Lecture 7- Hip Flashcards
Ligamentum Teres
Predominantly arises from the transverse acetabular ligament (inferior margin of the acetabulum)
Attached to the periosteum by 2 bands (ischial and pubic margin of the acetabular notch)
Flat near the acetabular and roundish on its femoral attachment (Fovea capitis)
Length 30 – 35 mm
Ligamentum Teres function
Evidence is lacking
– Strong, bundled and intraar1cular
– Can be considered as the ACL of the knee
– Taut when the hip is in its least stable posi1on (flexion/ adduc1on/external rota1on)
– Nocicep1on and coordina1on movement (because of its innerva1on)
– Provide blood supply to the developing hip joint
– Windshield wiper effect (synovial distribu1on)
– Pa1ents usually report an hyperabduc1on type of injury
Anterior hip pain, what could it be?
Most common: Synovitis Labral Tear Chondropathy Osteoarthritis
Lateral hip pain, what could it be?
Most common: Greater Trochanter Pain Syndrome Gluteus tear and tendinopathy Trochanteric Bursitis
Osteoarthritis (OA) of the Hip
- Insidious onset of dull ache in anterior hip/groin
• Symptoms located in part in the L3 dermatome
(groin, anterior thigh, the knee and the leg as far as the ankle)
• Sometime may present as unilateral lower back pain
• > 50 years
• Morning stiffness which eases with movement which become continuous, can disturb sleep - Exacerbated by weight bearing and cold weather
• Can be primary or secondary (90%) to trauma, bony abnormality or inflamma1on / infec1on
• Presents with a capsular paFern at the hip (internal rota1on most limited, flexion, extension and abduc1on*)
Osteoarthritis in early and late stages
In early stage
– Capsular stiffening (internal rotation, flexion, abduction and extension)
– Lost of the elastic end-feel In more advanced stage
– Gross limitation with loss of all rotational movement
– Functional is predominantly in flexion/extension – Hard end-feel associated with crepitus
Most osteoarthritis hips show what?
Most osteoarthro1c hips show superolateral migra1on of the femoral head with localized erosion of the car1lage at the lateral border of the labrum
Treatment for osteoarthritis
Early or slowly progressing (capsular paWern, ligamentous end-feel and no crepitus)
– Capsular stretching (flexion/extension/internal rota1on) – Trac1on
– Muscular re-educa1on (stretching/strengthening)
Advanced or quickly progressing (non-capsular paWern, hard end-feel and crepitus)
– Surgery (hip replacement)
– Intra-ar1cular Injec1on (temporary relief)
Hip Impingement
Abutment between the proximal femur and the rim of the acetabulum
Most oqen occur anteriorly with flexion and rota1on of the hip
Can start in adolescent or adulthood, gradually progressing and can injure the labrum and the car1lage (ADL)
Femeroacetabular impingement
FAI is a common cause of labral injury and has been iden1fied as being a major factor in hip OA as with hip dysplasia.
