injuries of the hip 2

Question 1

what conditions could cause buttock pain?

Answer 1

• deep gluteal syndrome
  -ischiofemoral impingement
  -proximal hamstring tendinopathy
• pathologies of the lumbar spine or pelvis

Question 2

what is deep gluteal syndrome?

Answer 2

• presence of pain in the buttock caused from non-discogenic (no disks) entrapment of the sciatic nerve

Question 3

what are symptoms of deep gluteal syndrome?

Answer 3

• buttock pain
  -there may be (+/-) posterior thigh pain
• there may be (+/-) Pins and needles or numbness
  -symptoms are aggravated by prolonged sitting, sit to stand, lifting, flexing forward or walking and lying side at night
  -females may have symptoms with sexual intercourse
  -there may be (+/-) pain with bowel movements

Question 4

what are examples of special tests that can be used in the physical exam for deep gluteal syndrome?

Answer 4

• FAIR
  -active piriformis stretch test
  -seated piriformis stretch test
  -beatty test
  -freiberg sign

Question 5

Describe the seated piriformis stretch test?

Answer 5

• patient is in seated position with 90 degree hip flexion
  -examiner extends the knee and passively moves the flexed hip into adduction with internal rotation while palpating 1cm lateral to the ischium (middle finger0 and proximally at the sciatic notch (index finger)
  -test is positive if the posterior buttock pain is reproduced

Question 6

Describe the active piriformis test

Answer 6

• patient is lying down on side
  -patient pushes heel down into the table and actively abducts with external rotation against the resistance of the physio
  -the examiner palpates at the level of the piriformis
  -test is positive if the posterior buttock pain is reproduced

Question 7

Describe the FAIR test

Answer 7

• flexion - adduction - internal rotation
  -hip is passively flexed, adducted and internally rotated
  -if pain is reproduced - positive test

Question 8

Describe the beatty test

Answer 8

• patient is lying on the unaffected side with the knee and hip flexed
• patient abducts the thigh to raise the knee off the table
• physio applies resistance to this
• positive if there is reproduction of the posterior buttock pain

Question 9

where are important areas to palpate during physical exam with the deep gluteal syndrome condition?

Answer 9

• quadratis femoris
• obturator internus
• piriformis
• palpate for areas of tightness, increased tone and trigger points

Question 10

Describe the management of deep gluteal syndrome

Answer 10

• strengthen the weakened muscles eg gluteals
• gentle sciatic nerve mobilisation
• caution with aggressive muscle stretching due to nerve sensitivity
• correct faultly movement patterns eg excessive adduction
• soft tissue mobilisation

Question 11

what is ischiofemoral impingement?

Answer 11

• impingement of quadratus femoris muscle between lesser trochanter and ischium
• ie the quadratus femoris muscles are compressed

Question 12

what are examples of the causes (aetiology) of ischiofemoral impingement?

Answer 12

• structural causes - ie narrow space between the femur and ischium
• hip osteoarthritis
• inter-trochanteric fracture
• coxa valgus (when angle between femoral shaft and neck is increased)

Question 13

what are the symptoms of IFI?

Answer 13

• more common in females
• may be bilateral but may not be symptomatic bilaterally
• buttock pain lateral to ischium
• there may be (+/-) posterior thigh pain
• pain aggravated by single leg loading activities
• pain also aggravated by passive flexion and internal rotation which stretches the quadricep femoris muscles

Question 14

what is recommended for the physical exam of a patient who may have IFI?

Answer 14

• long stride walking - tests positive if the post pain is reproduced during extension with long strides, whilst pain is alleviated when walking with short strides
• IFI test
• palpation

Question 15

what does the IFI test involve?

Answer 15

• patient is in side lying (SL) position
• physio passively takes patients hip into extension & adduction- this should reproduce symptoms if patient has IFI
• then physio puts hip into abduction and extended position and repeats - **pain should be eased **if patient has IFI

Question 16

what does the conservative management of IFI involve?

Answer 16

• activity modification
• pain management
• address any leg length dysfunction
• address any gluteal muscle weakness
• correct faulty habitual posture

Question 17

what is proximal hamstring tendinopathy?

what cohort of people can this affect? what is it characterised by?

Answer 17

• a conditon which is very common in long distance runners, athletes involved in sagital plane activites eg sprinting and running or change of direction… however may also affect people who dont play sport
• characterised by deep, localised pain in the region of the ischial tuberosity

Question 18

what can causes proximal hamstring tendinopathy?

instrinsic and extrinsic factors

Answer 18

1. instrinsic factors - age, increased BMI, and metabolic issues eg insulin resistance
2. extrinsic factors - training errors - increasing training loads too quick

Question 19

what are examples of symptoms of PHT?

