L4/5 Hip Conditions Cont. Flashcards by Hannah P Erickson

Non-arthritic joint problems

instability
dysplasia
femoro-acetabular impingement
labral tear
chondral lesion

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Extra-articular soft tissue problems

gluteal tendinopathy
groin strains

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Osteoarthritis Epidemiology

-one of the leading causes of disability and morbidity globally
-higher prevalence in US/Europe
-men are often more symptomatic for OA, receive more radiographs

Most common: Knee, Hip

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RF for OA

Age (>50 most common cause of hip pain)
hip developmental disorders
previous injury to hip
genetics
high impact sports (not running)
BMI
acetabular retroversion

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Natural History of OA

changes in shape, density, and biomechaanical capacity of bones, cartilage, periarticular fibrous tissue

muscle weakness, especially abductors
superior-lateral migration of femoral head
decreased AROM

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OA Radiograph

Will show joint narrowing
Mod OA <2.5mm
Severe OA <1.5 mm

osteophytes
sclerosis

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American College of Rheumatology clinical criteria for OA

Hip pain, groin, anterior, or lateral thigh
Either one of the following clusters:

a. hip IR <15°, Hip flexion ≤ 115°, Age > 50
b. hip IR ≤ 15°, pain with hip IR PROM, duration of morning stiffness ≤ 60 min, age >50

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Outcome measures for OA

6 min walk
TUG
30 s sit to stand

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PT and OA

Initial POC 6-12 weeks depending on level of function, pain, and patient compliance

PT ed: positions of comfort, weight management, activity mod, condition
Gait training
Balance training
Manual therapy
Flexibility
Strengthening

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Medical Management of OA

Bracing is not advices
NSAID injection may give short term pain relief
not enough evidence to support supplements
Visco-supplementation = not covered by insurance

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Indications for THA

incapacity pain
limited motion that isn’t improving
impaired weight bearing and gait
radiographic features
failed conservative care

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Posterolateral THA

more proven long-term outcomes
little blood loss
better visualization
shorter learning curve for surgeon
higher risk of dislocation
more muscle damage

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Anterior Approach THA

less risk of dislocation
minimal muscle damage
less post-operative pain
longer learning curve for surgeon
more operative blood loss
longer duration of surgery
typically faster rehab

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Bipolar hemiarthroplasty

used to change the angle of the femur head in the acetabulum

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Hip resurfacing

often used for athletes

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Complications with THA

anesthesia reactions
leg length inequality
infection
DVT
falls
dislocation

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Contraindications for posterolateral THA

no hip IR, adduction for 6 weeks
don’t cross legs while sitting, sleeping
don’t pivot towards that side while standing

After THA

-in patient rehab might be needed depending on approach, surgeon’s perspective, and patient’s health
-home health care
-outpatient PT for 1-12 weeks

the first 4-6 weeks will have pain, limited function, ADs, precautions

At 3 years s/p of THA

89% of patients were satisfied with the results

reasons why they weren’t satisfied:
higher function previously
expected higher function
didn’t have a better post op level of function

Primary areas of groin pain origin

adductor
illiopsoas
inguinal
pubic
other
hip

Groin Pain Epidemiology

mens soccer is very common
1/3 elite players will suffer groin pain

unreported injury may be much higher
hockey, rugby, baseball, football also have high incidence

Patient History, groin pain

often on dominant side
gradual onset
past history, loading history
night pain

Intrinsic risk factors for groin pain

previous groin injury, dec adduction strength, ROM
bony morphology

Extrinsic factors for groin injury

71% non-contact
follow a quick change of direction
70% overuse, possibly due to load management

Adductor related groin pain

S/S pain around the insertion of adductor longus tendon at the pubic bone. pain radiates distally along medial thigh more likely if patient presents with pain on adductor stretching

Illiopsoas related groin pain

pain the anterior part of proximal thigh more laterally located than adductor-related groin pain pain reproduced with resisted hip flexion

Inguinal related groin pain

pain in the inguinal region that worsens with activity can occur with coughing, sneezing, sitting up in bed pain reproduced with resisted abdominal muscle testing

Pubic related groin pain

pain in region of symphysis joint and immediate adjacent bone no particular resistance test, more likely if pain is reproduced by resisted abdominal and hip adductor testing

Hip related groin pain

mechanical symptoms present, such as catching, locking, clicking, giving way

FAI syndrome

motion or position related pain in hip/groin. pain may also be felt in the back, buttock, thigh. may describe clocking, catching, locking, stiffness, restricted ROM, giving way restricted IR, evidence of labral or chrondral damage

Snapping Hip Epidemiology

common in young athletes in teens and twenties can be external, internal, internal intra-articular

External Snapping Hip

ITB sliding over the greater trochanter more common in runners palpate greater trochanter as hip is actively flexed. applying pressure will stop snapping. correlates with ober's test

Internal Snapping hip

Iliopsoas sliding over femoral head, iliopectinal ridge, or iliopsoas bursa more common in dancers snapping is reproduced passively tender to palation of iliopsoas tendon w/resisted hip flex moving hip from flex/Er to ext/IR positions reproduces snapping

Internal intra-articular snapping hip

labral tear, synovial chondromatosis

Potential Interventions for snapping hip

-iliopsoas stretches, progressive strengthening -long axis hip distraction, post mob for pain -lumbar stabilization/anti-lordotic exercises -limiting passe developpe and grand battement -success of tx was determined as negative illioposas test and return to activities -all patients respond to conservative tx

In young and middle-aged adults presenting with anterior hip pain, where serious pathology has been ruled out, they most likely have

1. FAI 2. Dysplasia, instability 3. Other labral/chondral disorders imaging shouldn't be used in isolation FADIR helps to rule out hip pathology

Level A interventions for OA

flexibility, strengthening, endurance, joint mob, manual therapy Dosage: 1 to 5 times a week, 6 to 12 weeks

Level B Intervention for hip OA

patient education addressing WB activity modifcations provide exercises to support weight reduction discuss unloading the arthritic joint

Level C Interventions for hip OA

balance, functional, gait training proper use of ADs individualized exercise prescription based on values, needs, activities

OA and Manual Therapy

proven to be helpful for pain, ROM, and function in both short and long term includes distraction, mobilization dosage: 10 min or more, minimum bouts of 30 s Duration: 1-3x week for 2-6 weeks progress to include stretching, strengthening, etc

PTs role for prognosis

identify descrepancies between level of function by the individual, the capacity of the individual, their current abilities