is the active 30/90 test?
in sitting flex the hip to 30 degrees then 90 degrees and palpate the conjoint tendon lateral or the ischial tuberosity and resist knee flexion for 5 seconds
what are the clustered metrics for the active 30/90 and long stride tests?
sensitivity=96%
specificity=73%
(+)LR=3.61
(-)LR=0.05
what is ischiofemoral impingement?
narrowing of the space bw the ischial tuberosity and lesser trochanter
abnormalities of the quad fem ranging from deformity and edema to tears and atrophy
hip pain radiating to the med thigh
IFI is most associated with what?
trauma or surgery
what is the IFI test?
with the pt in SL, passively extend the hip in neutral and/or add
w/complaints of pain lateral to the ischium, repeat w/hip in abd
what is a (+) IFI test?
pain w/extension when the hip in in add that is relieved when the hip is in extension with abd
what are the stats for the IFI test?
sensitivity=82% (56-95%)
specificity=85% (54-97%)
t/f: FAI (anterior) has a relationship to neonatal hip deviations
true
what is FAI caused by?
abnormal contact bw the femur and the acetabulum
what population tends to be more affected by FAI?
younger ppl who push the extremes of hip ROM esp with pivoting IR (10x risk)
gymnastics, hockey, soccer, breast stroke
what is a cam lesion (FAI)?
osseous abnormality (bone bump) at the femoral head-neck junction
abnormality of the femur
impact damages articular cartilage
what is a pincer lesion (FAI)?
abnormality of the boney acetabulum leading to over coverage of the femoral head
damage to the labrum
what is a mixed FAI lesion?
cam and pincer (femur and acetabulum bone bump)
what is the FAI presentation?
when asked where the hip hurts, client will cup their hip just above the greater trochanter (c-sign)
groin pain w/FAdIR test
sharp pain/clicking and giving away
pain w/stair climbing and prolonged sitting
difficulty with max squat or making cuts
what is the c-sign?
when asked where the hip hurts, the client with cup their hip just above the greater trochanter
what is the FAdIR test technique?
passive hip flexion, add, and IR
what is a (+) FAdIR test?
reproduction of pain
what are the stats for the FAdIR test?
sensitivity=excellent
FAdIR + FAbER sensitivity=excellent
FAdIR + FAbER + resisted SLR +Thomas test specificity=excellent
what is the impingement test positon?
supine 90/90
what is the impingement test technique?
passive IR, some clinicians recommend adding some axial compression and overpressure to IR
what is a (+) impingement test?
pain into the groin
what are the stats of the impingement test?
sensitivity=poor-excellent
specificity=poor-high
w/axial compression and IR overpressure sensitivity=high, specificity=poor
what is the maximal squat test used for?
detecting a cam lesion (FAI)
what is the maximal squat test technique?
perform a deep squat
what is a (+) maximal squat test?
pain limiting ability to complete the squat
what are the stats for the maximal squat test?
sensitivity=high
specificity=poor
what is an intervention that is typically not helpful for FAI?
injections
what are some acute interventions for FAI?
3-5 days of cold application
activity modification about 6 weeks
NSAIDs
when inflammation decreased in FAI (about >5 days), what are some interventions?
stationary bike w/seat elevated
stretch prn (piri, illiospoas, quads, ITB)
strengthening prn (glut med, ER, and core musculature
functional balance exercises begin w/1 leg activities and progress to sport specific exercises
if conservative therapy for FAI is unsuccessful, what may be done?
surgical ex
correction of the abnormal shape of the femur (cam), acetabulum (pincer), or both mixed)
what are some interventions for immediate post-op debridement?
cryotherapy
gentle ROM in mid-range
post op bracing
NWB-PWB w/crutches about 2-4 weeks
