Hip (New) Flashcards
1
Q
Functional ROM of hip
A
0-90 flexion, 20 abduction, 0-20 IR/ER
2
Q
hip flexion ROM required for walking:
A
20-40 degrees
3
Q
Hip flexion ROM required for negotiating steps:
A
descending: 36 degrees; ascending: 40-67 degrees
4
Q
hip flexion ROM for sit to stand
A
104 degrees
5
Q
hip ROM norms
A
Flexion: 120-135 (90 with knee extended) Extension: 10-30 Abduction: 30-50 Adduction: 10-30 ER: 45-60 IR 30-45
6
Q
What type of injury occurs with adductor magnus (proximal) injury? where and why?
A
Adductor magnus wraps posteriorly to ishchial tuberosity and can avulse the ischial tuberosity. Due to broad origin it won’t develop tendonopathy
7
Q
Where do the hamstrings attach on the ischial tuberosity?
A
Laterally
8
Q
Normal angle of inclination of the hip: (collodiaphyseal angle)
A
125 degrees
9
Q
Definition of coxa vara and what it leads to:
A
Angle of inclination <120 degrees; can increase shearing forces and predispose to SCFE
–G.trochanter displaced more lateral and superior-increases lever arm of hip abductors
10
Q
Definition of coxa valga and what it leads to:
A
Angle of inclination >150 degrees; can alter cartilage forces and muscle activity at the joint
–Moment arm of hip abductors shortened, placing these muscles in mechanical disadvantage
11
Q
Center edge angle:
A
measured from center of femoral head through lateral acetabulum in frontal plane; normally 30 degrees (if <30 suggests dysplastic changes of joint)
12
Q
Femoral neck torsion (norms and how to measure):
A
12-15 degrees normal; measure with Craig’s test
13
Q
Anteversion: define, what causes it; what is predisposes
A
Increase in torsion angle (excessive anterior rotation); results in increased hip IR and decreased hip ER; may predispose joint cartilage to increased stress (i.e. early hip OA) and cause increased incidence of LE tendinopathies
14
Q
Retroversion: define, what causes it, what it predisposes
A
Decrease in torsion angle; results in increased hip ER and decreased IR; may predispose to anterior superior acetabular labral degeneration
15
Q
What phase of gait has greatest compressive stress to hip and how can you decrease this?
A
stance phase; cane can decrease load 40%
16
Q
Iliofemoral Ligament (Y ligament)
A
Limits hip EXTENSION, external rotation
- blends with iliopsoas muscle
- strongest ligament in body
17
Q
Pubofemoral ligament
A
limits hip extension, ABDUCTION, external rotation
-blends with inferior band of iliofemoral ligament and pectineus muscle
18
Q
Ischiofemoral ligament
A
limits hip EXTENSION, INTERNAL ROTATION, abduction
- works with arcuate ligament
- more commonly injured than other hip ligaments
19
Q
Inversion of muscles: what hip adductors become hip extensors (and at what degree hip flexion)?
A
- Add longus: becomes hip extensor at >70 deg flexion
- Add brevis: becomes hip extensor at >50 deg flexion
- Gracilis: becomes hip extensor at 40 deg flexion
20
Q
Inversion of muscles: what happens to the piriformis with hip flexion?
