L3 Hip Conditions Flashcards
Instability
excessive mobility that causes pain with or without the symptom of hip joint unsteadiness
can be dysplasia, subluxation, dislocation
Causes of instability
traumatic
atraumatic
Traumatic instability
MVA or other high energy event is the cause
Atraumatic Instability
repetitve axial loading and rotation in the presence of anatomic variation
RF for Atraumatic Instability
golfers, gymnastics, football, hockey, figure skating, ballet, adolescent athletes with mobility
acetabular dysplasia
soft tissue hypermobility
ligamentum teres tear
Instability S/S
pain in groin or anterior thigh
popping, locking, snapping
worsening pain with sitting, walking, running
limping, weakness, sensation of dead leg
unable to perform strenuous activities
Instability Imaging
Center edge angle can be altered
can develop labral hypertrophy to stabilize
can progress to labral tears and OA in adulthood
Center Edge angle
femoral head and acetabulum
<25° dysplasia
>39° over-coverage/pincer type FAI
PT management of instability
- Patient Ed
- Postural re-education
- Avoiding long lever hip flexion and high impact
- Strengthening of rotators, abductors, extensors, adductors
- Neuromuscular training/Proprioceptive
Should have PT for 8-12 weeks before considering surgery
Pericetabular Osteotomy
-for pts <40 and have failed with PT
-may delay or avoid need for THA in future
-high rate of complications
-NWB for 6-8 weeks
-return to school in 12 weeks, sport in 6-12 mo
Dysplasia
(the acetabulum is too shallow)
reduces joint stability, but joint can be unstable without having it
left untreated will lead to labral tears and OA
dysplasia + OA = need for THA
Femoracetabular Impingement
abnormal contact between femoral head/neck and acetabular margin from structural variations in proximal femur and/or acetabulum
may result in labral tears, chondral damage, OA
CAM structure
non-spherical shape of the femoral head, protrusion of the head-neck junction
thickening
PINCER structure
deeper acetabular socket, associated with acetabular retroversion
increased center edge angle
MIXED Structure
combination of cam and pincer, most common category of impingement
Epidemiology of FAI
10-15% of population
CAM = young, male athletes
Pincer = active middle aged women
most likely to be symptomatic with high speed, high impact rotational sports
FAI Clinical Exam
Hx = anterior groin pain, C sign, clicking, giving away
Obs = pelvic tilt
ROM = decreased flexion and IR, tight ilioposoas and joint
overall weakness
gait will show a slower cadence and limited hip extension. Squats will have limited motion
FAI and muscle weakness
not a strong correlation between FAI and specific muscle weakness
global hip muscle weakness moderate predictor of whether FAI was symptomatic
Does FAI mean automatic pain?
asymptomatic individuals is 29%
20-40s are most likely to have pain that is ONLY FAI. vs older will have OA w/FAI
self-efficacy and psychologic factors are more present in pts with pain and weakness
PT Management for FAI
activity modifcation
patient ed
manual therapy
avoid end range stretching
progressive pain-free strengthening
neuro re-education
squat variations
Labral Tear Epidemiology
most common in 4th decade, more women vs men
22-55% of patients with hip or groin pain
74% have no clear MOI
Traumatic Labral Tear
acute, rapid twisting, hyperabduction, falling
compression from MVA
Atraumatic Labral tear
combo of anatomic variants with repetitive forces
RF for Labral tears
female
FAI
higher BMI
capsular laxity
hip dysplasia
illiopsoas overactivity
degeneration of surrounding tissues
Subjective Labral Tear
sharp, deep, intermittent pain
anterior hip/groin pain
associated clicking or catching in hip
end of range pain with flexion or extension
Labral Tear Exam
possible anterior or posterior pelvic tilt
flexed knee gait pattern, decreased stance time and stride length
special tests = none with high spin or snout
Labral Tear and FABER/FADIR
FADIR will be + if its anterior
FABER will be + if its posterior
PT Management for Labral Tear
sit in a higher chair
increase cadence to shorten stride
consider muscle imbalances
optimize mechanics
avoid loaded, rapid pivoting/twisting
manual therapy –> low grade joint mob for pain
Medical Management Labral Tear
injection to relieve pain
surgery (successful if patient fails PT, low age, interest in surgery)
1/5 pts having surgery for labral will need another surgery
Labral and surgery
most labral tears are asymptomatic; the decision to do surgery should be with caution and after conservative treatment has failed. Labral tears have a low chance of developing symptoms if asymptomatic
Gluteal Tendinopathy
most prevalent of all LE tendinopathies
possible association with future development of OA
usually have concurrent LBP
takes between 3 wks to 1 year to heal
Trochanteric Bursitis
true bursal inflammation may result from either chronic microtrauma, regional muscle dysfunction, overuse or acute injury
Mechanisms and Pathophys of GT
chronic progressive tendon irritation from combination of compressive and tensile loading
compressive load increases naturally with increasing hip adduction; 40° of adduction has 106 N of force
Epidemiology of GT
3 F vs 1 M
1 in 4 women over the age of 50 will be diganosed
RF for GT
non-modifiable, female >40 y/o
abnormal biomechanics, plyometric overload, training error
S/S of Gluteal Tendinopathy
lateral, posterolateral hip pain that can refer down lateral thigh
achy, dull or sharp
trendelenburg sign
aggravates: side-sleeping, WB activities, standing after prolonged sitting
Eases: bell curve of activity, mid range postures
palpation tenderness
Imaging for GT
PT Management GT
conservative treatment has high success rate over 6-12 weeks
relative rest
reduce intensity, duration, frequency of training
avoid sidelying sleeping, asymmetric standing, crossed legged sitting
minimize stretching
address any other deficits
isometrics
massage
taping
Patient Ed for GT
patients often catastrophize, have depression, low self-efficacy, higher BMI
condition will be exacerbated with psychologic factors
Medical Management for GT
injections of cortizone (only provided relief for about 3 mo)
surgery = irresponsive or grade 3-4 tears, does have good outcomes
