Hip Pathologies Flashcards
Pathology of GTPS
Compressive forces cause impingement of bursa and glute tendons onto the greater trochanter by the ITB
Compression increased by weak hip adductors - hip joint ABD causes overstretching of ITB leading to compression and lateral pelvic tilt to contralateral side
Define Greater Trochanteric Pain Syndrome (GTPS)
Attributable (caused) to tendinopathy of gluteus medius and/or minimus +/- bursal pathology.
GTPS is a common cause of lateral hip pain
Causes of AVN of femur
The femoral head receives its blood supply through the neck of femur. Fractures across this zone may cause a loss of this supply leading to tissue death; Femoral neck # -> AVN to femur
Trauma causes - # femoral neck, # dislocated hip, surgery around hip
Non-trauma causes (affects both hips bilaterally)- prolonged use of corticosteroids (management of asthma), XS alcohol
Stress # for female athletes
Female athletes developing Relative Energy Deficiency Syndrome (REDS)/ Female Athlete Triad
Risk factors: in teens-20s, High levels of exercise and eating insufficient nutrients to accommodate exercise levels, increasing risk of lowering BMD thus greater risk of stress #
Signs: Low body fat, menstrual cycle stopped/dysfunctional, Previous #, high levels of exercise
Risk factors of Hip Impingement
Repetitive hip motion
High levels sports
Pediatric diseases (slipped/# epiphyseal (growth) plate)
Femoral neck #
Previous hip surgery
Define Avascular Necrosis (AVN)
AVN is condition in which there is loss of blood supply to the bone. Bone is living tissue, hence loss of blood supply, means bone death. If bone death progresses, leads to bone collapse
Prevalence of Avulsion Injuries
May not be able to surgically repair tendons that have avulsion injuries for a prolonged period
More common in adolescents involved in sports because the tendons are stronger than apophyses (where tendon attached to bone) - because in adolescents bone have yet to fully ossify
Clinical Presentation of AKP
Complaint of ‘deep ache in front of knee’ ○ Aggs = when patellofemoral joint lowered; deep knee flexion
○ Eases = with rest
○ localised tenderness around medial extensor retinaculum + lateral knee pain
○ haemarthrosis
recurrent dislocation likely: 15-44%
Pain is the main symptom all patients experience; syndrome indicates presence of other common conditions: Tightening of muscles anterior/posterior to knee causing a change to knee biomechanics, creating pain.
Altered alignment
Superior/inferior migrated patella
Direct trauma
Overuse - jogging/overweight
HPC: Dislocation: patella slipped out and had to be manually relocated
Subluxation: patella slipped out and spontaneously relocated
Clinical presentation of patient with GTPS
Age 40-60
Female - more common due to biomechanics - females have larger pelvic width w/ greater prominence of trochanters, which is associated w/ greater stretching of ITB as it passes over greater trochanter
Post-menopause
Lower femoral neck shaft angle - increases compression of gluteus medius tendon over greater trochanter
Increased BMI
Systemic factors?
Explain Pincer-type FAI
Result of excess acetabular coverage of the femoral head.
Over coverage can be either:
□ Global (coxa profunda) - due to deepened acetabulum
OR
□ Focal anteriorly (acetabular retroversion) - due to altered orientation of acetabulum
Results in abutment of the femoral head neck junction against the acetabular rim pressing upon the labrum, in turn causing damage to articular cartilage (chondral injuries)
Picked up on AP viewing (radiographic imaging) looking at lateral center edge angle = x>40o
Signs of Hip Dysplasia in infants
limping when first walking or one hip is less flexible when changing baby
Types of Hip Impingement
CAM-type Femoral Acetabulum Impingement (FAI)
Pincer-type Femoral Acetabulum Impingement (FAI)
Mixed FAI - some patients exhibit both impingements
Symptoms of Hip Impingement
Sitting cross legged is difficult or painful
Difficulties putting socks and shoes (52%)
Unable to sit for period of time (23%)
Slight or more severe limp (65%)
Adductor related symptoms
Walking long distance painful and pain doesn’t disappear straight away with rest
Significant pain after sports activities
> 40% buttock / low back pain
Define Hip Dyplasia
Hip socket (acetabulum) does not cover femoral head fully causing hip joint to be partially/completely dislocated
Pathology of Hip Impingement
• Pathophysiology of FAI is unclear - brought by bony deformities from birth/developmentally acquired through overuse, causing repetitive abutment and wear of articular cartilage (chondral injuries)
Explain CAM-type FAI
Caused by an irregular osseous prominence of the proximal femoral neck or head-neck junction.