A
Piriformis is an external rotator until 60 degrees flexion at which point it becomes an internal rotator
21
Q
Innervation to anterior hip joint and referred pain patterns
A
Femoral and obturator nerves: groin and anterior thigh pain
22
Q
Innervation to posterior hip joint and pain patterns
A
sacral plexus: posterior hip pain
23
Q
innervation to pubic symphysis and pain pattern
A
Anterior L2-4 causing referred groin pain
24
Q
3 fiber systems in the hip JC:
A
- Longitudinal fibers: course along JC length from prox to distal insertions–creates tensile constraint along JC
- Transverse fibers: course in circular fashion around diameter of JC at neck–creates ring of Webber (JC narrows at neck)
- Arcuate Fibers: create loops at prox insertion at labrum and reinforces that insertion
25
Teres Ligamentum
Fovea centralis of femoral head -->acetabular rim
-is entirely enclosed in synovial membrane
-conduit for neuvascular supply to femoral head
Important stabilizer esp. when hip ER in flexion or IR in extension
26
Iliopsoas muscle action and innervation
most powerful hip flexor; weak adductor and ER
| -Innervation: Lumbar plexus
27
Pectineus muscle action and innervation
adductor, flexor and IR of hip
| -innervation: femoral or obturator nerve
28
TFL muscle action and innervation
hip abduction;
- through ITB produces knee flexion moment in knee flexion and extension moment in extension
- innervation: Superior gluteal nerve
29
Sartorius muscle action and innervation
Flexes, abducts, and ERs hip
| -innervation: Femoral nerve
30
Adductor longus muscle action and innervation
primarily adduction; assists in ER, extension and IR
| -Innervation: Obturator nerve
31
Gracilis muscle action and innervation
adducts and flexes thigh; flex and IR leg
| -innervation: obturator nerve
32
adductor brevis action and innervation
adduction
| -innervation: obturator nerve
33
3 main functions of hamstrings during running
1. decelerate knee extension at end of forward swing phase of gait cycle
2. @ foot strike elongate to facilitate hip extension through an eccentric contraction (stabilizes leg for WB)
3. assists gastrocs in paradoxially extending knee during takeoff phase of running cycle
34
When in gait cycle do most hamstring injuries occur?
@ end of swing phase or at foot strike
35
Muscles that attach to the ischial tuberosity (6)
1. semimembranosus
2. semitendinosus
3. LH biceps femoris
4. adductor magnus
5. quadratus femoris
6. gemellus inferior
36
Muscles that attach to greater trochanter: (6)
1. piriformis
2. glut med
3. glut min
4. obturator internus
5. gemellus superior
6. gemellus inferior
37
What happens at pelvis during (B) hip flexion?
innominate posterior rotation, adduction and ER
38
MMT of adductors: what hip flexion angle to test which hip adductor?
0 deg hip flexion = adductor longus, gracilis
45 deg = pubic symphysis
90 deg hip flexion = pectineus
39
Hip Capsular pattern:
IR most limited; flexion, extension and abduction also limited
40
Hip OA CPR
3/5+ predict OA:
1. Squat increases Sx
2. Active hip flexion causes lateral hip pain
3. active hip extension causes pain
4. scour with add causes lateral hip/groin pain
5. PROM IR
41
Reasons not to perform joint mobilizations with arthritis (synovitis):
1. patient on anticoagulants
2. joint instability
3. non-traumatic synovitis (RA, AS, or suspected LCPD)
42
Primary VS secondary degenerative OA
Primary: natural wear/tear; typically >40 y/o
Secondary: due to fx, instability, long standing loose body, Hx dysplasia
43
THA posterior approach precautions:
1. no flexion >90 deg or adduction past midline within 6 wks post op
2. no sleeping on involved hip, use adductor pillow b/t legs
44
what to avoid after anterolateral or lateral approach of THA
hip ABDuction
45
WB restrictions in cemented vs cementless THA
cemented: WBAT
cementless: PWB or TTWB 6 weeks
46
minimally invasive THA function:
- can drive in 6 days
- normal gait w/o AD in 9 days