Answer 19

• deep localised pain in the region of the ischial tuberosity
• aggravated by running at high speed or uphill, deep hip flexion (lunging, deep squat), sitting on hard surfaces

Question 20

describe the pain behaviour of PHT

Answer 20

• worse in AM
• warming up patterns -eases with activity
• worse after activity

Question 21

what are 3 different tests that can be done to diagnose PHT?

Answer 21

1. puranen - Ovrara test
2. bent knee stretch test
3. modified bent knee stretch test

Question 22

what does the puranen -ovrava test involve?

Answer 22

• patient is standing up
• stretching hamstrings in standing with hip flexed at 90 degrees
• knee fully extended
• foot is on a support - eg plinth

Question 23

what is a positive result of the 3 tests for proximal hamstring tendinopathy (hpt)?

Answer 23

• positive result - pain with the stretch tests - ie if the pain in the buttock is reproduced

Question 24

what does the bent knee stretch test involve?

Answer 24

• patient in supine position
• hip and knee of symptomatic leg are maximally flexed
• examiner slowly straightens the knee

Question 25

what does the modified bent knee stretch test involve?

Answer 25

• pateint lies in supine position with legs fully extended
• examiner grasps symptomatic leg behind the heel with 1 hand and at the knee with the other hand and maximally flexes the hip and knee
• the examiner then rapidly straightens the knee

Question 26

what are the clinical signs of PHT on physical examination of a patient?

Answer 26

• pain with hamstring contraction
• resisted hip extension with knee flexed - eg single leg bridge, long lever bridge (leg in air as you are doing bridge)

Question 27

Describe the management of PHT?

Answer 27

• reduce tensile and compressive loads so rest from aggragating activities
• avoid hamstring stretching
• start introducing loading activities when pain reduces (0-3/10) - 3 phases
• phased return to sport activity

Question 28

what are the 3 phases of loading activities associated with PHT?

Answer 28

1. phase 1 - isometric hamstring - eg bridge, single leg bridge, long level bridge
2. phase 2 - isometric hamstrings with minimal hip flexion eg nordics, hamstring curls
3. phase 3 - isotonic hamstrings with increased hip flexion - RDLs, hip thrusts, lunges etc

Question 29

what is an isometric exercise?

Answer 29

• exercise involving the static contraction of a muscle without any visible movement in the angle of the joint

Question 30

what is isotonic exercise?

Answer 30

• exercise where muscle tension remains the same whilst the muscle length changes - there are 2 types - concentric 9muscle shortens or angle between joint shortens )and eccentric contraction (lengthening - ankle between joint increases

Question 31

what kind of condition causes lateral hip pain?

Answer 31

• greater trochanter Pain syndrome (GTPS)

Question 32

what is greater trochanter pain syndrome?

Answer 32

• clinical diagnosis of lateral hip pain and includes trochanteric bursitis associated with tendinopathy - eg gluteus medius and minimus tendons

Question 33

where is the pain felt in a patient that has GTPS?

Answer 33

• pain is felt posterolateral in the hip
• it MAY be felt (+/-) down the lateral aspect of the lower limb, sometimes below the knee

Question 34

what is greater trochanter pain syndrome aggravated by?

Answer 34

• sleeping on the affected side
• weight bearing - walking or single leg stance
• stairs

Question 35

what are examples on the clinical features of GTPS?

Answer 35

• pain on palpation over the greater trochanter
• pain and weakness on resisted abduction of the hip
• pain reproduction during loading - eg 30 second single leg stance
• pain reproduced during the FABER test (flexon, abduction, external rotation
• pain also reproduced during FADER (adduction instead of abduction)

Question 36

how is greater trochanter pain syndrome managed?

Answer 36

• a program involving strengthening exercises and load management is essential
• strengthening of** glut medius and minimus**
• load management - avoid compressive positions or activites
• progressive loading through ADL’s and exercise

note ADL- acitivies of daily living

Question 37

what are the roles of the gluteus medius in the rehab of hip pathologies?

Answer 37

• mainly functions to stabilise the femur and pelvis in the frontal plane
• anterior fibres also contribute to internal rotation
• posterior fibres can assist in hip extension and external rotation

Question 38

what are the roles of the gluteus maximus in rehab for hip pathologies?

Answer 38

• strong hip etxnsor
• most powerful external rotator of the hip
• the upper portion of G max can also abduct the hip similar to gluteus medius
  *

Question 39

what are examples of conditions, in which gluteal rehab is very important?

Answer 39

• Osteoarthritis
• deep gluteal syndrome
• IFI
• labral lesions/ FAIS
• greater trochanter pain syndrome
• adductor pathology
• patellofemoral pain syndrome