Cam impingement can become symptomatic in physically active young males (athletes)
Bony protrusion located at the anterosuperior aspect of the femoral head-neck junction
Picked up on Dunn view (radiographic imaging) looking at alpha angle = 90o flexion & 20o ABD
Risk factors of babies acquiring Hip Dysplasia
Born in breech position; foot deformities
Types of Snapping Hip Syndrome
Internal - caused by iliopsoas over iliopectinal eminence, paralabral cysts
External - caused by ITB “snapping” over greater trochanter OR proximal hamstring tendon rolling over ischial tuberosity, TFL OR glut max over the greater trochanter
Define Snapping Hip Syndrome (Coxa Saltans)
Clinically characterised by a audible and palpable ‘snapping’ sensation heard/felt during hip movement
Define Avulsion Injuries
Joint capsule, ligt or muscle attachment site fall of bone, usually taking fraction of bone with it
Diagnosis of Stress #
- Early diagnosis is difficult because - Plain radiograph could only be positive in less than 10% of cases.
- Hence for early signs MRI is the gold standard test looking for bone marrow oedema.
- Physiotherapists should have high index of clinical suspicion in athletes presenting history of gradual onset of symptoms VS sudden onset (traumatic #)
Symptoms of AVN
Symptoms may include stiffness in the hip, night pain, limp, pain in the groin, buttocks, front of thigh.
Define a osteochondral defect
An osteochondral defect refers to a focal area of damage that involves both the cartilage and a piece of underlying bone
Pathology of Hip Dysplasia
Superior surface of hip joint covered in hyaline cartilage that gradually hardens into bone, if femoral head is not seated firmly into acetabulum the socket will not fully form around femoral head becoming too shallow -> XS movement in hip joint -> partial/complete dislocation of hip joint
Diagnosis of Hip Dysplasia
On X-ray looking at Center edge angle:
25-40 = normal
25-30 = borderline dysplasia
<20 = dysplasia
<16 = almost certainly will develop OA
Define a chondral defect
A chondral defect refers to a focal area of damage to the articular cartilage (the cartilage that lines the end of the bones).
Prevalence of Hip impingements
Radiographic findings consistent with FAI and dysplasia were common and were not associated with the presence of OA
Diagnosis of labral tears
Standard MRI only has 35% sensitivity (detection) and accuracy in detecting labral pathology.
Sensitivity and accuracy can be improved to reach up to 90% using contrast (fills tear in capsule thus easier to identify)
Prevalence of labral tears
Associated with chondral injuries = injury to articular cartilage; hip dysplasia
Causes of Osteochondral defect
Can occur acutely or develop as a result of several chronic conditions including:
○ Separation of the osteochondral fragment caused by an acute traumatic injury or as the end result of an unstable fragment in osteochondritis dissecans (small segments of bone begins to separate due to lack of blood supply)
○ Acute osteochondral impaction of the bone with resultant contour deformity.
○ A collapse of the subchondral bone in a subchondral insufficiency fracture (SIF) or avascular necrosis (AVN) or a bone collapse uncovering a large subchondral cyst (can occur from OA)
Prevalence of Hip Dysplasia
More common in babies and girls
Define Hip Impingement
Pathological hip condition characterised by abnormal contact between acetabulum & femoral head-neck junction
Pathology of subchondral cyst
The synovial fluid intrusion theory -proposes that articular surface defects and increased intra-articular pressure allow intrusion of synovial fluid into the bone, leading to formation of cavities.