- ADLs in 10 days
- walk .5 miles in 16 days
47
Incidence rate of DVT post THA
10-20%
48
Treatment postop THA
1. early isometrics and AROM help early but no difference long term
2. WB activity/exercise effective **PT secrets recommends continuing muscle strengthening 1 year post op**
3. ROM goals: flexion 110-120 degrees; should be able to don/doff shoes 6 weeks
49
postop THA outcomes
most components still intact 15-20 years post op
| **PT secrets states tennis may be achievable at 7 months s/p but depends on MD**
50
Transient synovitis definition and treatment
Viral, autoimmune, or microtraumatic origin
Boys <6 y/o; antalgic gait with preceding illness, no findings on imaging
TX: 2-4 days bedrest with traction and then progress to WB; typically self resolves
51
SCFE
M>F (2:1) males 13-15, females 11-15; 30% chance (B) involvement **Doesn't need to happen at same time**
Risk factors: overweight
s/Sx: groin pain/anterior knee Sx; decreased IR with increased ER (Like retroversion) + Drehmann sign
TX: surgery (percutaneous pinning) with PWB 4-6 weeks for protection
52
LCPD
AVN
3-10 y/o; self limiting
presents same as SCFR but CT scan can diagnose early
-Conservative TX: rest with traction (hip placed in ABD with serial casting) orthoses of the hip ABD/IR (**NOT for patients > 6 y/o with >50% femoral head involvement**); TE to increase hip ABD
-Surgical TX: various procedures; if osteotomy, PROM ok but no hip flexion/ABD AROM until 40 days s/p; prone to prevent hip flexion contracture PWB for 3-6 months
53
Adult osteonecrosis of the femoral head: how to DX and TX
- CT and MRI both able to detect early onset
| - TX: Typically core decompression fibular grafts, iliac grafts, or osteotomies--PWB 3-6 months s/p
54
Loose body Triad
1. Noncapsular pattern (cardinal sign)
2. sharp-shooting pain with pathological end feel (often during ADD or ER)
3. giving way due to pain
55
PT manual TX for loose body due to OA cartilage, flake fracture or idiopathic loose bodies:
HVLA traction/rotation mobilization/manipulation
56
When loose bodies need to be managed surgically
due to OCD, synovial osteochrondromatosis, ischemic necrosis of femoral head
57
Snapping hip: Intra vs extraarticular and TX
1. Intraarticular: iliopsoas tendon over iliopectineal eminence
2. extra: IT band, iliopsoas over pectin pubis, glut max tendon, bursa
**all can snap with hip flex, IR or ER
TX: may need surgical intervention if severe/persistent; TFM, NSAIDS
58
Avulsion FX: muscles that it occurs with; complete vs partial; how to DX; and TX
1. Muscles: adductors (NOT magnus), sartorius, R.femoris, iliopsoas, b.femoris
2. complete = increased pain but then decreased with weakness
3. partial tear = increased pain and no decrease with pain
4. DX: MRI or diagnostic US
5. TX: conservative, usually 4-6 weeks rest; TFM, NSAIDS
59
Causes of Pain with sitting: Differential Dx for groin pain vs buttock pain
- Groin pain with sitting: SLAP lesion
| - buttock pain with sitting: ischial bursitis, hamstring syndrome gluteal bursitis, lumbar disk
60
Red flags for colon CA
1. Age >50 2. bowel disturbances (rectal bleed, black stools) 3. unexplained weight loss 4. Hx colon CA in immediate family 5. pain unchanged by position/movement
61
Red flags for pathological Fx of femoral neck:
1. older women (>70) with hip/groin/thigh pain 2. Hx fall from standing position 3. severe/constant pain thats worse with movement 4. shortened and ER LE
62
What does gluteal atrophy suggest:
S1-2 root level involvement
63
Sway back posture
PPT and hyperextension of knees resulting in stretch on anterior hip JC and stress to iliopsoas
64
Laslett SIJ provocation cluster:
1. compression 2. thigh thrust 3. distraction 4. Gaenslen 5. Sacral thrust
* *3+ highly suggestive of SIJ dysfunction
65
How to test for structural anteversion and retroversion
- When IR >ER in both hip F and E -->structural anteversion
- When ER>IR in both hip F and E -->structural retroversion
