Hip Pathologies Flashcards
What is the acetabulum and what bones form it?
Hip joint socket
Ilium, ischium and pubis
What structures cover the acetabulum and what are their functions?
Acetabulum labrum and transverse ligament
Deepen the socket to increase stability
Name the bony landmarks of the hip
Anterior superior iliac spine (ASIS)
Anterior inferior iliac spine (PSIS)
Ischial tuberosity
Posterior superior iliac spine (PSIS)
Iliac crest
Greater trochanter
Lesser trochanter
Explain the anatomy of the femur
Long bone
Femoral and obturator artery
Femoral head and neck
Name the important ligaments of the hip
Iliofemoral (Y-shaped) transverse (stops add and ER) and descending (stops IR), strongest ligament - illium to femur
Pubofemoral (stops abd) - Pubis to femur
Ischiofemoral (stops IR) - Ischium to femur, blends in with the posterior capsule
Ligament of head of femur - Head of the femur to the acetabulum, branch of obturator artery
Transverse acetabular ligament - part of the acetabulum
Inguinal ligament - ASIS to pubic tubercle
Name the anterior muscles of the hip
Iliopsoas - iliacus (origin iliac crest) and psoas major (origin - transverse processes of the Lx), both insert into the lesser trochanter - Hip flexion, Lx flexion and side flexion
Rectus femoris - Origin AIIS, Insertion quadricep tendon - Hip flexion and knee extension
Sartorius - Origin ASIS, Insertion pes anserinus - Hip flexion and ER, knee flexion and IR
Adductors
3 ducks, pecking grass
Adductor Magnus - Origin ischial tubersosity, adducotr tubercle - most posterior also helps with hip extension
Adductor Longus - Origin pubis, Insertion femur
Adductor Brevis - Origin pubis, insertion femur
Pectineus - Origin pubis, insertion femur, also hip flexor and IR
Gracilis - Origin pubis, insertion pes anserinus, also knee flexion and IR
Name the lateral and posterior muscles of the hip
Glute max - Origin sacrum and ilium, Insertion gluteal tuberosity and ITB - Hip ext, upper fibres abd and ER lower fibres add and IR
Glute Med - Origin ilium, insertion greater troachanter - Abd and IR
Glute min - Origin ilium, insertion greater troachanter - Abd and IR
Tensor fascia latae (TFL) - origin ASIS, inseriton ITB - Hip
Deep Muscles Piriformis Obturator internus and externus Gemelli superior and inferior Quadratus femoris
Hamstrings
Long head of bicep femoris
Semitendinosis
Semimembranosus
What are the main nerves of the hip?
Femoral nerve (anterior)
Obturator nerve (medial)
Sciatic nerve (posterior)
Superior and inferior gluteal nerve (posterior)
What are the anatomical features of the hip joint and its normal movements?
Synovial ball and socket joint - deep so difficult to dislocate
Proxmial - acetbaulum, larbum and transverse ligament
Distal - head of the femur
Movements Flexion - 140 Extension - 10 Abd - 45 Add - 30 IR - 40 ER - 50
What is the function of the glute med during gait?
Activates on the ipsilateral side to maintain a level pelvis
When there is contralateral pelvic drop during gait or single leg stance what is this called?
Trendeleburg gait
What is the Duchenne sign?
Trunk side flexion towards the stance leg to compensate for pelvic drop and weak glute med
What other structures could be contributing to hip pain?
Lx
SIJ
Knee and/or ankle
Non MSK
Name some common and less common causes of lateral hip pain
Common
Greater trochanteric pain syndrome (GTPS)
Glute med tears and tendinopathy
Trochanteric bursitis
Less Common
Referred pain from Lx
What lateral hip pain pathologies are not to be missed?
Fracture of neck of femur
Nerve root compression
Tumour
Name some common and less common causes of anterior hip pain
Common Synovitis Labral tear Chondropathy - early onset hip OA OA Femoroacetabular impingement (FAI)
Less Common Calcification of acetabular rim Ligament of head of the femur tear Stress fracture Hip joint instability
What anterior hip pain pathologies are not to be missed?
Synovial chondromatosis - non-cancerous tumour in the joint
Avascular necrosis of head of femur
Malignancy
What is the clinical presentation for Avascular necrosis of the head of the femur?
Lamb et al. 2019
Pain >6 weeks
X-ray -ve
Need MRI
Usually Males 22-55 years and older in females
Family Hx of avascular necrosis of femoral head
Heavy smoking, alcohol abuse
Overweight
Circulatory problems
HIV
Steroid abuse
Recent pregnancy
Chemotherapy
What are the possible causes of groin pain?
Doha agreeement
Adductor-related groin pain Iliopsoas-related groin pain Inguinal-related groin pain Pubic-related groin pain Hip-related groin pain
Hernia
Obturator Nerve entrapment
Referred pain from SIJ or Lx
Avulsion fracture ASIS, AIIS, Pubic bone
What groin pain pathologies are not to be missed?