FAI is mainly related to 2 components:
– Morphological abnormali1es (head/neck/ acetabular)
– Repeated hip flexion
… Resul1ng in an impingement of the
femoral neck on the labrum
Patient history of a patient with hip impingement
• Pa1ent 20 – 50 years old (male 2/3 of cases)
• Anterolateral hip gradual and progressive pain
• C-sign
• Sharp pain when turning toward the affected hip
• Prolonged sirng, rising, and gerng out of car
• Leaning forward
• Usually no pain during walking
Diagnosis of a patient with hip impingement
As such… the diagnosis rests on 3 converging lines of evidence
1. Pattern of pain
2. + impingement maneuver
3. Imaging study
a. Cam-effect (66 – 75%)
b. Pincer effect (25%)
c. Mixed-type (prevalence 19 – 42% to 80%)
Impingement test: FADIR pain is a positive for hip impingement
Treatment options for hip impingement
– Rest is not likely to help
– Physical therapy
– Surgery
The labrum
The labrum is analogous to the Knee meniscus and GH labrum
Func1on:
1. Enhance joint stability(seal)
2. ↓force transmitted to the articular cartilage
- Proprioceptive feedback
The joint capsule is supported by: - Pubofemoral(inferiorly)
- Ischiofemoral(posteriorly)
- Iliofemoral(anteriorly)
Labral tears are commonly associated with
– Femoroacetabular impingement
– Capsular laxity
– Articular cartilage degeneration
– Hip dysplasia
How an acetabular tear occurs
Shearing force that occur with
• Twisting
• Pivoting, and
• Falling
Because of its innervation (free nerve ending), labral tear will likely produce pain
North America: Anterosuperiorly (twisting/ pivoting)
Asian: posteriorly (hyperflexion/squatting motion)
Types of labral tear
- Radial flap (+++)
- Radial fibrillated
- Longitudinal peripheral
- Abnormally mobile
Most commonly occur in an anterior and anterosuperior loca1on
Mechanism of injury oqen relates to an external rota8on force in a hyperextended hip positon or repe88ve microtrauma associated with twis8ng and pivo8ng.
Signs and symptoms of acetabular Labral tears
ALT is a frequent cause of anterior hip and groin pain (90%) but too oqen undiagnosed or misdiagnosded for many years
Pain in the lateral hip region is likely associated with trochanteric bursi1s or ilio1bial band syndrome
Anterior Tear: anterior pain
Posterior Tear: BuWock pain
Pa1ent also report:
– Clicking and locking (+++) – Catching or giving way
Tests for Labral tears
- FABER test- pain in hip, SIJ or abductors is positive sign
- Scour test-Positive is pain, apprehension or “catching” in hip.
- Resisted straight leg raise test- pain in hip area is positive
If a Labral tear is found, what else should you test your patient for
potential impingement, capsular laxity, and articular cartilage degeneration
- Impingementtest(FADIR)
- Logrolltest
- Long-axisfemoraldistrac1on 4. Generalligamentlaxity
- HipROM
Slipped Capital Femoral Epiphysis
• Late childhood to adolescence
• Boys > Girls
• Obesity is a factor
• Can occur bilaterally too
• Presents with a limp and ↓ROM
Leg-Calve Perthe’s
Avascular necrosis of the femoral head leading to collapse & fragmenta1on
– Younger children (ages 4 to 9) usually
– Boys > girls
– Bilateral involvement uncommon
May be idiopathic, or it result from
• slipped capital femoral epiphysis,
• trauma,
• steroid use,
• sickle-cell crisis,
• toxic synovi1s, or
• congenital disloca1on of the hip.
Hip Dysplasia
Used to be termed CDH, now DDH – why?
Dysplasia means ? Of what?