* *If more rotation ROM available in prone than supine, a muscle restriction is present**
66
WOMAC: MCID; general scoring
12-22% MCID; higher scores/% are worse functioning
67
LEFS: MCD/MCID; general scoring
MCD/MCID: 9 points; 80 points = max functioning
68
6MWT MCD for those with hip and knee OA
61.34 M
69
stair test MDC for those with hip and knee OA
5.5 seconds
70
TUG MDC for those with hip and knee OA
2.5 seconds
71
Hamstring syndrome
-Proximal sciatic nerve entrapment at ischial tuberosity and biceps femoris under fibrosus band
-Presentation: runners/sprinters/jumpers; Hx LBP/prior hamstring injuries; stretching aggravates pain
-Clinical Triad: Increased pain with sitting; Sx with SLR; Sx with 90/90 hamstring MMT
-D/Dx: no Sx with contraction prone but Sx increased with DF vs head motion (suggest distal irritation); lateral ischial tuberosity palpation painful
TX: no stretching, ionto to glutes, nerve glides, seated use of wedge
72
Piriformis syndrome
-nerve entrapment at caudal edge/through piriformis
-S/Sx: increased pain w/ walking, sitting decreases pain; may radiate to posterior thigh
D/Dx: FABIR (flex, abduct, IR) causes andulation of nerve at ischial spine and can reproduce Sx; +SLR/slump; +piriformis palpation
TX: same as hamstring syndrome (ionto to glutes, nerve glides, seated use of wedge); surgical release in extreme cases
73
Hamstring tendonopathy
- Cause: repetitive microtrauma (runners)
- D/Dx: Sx with MMT hip in flexion and extension; (-) neurodynamics; no pain with sitting
- Tx: Stretches, eccentric hamstring exercises, TFM to tendon insertion, strength and agility training
74
Pudendal nerve entrapment:
-sharp burning buttock pain
-entrapped b/t sacrotuberal and sacrospinal ligaments or w/in pudendal canal
-S/Sx: pain/burning sensation in the perineal area (posterior taint) that worsens with sitting (ex: bicycling) and improves with standing
TX: local injection, radiofrequency thermal coagulation, pulsed radiofrequency, cryoneurolysis, neuromodulation; donut sitting; avoid deep squatting
75
Greater trochanteric (gluteal) bursitis
-Sx with full flexion and ADD + IR/ER; (-) neurodynamic testing; TTP over g. trochanter
TX: NO TFM; rest, ice, NSAIDS, tape glut med off trochanter; image guided injections, habit changes with sitting
76
Gluteal Tendinopathy
- presents similar to bursitis
- MOI often rocking action of pelvis with running, and seen in swimmers (PT secrets)
- D/Dx: decreased pain with full flex+ ADD+ IR/ER but increased pain with resisted IR when positioned in full flex/ADD/ER
- TX: image guided injections; habit changes with sitting
77
Persistent Bursitis
-lateral hip pain due to bursitis/tendonopathy that persists; may indicate cacify tendonitis/glut med tear
-MRI can detect: good sensitivity but poor specificity (many with abnormality are asymptomatic)
TX: injections, heel lift on opposite side, use of cane, avoid cross legs; often need surgery to reattach glut med
78
Hip Pointer
Contusion to lateral hip
TX: PRICE, NSAIDS not until after 48 hrs (due to risk of increasing hematoma), gradual stretching, US, TENS, heat, ice
-Prognosis: Gr I return to sports in 1 week; GR II-III may take 6 weeks to return
79
Causes of increased groin pain with resisted hip Adduction
1. Adductor tendonopathy (acute or chronic)
2. rectus abdominus
3. obturator nerve
4. osteitis pubis
5. ossifying myositis
6. pubic symphyseal
7. SIJ
80
Causes of no increased groin pain with resisted hip adduction:
1. non-musculoskeletal (vascular, gynecologic, urological, lymphatic)
2. Hernia
3. Labral tear
4. fracture
5. psoas tendonopathy/bursa
6. abdominal wall dysfunction
7. spinal referred pain
81
Provocative resistive test position for iliopsoas
Hip flexion and ER (**NOT Adduction)
| --can occur after THA, F>M, younger >older patients
82
Provocative resistive test position for adductor longus and brevius
Hip adduction with 0 deg hip flexion