Stress fracture of neck of femur, pubic ramus or acetabulum
Avascular necrosis
Intra-abdominal abnormalities e.g. UTI, kidney stones
Ankylosing spondylitis
Tumours
Reactive or infection arthritis
Name some common and less common causes of buttock pain
Common Referred pain from Lx or SIJ Hamstring origin tendinopathy Ischiogluteal bursitis Myofascial pain
Less Common Quadratis femoris injury Piriformis conditions (muscle strain/impingement) Sciatic nerve injury Prolapsed intervertebral disc Stress fracture of sacrum Proximal hamstring avulsion Glute med tendinopathy
What buttock pain pathologies are not to be missed?
Ankylosing spondylitis
Reiteir’s syndome (reactive artritis)
Psoriatic arthritis
Arthritis associtaed with bowel disease
Malignancy
Bone and joint infection
What or the most relevant examples of hip pathologies?
OA of Hip
Femoroacetabular impingement (FAI)
Greater trochanteric pain syndrome (GTPS)
Groin pain
Hamstring injuries
What is the clinical presentation of hip OA?
Most common hip pain pathology >38 years
Capsular pattern
Flex more restricted than ext
IR more restricted than ER
Abd more restricted than Add
Loss of muscle strength (Abd, hip flex and ext)
Unclear pain distribution (somatic referred pain)
Pain can be linked to central sensitisation, so screen for psych factors (Willet et al., 2020)
What are the risk factors of hip OA and what are the factors that predict progression?
Risk Factors Age High BMI Previous injury Intense sporting activities Genetics
Progression Age Symptomatic Female Intense sport activities
What is the treatment for hip OA
NICE Guidelines
Patient education
Strengthening and aerobic exercise
Mobilisation
Pain relief
Gait retraining
Severe OA = Hip replacement
Name the 2 types of femoroacetabular impingement (FAI)
Cam - flattening or convexity of the femoral neck
Pincer - Over-coverage of femoral head by the acetabulum
Which is the most common type of FAI?
Combination of pincer and cam
What movement is problematic for FAI?
Flexion and IR
How can you diagnose a FAI?
Warwick Agreement
Diagnosis
Symptoms, clinical signs and imaging all be present
Symptoms
Position/motion related hip or groin pain which also may be felt in the back, buttock or thigh
Clicking, catching, locking, stiffness, restricted ROM or giving way
Clinical Signs
Hip impingement tests reproduce pain
Limited hip flex and IR
Imaging
X-ray - 1st
MRI or CT
How can you differeniate between FAI and OA?
FAI patients are younger
What is the treatment for FAI?
Warwick agreement
Conservative Rehab
Education
Lifestyle and activity modification
Improve hip stability, neuromuscular control, strength, ROM and movement patterns
Surgery
Open or arthroscopic
What is the prognosis of FAI?
Patient frequently improve and return to full activity
May be associated with hip OA
What is the clinical presentation of greater trochanter pain syndrome (GTPS)?
Grimaldi and Fearon, 2015
Most are likely to be gluteal tendinopathy, bursae less likely
Pain lying on their side at night, standing, walking, climbing up or down stairs, sitting
Psychological factors
What causes GTPS (gluteal tendinopathy)?
Grimaldi and Fearon, 2015
Overload (change in activity, increased load)
Decreased longitudinal TENSILE load
Excessive COMPRESSION
Psychological factors
How can you increase compressive loading of the gluteal tendon during objective testing?
Grimaldi and Fearon, 2015
Place hip in adduction
How does compressive load of the glute med tendon occur?
Tension of the ITB compresses the glute med tendon against the greater trochanter
What hip and pelvic positions increase compressive load on the glute med tendon?
Lateral pelvis rotation away from the affected side
Increase angle of the femur away from the affected side
What is the clinical presentation of adductor-related groin pain?
Doha agreement
Adductor tenderness
Pain on resisted adduction
What is the clinical presentation of iliopsoas-related groin pain?
Doha agreement
Iliopsoas tenderness
Pain on resisted hip flexion and/or stretching of hip flexors
What is the clinical presentation of inguinal-related groin pain?
Doha agreement
Pain in the inguinal canal region
Tenderness of the inguinal canal
No palpable hernia
Pain increased with resisted abdominals, cough, sneeze
What is the clinical presentation of pubic-related groin pain?
Doha agreement
Tenderness on palpation of pubic symphysis and adjacent bone
Muscle testing -ve
What is the clinical presentation of hip-related groin pain?
Hx (onest, nature, location, mechanical symptoms, catching, locking, clicking, giving way)
PROM, FABER, FADIR
(same as FAI clinical presentation)
Name the injury classification for hamstring injuries
British Athletics Muscle Injury Classification
Grade 0 - Generalised muscle pain following exercise
Grade 1 - Small muscle tear
Grade 2 - Moderate muscle tear
Grade 3 - Extensive muscle tear
Grade 4 - Full-thickness tear of muscle/tendon
What are the special questions to ask for hip pathology?
Clicking, catching, locking, giving way, putting on shoes, squatting, cerpitus, stiffness
Hx of trauma
What is the 24 hour pattern for someone with hip OA?