• Usually noted in the first few months of life but can be diagnosed as late as 18 months (walking age)
• More common in 1st born and in breech presenta1ons
AVASCULAR NECROSIS
- Poorly understood process
* Leads to OA
• Trauma1c or non traumatic
Aetiological Factors of avascular necrosis
Most cases of AVN are atrauma8c and include the following:
• Excessivecor1costeroidusageandalcoholabuseaccountforas many as 90% of new cases
• Coagula1onsecondarytovesselwallinjury(eg,chemotherapy, radia1on), or a thromboembolic event (eg, fat emboli)
Traumatic causes of femoral head AVN include the following:
• Femoral neck fractures
• Hip disloca1on
• Slipped capital femoral epiphysis(SCFE)
Treatment for avascular necrosis
Conservative treatment = yields unfavorable results
Physical therapy = symptomatic control ≠ disease progression
Surgical treatment
– Prophylactic measures (to retard progression) or
– Reconstruction procedures (aqer femoral head collapse)
“Snapping Hip” Syndrome
Benign, painless snapping in the hip is common in the general population
Symptoma8c snapping hip with debilitating pain and weakness is oqen seen in athletes
3 types:
1. External/Lateral (ITB)
- Internal (iliospoas)
- Intraar1cular (Labral)
External snapping syndrome
Posterior fibers of ITB or ant fibers of gluteus max
moving over the greater trochanter in flex/ext
– “snap” may be palpable/audible/both
– Trochanteric bursitis may ensue
Internal snapping syndrome
Occurs when the iliopsoas tendon in the flexed, abducted and externally rotated hip moves to a position medial to the hip capsule during extension
Intra-articular snapping syndrome
Usually loose bodies or labral tears
Symptomatic snapping hip is diagnosed through
– History
– Local palpation with ROM for the “snap”
– RIM muscle testing should reveal pain/weakness
– Ortho tests that focus on muscles pathology
GREATER TROCHANTERIC PAIN SYNDROME
Describe pain and tenderness in the region of the greater trochanter and the juxtaposed soft tissues of the buttock and lateral proximal thigh
Estimated that 10 – 25% of the general population will develop lateral hip pain
Common misconcep1on of the ae1ology of lateral hip pain… incomplete treatment approach… temporal relief
Causes of greater trochanteric pain syndrome
• Most common causes is hip abductor tendinopathy
– Gluteus Medius and Minimus
• Trochanteric bursitis in not usually the most common cause of GTPS
Tests for greater trochanteric pain syndrome
• FABER +++
• End-range adduc1on
• Typically not aggravated by passive hip internal rota1on
Pain with ac1ve internal/external rota1on or resisted abduc1on at 450 of hip flexion (gluteus Medius/Minimus)
– + 30s single-leg stance (SN 100%/SP 97.3%)
– + Resisted external derota1on test (SN 88%/SP 97.3%) – + Trendelenburg test (SN 73%/SP 77%)
– Ober test
– Hip lag-sign
Differential diagnosis for greater trochanteric pain syndrome
The most common mimickers:
– L2-L3 lumbar radiculopathy
– Lumbar facet syndrome
– Subcostal and iliohypogastric entrapment neuropathies
Treatment for GTPS
• Rest, Ice, and acetaminophen (ini1al relief)
• Activity modification
• Avoid exacerba1ng ac1vity
• Avoid lying on the affected side
• NSAID and physical modalities
– controversial
• Passive and active stretching
• Cor1costeroid injections (short-term relief)
• Surgery
Trochanteric Bursitis
Cause
• Direct trauma (can follow hip pointer)
• Repetative Activities
• Inflammatory Arthritis
• Females > Males (width of pelvis)
• Common in long distance runners
History and symptoms of trochanteric bursitis
Hx: Insidious onset or patient may report a specific event of feeling a “pop” as ITB snapped over greater trochanter
Sx’s: Pain lateral hip; may refer along lateral thigh; may report a “snapping” sensa1on on lateral hip
Exacerbated by:
– Stairs / walking uphill
– Side lying (night pain) – which side?
Physical examination findings on a patient with trochanteric bursitis
– Point tenderness over greater trochanter
– Evidence of local inflamma1on present
– ROM: Pain with specifically with ac1ve/passive ADD, and IR – why?