83
Provocative resistive test position for gracilis
hip adduction with 0 deg hip flexion but also with resisted knee flexion
84
Provocative resistive test position for pectineus:
hip flexion, hip adduction with 90 deg hip flexion
85
Provocative resistive test position for rectus abdominus:
hip adduction, resisted trunk flexion in supine
86
Provocative resistive test position for rectus femoris:
pain provoked with resisted knee extension in neutral hip position in prone, also hip flexion mildly painful
87
Iliopectineal bursitis:
-insidious onset; psoatic gait with hip in ER/add/flexed during swing
-TTP and may report snapping at anterior hip when moving from flexed to abd/er and return to neutral
-D/Dx: PROM hip ER in fully flexed position causes Sx
-->iliopsoas tendinopathy will be painful with contraction
TX: US, IFC, gentle stretching of iliopsoas
88
Pubic Symphysis Pathology
- due to hormonal changes, RA, gout
- provoked during WB (walking, running, hop, land from jump)
- resisted hip adduction with 45 deg flexion painful; reduced with stabilization belt: + ASLR
89
Osteitis Pubis:
pubic bone stress fracture often due to athletic trauma
- T2 MRI reveals bone edema and patient may present with limited hip IR/ER
- Conservative Tx often not helpful; often need injections for stabilization or surgical management
90
Sportsman's hernia (athletic pubalgia)
compromise of transversalis fascia, tendon, and/or internal oblique (inside-out hernia)
-S/Sx: low abdominal, inguinal, groin pain (U/L or (B)) with aggravation with valsalva and increased activity (no decrease in pain with use of abdom. belt)
-often soccer or hockey player
-no tenderness of adductors
-US is diagnositic
TX: laparoscopic or mesh repair (mesh may be superior)
91
Obturator Nerve entrapment
-lies b/t adductor longus and brevis
-may be due to competitive athletics or prior pelvis fracture, acetabulum or Hx hip surgery causing fibrosis
S/sx: pain with hip adduction; patient may not NT and medial thigh and weakness post exercises
TX: surgical neurolysis is preferred
92
CAM impingement
Nonspherical femoral head
- often > in males
- often related to SCFE/other epiphyseal injry
- increases risk of articular cartilage delamination
93
Pincer impingement
- deep hip socket (protrusio)
- > in females
- typically secondary to retroversion
* *most FAI is mixed and use FADIR testing to confirm
94
Traumatic verse degenerative labral tearing
Traumatic tearing vertical
| Degenerative tearing horizontal
95
S/Sx + exam+ diagnosis findings labral tear
1. Age 18-40 y/o 2. increased Sx with sitting/ascending stairs 3. note clicking/popping/locking/giving way 4. pain located at groin (not increased w/ hip add), buttock, trochanteric region or thigh
Exam: pain/possible limitation PROM IR in hip flexion but not in extension
MRA = gold standard diagnostic study
96
Conservative management for labral tear:
education of unloading, nature of condition, reducing hip flexion in sitting; avoid aggrevating activities
- Cycling
- Manual: HVLA rotational mobilization (supine 2 person technique, hip flexed to 90 and in IR)
97
Stress fractures:
-Proximal 1/3 femur, femoral neck, pubic ramus
-Presentation: Immediate onset Sx with WB, relief with rest; + hop test, + fulcrum test
-Confirm with bone scan and MRI
Tx: if impact related, reduce unloaded activity until fracture healed
98
Femoral nerve entrapment
Under inguinal ligament
-produces weak quads
TX: neural mobilization: patient supine, flex hip, patient supports leg over pillow and rhythmically F/E knee
99
Lateral femoral cutaneous nerve entrapment
Meralgia Paresthetica: lateral sensory changes only
-associated with tight paints, sitting cross legged
TX: nerve mobilizations
100
ilioInguinal nerve entrapment
medial proximal thigh
101
Iliohypogastric nerve entrapment
anterior and lateral proximal thigh
102
Genitofemoral nerve
anterior and mid thigh with genital and groin Sx