Worse in the morning
Worse when seated for long periods
Eases when they start walking
Worse if they walk for too long
During the objective assessment what other joints would you test?
Lx and SIJ
What are some functional tests for the hip?
Single leg squat
Step down test
Squat
Jumping
Should you palpate the iliopsoas and piriformis?
No, because theres too much structures inbetween so cant be sure if your palpating it or not
What muscles attach on the clock when palpating the greater trochanter?
12 - Glute med
1:30 - Glute min
3 - Glute max
4:30 - Vastus lateralis
7 - Quadratus femoris
10 - Piriformis
What could be restricting PROM hip flex?
Iliopsoas tightness on the contralateral side
What combined movement can be used for articular testing?
Flexion and add - resistance or reproduction of symptoms
Can add compression
What are the muscle length tests for the Hip?
Obers test - Flexed knee = TFL, Ext knee = ITB (inserts on the tibia)
Modified Thomas test - Iliopsoas and rec fem length
90/90 hamstring test
Remember = Could also stress nerves if these tests are positive. Use neurodynamic testing
What position would you muscle test abd?
Side-lying
What is the special test for a femoral stress fracture?
Fulcrum test
Place hand under thigh with patient in sitting, with other hand press down on femur = creates shear force
Positive if patient is apprehensive or reproduces symptoms
high sens and spec
What are the special tests for Femoroacetabular Iimpingement (FAI)?
FADIR - high sens low spec
Anterior impingement test (AIMT) - same as FADIR but 90 degree flex not full flex - high sens low spec
FABER - high sens low spec
Foot progression angle walking test (FPAW) - moderate sens and spec (IR increases pain, ER reduces pain)
Maximal squat test - high sens low spec
Passive IR ROM - high spec low sens
What are the special tests for Greater Trochanter Pain Syndrome (GTPS)?
Grimaldi et al 2017 Test Battery
Positive pain on palpation of the greater trochanter, positive FADIR-R and negative single leg stand (30 sec) = POSITIVE GTPS
Positive pain on palpation of the greater trochanter, positive ADD-R, negative FADER-R and negative single leg stand (30 sec) = POSITIVE GTPS
Positive pain on palpatino of the greater trochanter but negative ADD-R, FADER-R and single leg stand (30 sec) = NEGATIVE GTPS
Single leg stand - 30 seconds - positive if pain and/or pelvic drop
FADER-R = Resistance into IR - Positive if symptoms are reproduced
ADD-R = Sidelying, let leg drop into add and resist abd - positive if symptoms are reproduced
What are the special tests for groin pain?
Adductor squeeze test in 45 degrees flex - low sens high spec
Double adductor test, supine extended knees, legs passively lifted - low sens high spec
Groin pain Doha statement - contraction and/or stretch of muscle and palpation
How can the objective assessment affect your treatment?
Joint above and bellow (Lx, SIJ, Knee)
If it is stiff = mobilise it (arthrogenic/myogenic)
If it is weak = strengthen it (myogenic)
What are the 4 key components for hip conservative treatment?
UK FASHiON conservative treatment (Wall et al., 2016)
Patient education and advice
Patient assessment
Help with pain relief
Exercise-based hip programme
What exercises have the best EMG activation for glute max?
Neto et al. 2020
Different varieties of step ups > weighted step up
Deadlift
Hip thrust
Squat
Done in asymptomatic populations
Patients preference
What exercises have the best EMG activation for glute med?
GTA Index (Selkowitz et al. 2013)
Exercises that have significantly more EMG activation of the glute med compared to the TFL
GTPS = TFL overactive because glute med is weak
Progress with thera band around legs
Clam
Bridge
Sidestep
Quadruped hip ext knee flex or ext
Done in asymptomatic populations
Patients preference
How can you make monster walks more glute med focused?
Put thera band around toes not knees
What is the treatment for GTPS?
Education of load management more effective than corticosteroid injection and no treatment (Mellor et al 2018)
Grimaldi and Fearon 2015
Abd strengthening progressing from iso to bilat abd and squatting
Glute strengthening e.g. bridging
Core strength
! Do not increase compressive loads during rehab ! -> Start clam with pillows between legs so patient not in add
What is the treatment for adductor-related groin pain?
Prevention program
Strengthening of the add, glutes, core and other hip muscles
What are some effective passive hip treatment techniques?
Flexion/add mobilisation
Mulligan mobilisation lateral glide with belt = decrease pain and increase flex/IR
METs
Traction mobilisation
What are the general red flags?
Hx of cancer
Constant progressive unremitting night pain
Unexplained weightloss
Chemotherapy / Radiotherapy
IV drug abuse
Long term steroid use
Drug and alcohol abuse
Epilepsy
Asthma
Diabetes
Osteoporosis
Rheumatoid arthritis
5Ds & 3Ns - Diplopia, dysarthria, dysphagia, drop attacks, dizziness, nystagmus, nausea, numbness
Hx of trauma
Pregnancy
Poor general health
Cardiac and circulatory problems
Cauda equina symptoms
Anticoagulants
