L4/5 Hip Conditions Cont. Flashcards
Non-arthritic joint problems
instability
dysplasia
femoro-acetabular impingement
labral tear
chondral lesion
Extra-articular soft tissue problems
gluteal tendinopathy
groin strains
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
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
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
OA Radiograph
Will show joint narrowing
Mod OA <2.5mm
Severe OA <1.5 mm
osteophytes
sclerosis
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
Outcome measures for OA
6 min walk
TUG
30 s sit to stand
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
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
Indications for THA
incapacity pain
limited motion that isn’t improving
impaired weight bearing and gait
radiographic features
failed conservative care
Posterolateral THA
more proven long-term outcomes
little blood loss
better visualization
shorter learning curve for surgeon
higher risk of dislocation
more muscle damage
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
Bipolar hemiarthroplasty
used to change the angle of the femur head in the acetabulum
Hip resurfacing
often used for athletes
Complications with THA
anesthesia reactions
leg length inequality
infection
DVT
falls
dislocation
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
- FAI
- Dysplasia, instability
- 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
