injuries of the hip 1

Question 1

where could pain be felt in hip conditions?

Answer 1

• pain could be felt in buttock, pelvis, hip, groin, anterior thigh to knee and posterior thigh
  -need to outrule abdominal or pelvic organ pathology, referral from lumbar spine etc

Question 2

what are the 2 common sites of hip pain?

Answer 2

• intra-articular - in the joint
  -extra articular - outside the joint

Question 3

what are examples of intra-articular disorders?

Answer 3

-labral tears
-femoralacetabular impingement syndrome (FAIS)

Question 4

what are examples of extra-articular disorders of the hip?

Answer 4

• adductor related groin pain (anterior/medial)
  -adductor strain (anterior/medial)
  -deep gluteal syndrome (posterior)
  -ischiofemoral impingement (posterior)
  -proximal hamstring tendinopathy (posterior)
  -greater trochanter pain syndrome (lateral)

Question 5

what is femoroacetubular impingement syndrome?

Answer 5

• FAI syndrome is a motion related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings
  -it represents symptomatic premature contact between the proximal femur and the acetabulum
  -mechnical mismatch and abnormal contact between head of femur and acetabulum due to morphological changes of structure of joint

Question 6

from what ages is FAIS most common?

Answer 6

• those aged 20-40’s
  -developmental hip abnormality in early adolescence

Question 7

what are different types of hip impingement? (ie the ball and socket don’t fit together properly)

Answer 7

• normal hip
  -cam impingement
  -pincer impingement (excessively deep acetabular socket)
  -combination of cam and pincer impingement

Question 8

describe the aetiology/ causes of FAIS

Answer 8

• morphological changes can appear as young at age 12-13 but symptoms may not appear until early adulthood
  -related to growth plate changes
  -more common in males than females
  -seen in sports which require quick changes in direction eg soccer
  -there is a dose response effect - ie the higher the level the sport, the higher the loading is across the hip

Question 9

what are the symptoms of FAIS?

Answer 9

-motion related or position related pain in the hip or groin
-pain may also be felt in the back, buttock or thigh
-pateints may also describe clicking, catching, locking, stiffness, restricted ROM
-pain is aggravated by prolonged sitting, driving, climbing stairs (ie when hip is flexed)

Question 10

what are the signs & symptoms of FAIS upon physical examination?

Answer 10

-painful limited internal rotation
-positive scour/quadrant test
-positive flexion/ Add/IR (FADDIR)
-decreased ROM into flexion and adduction
-reduced hip adductor and hip flexor strength
-altered biomechanics during squatting, step down etc

Question 11

what are the 2 types of management of FAIS?

Answer 11

• conservative - physio led exercise
  -surgical - aims to restore anatomy to as close to normal as possible - femoral or pelvis osteoplasty (remodelling)

Question 12

what is the labrum?

Answer 12

a fibrocartilaginous structure

Question 13

what are the functions of the labrum?

Answer 13

-enhances hip joint stability
-contains proprioceptive fibres which send info to the brain about where the hip is in space

Question 14

what do the signs and symptoms of labral tears depend on?

Answer 14

the level of severity - ie if it is a partial or complete tear

Question 15

what is the aetiology/causes of labral tears?

Answer 15

-traumatic injury ie from twisting or pivoting/ rotating
-can be caused by one single episode eg contact sports but more commonly it is repeated micro trauma over time
-can be seen with FAIS, osteoarthritis & developmental dysplasia

Question 16

what are the symptoms of a labral tear?

Answer 16

-broad range - depending on location and severity of tear
-if anterior tear (90%) - groin pain and lateral hip pain
-buttock pain is present if it is a posterior tear - less common
-deep seated pain, dull ache or sharp with movement or loading
-pain is worse when walking for long periods, climbing stairs, sports, pivoting etc

Question 17

describe the physical exam of a labral tear?

Answer 17

-variable due to variable location of tears - may be difficult to differentiate between FAIS and tear
-ROM may be normal, increased or slightly limited
-labral tests eg Fitzgerald test will reproduce pain and may cause clicking symptoms
-scour test/ quadrant test

Question 18

what movements may be affected if there is an anterior tear of the labrum?

Answer 18

• flexion
  -adduction
  -internal rotation

Question 19

what movements may be affected if there is a posterior tear of the labrum?

Answer 19

• hyperextension
  -abduction
  -external rotation

Question 20

what kind of investigations can be done with labral tears?

Answer 20

• arthroscopy - ie key hole surgery
  -MRA - a type of MRI imaging - higher sensitivity and specificity

Question 21

what kind of surgical treatment can be done on a labral tear?

Answer 21

Goal is to eliminate the tear which is causing pain
-can do through arthroscopic repair - for peripheral tears which have blood supply to heal
-can also do arthroscopic debridement - for larger tears with less ability to heal

Question 22

briefly describe what the physiotherapy management of intra-articular conditions of the hip involves

Answer 22

• exercise based treatment is recommended for people with hip pain
• aim is to strengthen, optimise ROM and retrain movement pattern (functional training - eg if patient is walking funny)
  -should be at least 3 months duration
  -patient reported outcome measures (proms), psychological factors and physical impairment should be used to monitor response to treatment

Question 23

for hips, what should the exercise prescription involve?

Answer 23

• exercises should focus on all 3 planes - ie flex/ext in sagittal, and/add in frontal and rotations in transverse plane
  -task specific - eg with everyday living or sport related
  -single limb
  -include the trunk and pelvis - eg include core exercises

Question 24

what is normally the most common cause of acute groin pain in athletes?

Answer 24

adductor (groin) strain

Question 25

what causes adductor strains?

Answer 25

• usually a strong forceful eccentric contraction eg kicking, change of direction, jumping

Question 26

what adductor muscle is most prone/ common to an adductor strain?

Answer 26

the adductor longus and Magnus muscle

Question 27

what would the subjective exam of an adductor strain involve?

Answer 27

-history taking may be the most informative part of exam to determine if it is a strain
-pain in inner thigh which is well localised
-distinct mechanism of injury (MOI)
-acute presentation

Question 28

what are the 3 levels of muscle injury grading during a physical exam?

Answer 28

• contraction
  -stretch
  -palpation

Question 29

what does a physical exam of an adductor strain involve?

Answer 29

• pain with resisted adduction and pain with the adductor squeeze test
  -pain when stretching and there is a limitation on passive and active abduction of thigh
  -localised tenderness when palpating the groin

Question 30

what does the management of an adductor strain involve?

Answer 30

• relative rest
  -POLICE - protect, Optimal Loading, Ice , compress and elevate
  -eccentric strengthening
• caution with overstretching adductors - may lead to chronic adductor related pain
  -core stability training
  -graded / slow return to sport

Question 31

what is the holmich protocol ?

Answer 31

the most appropriate method for the treatment of long standing adductor related groin pain

Question 32

what is inguinal related groin pain?

Answer 32

• pathology involving the inguinal canal
  -weakness in posterior wall of inguinal canal
  -tears in inguinal ligament
  -often called sports hernia