The bone contusion theory - according to which non-communicating cysts arise from subchondral foci of bone necrosis that are the result of opposing articular surfaces coming in contact with each other
Define Apophysis
A normal developmental outgrowth of a bone, which fuses later in adult development
Found where major tendons and ligaments attach to bone, e.g. the tibial tubercle apophysis is an insertion for the patellar tendon
Define labral tears
Tears of the acetabular labrum
Causes of labral tears
The majority are not associated with a specific event or cause but most commonly is the result of repetitive stress (loading) irritating the hip
End range motion in position of hyperabduction, hyperextension, hyperflexion and external rotation contributes to labral tears
High risk: athletes in football, ice hockey, rugby, golf, balle, long distance running
Prevalence of Stress #
Common among joggers and runners
Metatarsals & tibia = most common # sites
Estimated 1% # at femoral neck - Early recognition is required to prevent progression of # of femoral neck because if it becomes displaced -> avascular necrosis of femur
Symptoms of femoral neck stress # = Exertional groin pain, worsening on exercising; pain at full hip ROM
Common LL #s
NOF- risk of AVN, # Acetabulum, Long bone #, Tibial Plateau #, OCD – Osteochondral defects, Weber #, Stress #
Management of LL #s
Aim - stabilise #, Restore Function
- Gait-re-ed - use of parallel bars, zimmer frames, crutches
- ROM - try maintain as much in early stages
- Strength - After consolidation - WB activity, progressive strengthening
- Pain relief
Common LL muscle injuries
Hamstrings>Calf>Groin>Quads
MOI of muscle injuries
Sport/activity dependent
Proximal muscles MOI - high speed contractions usually kick in during high level activities
Distal muscles MOI - can be lower speed contraction as they are active during all levels of activity.
Hamstring strain management
- POLICE - activity modification
- Early load - 2-3 days in elite sports
- Length of muscle (ROM/stretch) - prevent scar tissue formation in shortened state
- Strengthen - early as best stimulus for recovery via mechanotherapy.
- Pain relief if needed - heat/cold therapy, walking aids, medication.
Groin strain causes
Adductors, Iliopsoas, Rectus Femoris affected
Causes:
- Inflammation from overuse of muscle/tendon
- Direct trauma/Biomechanical
- Inflammation, pain on movement/contraction, loss of function/weakness
- Visible/palpable defect (if grade III tear)
Define Perthes Disease
Avascular necrosis of the femoral epiphysis (head)
Prevalence of Perthes Disease
Self limiting with revascularisation occurring within 2-4 years. Femoral head may remain deformed resulting in OA. Cause unknown.
Median age onset – 6 years (2-12 years)
Male:Female = 4:1
Clinical presentation of Perthes disease
knee pain only and a limp - need to assess the hip in these cases
Adults especially with alcohol problems (Bilateral symptoms) - assess hip
Management of Perthes disease
Management:
Reduce WB and rest - allow to recover
Define Slipped Femoral Epiphysis (SFE)
disorder of adolescents in which the growth plate is damaged and the femoral head moves (“slips”) with respect to the rest of the femur. The head of the femur stays in the acetabulum while the rest of the femur is shifted
Clinical presentation of SFE
Age 10-17 in males, 8-15 in females
Presents with pain- maybe in hip/groin, thigh or knee (can present with just knee)
Differentiate between SFE and Perthes with age and x-ray.
Pain initially then limp progressing onto leg length differences in severe cases.
Common LL pathologies
Sprains (ligs):
- Knee (ACL/PCL, MCL/LCL)
- Ankle sprains low (LLS – ATFL and CFL) and high (syndesmosis injuries)
Adolescents:
- OGS, SLJ’s, Perthe’s, SFE’s (Slipped Femoral Epiphysis), Sever’s
Bone:
- Stress #s
- # s - # NOF- risk of AVN, # Acetabulum, Long bone #, Tibial Plateau #, OCD – Osteochondral defects, Weber #, Stress
Vascular:
- Arterial = PVT, arterial entrapment
- Venous = DVT
Muscle/Tendon:
- Tendinopathies – Gluteal, Achilles, Plantarfascia and PTTD. Tendon rupture (Achilles)
- Muscle Strains - hamstring>calf>groin>quads
Joint:
- Degenerative - OA – HIP>Knee> Ankle, Joint replacements
- Inflammatory
- Traumatic
- Joint disorders – FAI,PFPS, meniscal tears