Treatment for trochanteric bursitis
– Treat inflammation
– Address MOI if possible
– Corticosteroid injection not uncommon
HIP POINTER
Iliac Crest contusion due to direct blow or a fall resulting in an hematoma
• +/- 5 – 9% of hip injuries
• MOI
• TFL belly may also be involved
• Radiographs may reveal iliac crest fracture in severe cases
Hip pointer- differential diagnosis
Hip dislocation
Hip Fracture
Hip Tendinitis and Bursitis ITBS
Osteitis Pubis
Sacroiliac Joint Injury
Clinical presentation and Evaluation of a hip pointer
• Pain over the iliac crest
• Difficulty ambulating
• If hematoma is present: fluctuant mass
• Lateral hip pain with decreased ROM
• MOI differ from muscle strain or avulsion
Hip pointer treatment
Conservative Care
– Rest, Ice, NSAID, Compression
– Crutches
– As pain improve: ROM and active resistance exercises
– If big hematoma: aspiration
– Be aware: Myositis Ossificans
– Padding may be recommended initially to present reinjury
– Sometime use of local anesthetic (reinjury)
AVULSION FRACTURES
Avulsion fractures mainly occurs in adolescents
– Eccentric phase of sporting activity
– Rarely occurs in older population
Other site of avulsion fracture are:
– Greater Trochanter: Piriformis
– Lesser Trochanter: Iliopsoas
Most commonly reported sports:
– Soccer (20%)
– Running (40%)
Usually respond well with conservative care (surgery may be necessary)
GROIN PAIN
Groin pain among competitive athletes is a frequent and complex ailment
– 2 – 5% sports related pain
– 5 – 18% among soccer and tennis players
– Oqen leads to long rehabilitation
– Increasing problem in recreational sports
• 3.1 – 5.6%
MOI
– Recurrent abruptly flexing and rotational hip joint and groin movement
– Rapid change in direction and high torqueing
– Kicking
Differential diagnosis for groin pain
- Femoral stress fractures
- Osteitis Pubis
- Hamstring strain
- High Hamstring Tendinopathy
Femoral Stress Fractures
Reaction of bone caused by accelerated, unaccustomed, repeated submaximal, cumulative stresses rather than a specific traumatic episode
May develop in up to 15% of runners or military personal (5 – 10% neck)
Risk factors include:
– Extrinsic - Running!
– Intrinsic
– LLI; hip, knee & foot structural alignment; smoking, caffeine
– Female specific – BMD, BMI, Age
Femoral stress fracture: symptoms
Femoral neck or diaphysis most commonly involved
– Presents as vague, aching, “tired” often medial (diaphyseal) thigh or groin (fem neck) pain
– Worse with activity
– May present as night pain
May take up to 6 months of therapy
Osteitis Pubis
Inflammation of the pubic symphysis resulting
in sclerosis/bony changes
• Men 30-50 years, women mid-30s
• Athletes: runners, soccer players, swimmers, hockey players
• Presents as:
• Pubic pain (usually)
• Groin pain (often)
• Lower abdominal pain
• Medial thigh pain
Osteitis pubis
Presentation:
– “waddling” gait – why?
– Clicking/Popping when rising from seated, turning in bed, walking uneven ground
• Pain and weakness on active/passive hip ABD and specifically RIM hip ADD
• Point tenderness of pubic symphysis
Hamstring Strain
Most frequently strained muscle in the body and account for approximately 29% of all sports injuries
– Reinjury common (12 – 31%)
Accounts for 50% of muscle injuries in sprinters
Range from mild damage without loss of structural integrity to complete tear
Loca1on
– distally near the musculotendinous junc1on
Hamstring strain- MOI
MOI
– Rapid, uncontrolled stretch or forceful contrac1on
• Hurdlers: Maximal hip flexion with knee extension
• Sports: Running/Sprin1ng, Soccer, Football, & Rugby
• Seasonal has been demonstrated
Grade I & II common, III rare (avulsion more likely) Location
– Distally near the myotendinous junc1on (experience the most eccentric loads)
– Muscle belly less common
Hamstring strain- provocative tests
Special provoca1on tests
1. The Puranen-Orava*
2. The bent-knee stretch test*
3. The modified bent-knee stretch test*
Hamstring strain- clinical presentation
Patient will present with a sudden sharp pain oqen repor1ng an audible snap associated with a combina1on of hip flexion and knee extension.
– S1ff-leg gait
– Knee-flexion angle
Hamstring strain- treatment
Treatment is oriented according to the muscle injury site
1. Noninsertional injuries
2. Proximal Insertional injuries
• Nonopera1ve care single tendon and/or mul1tendon ≤ 2cm retrac1on
• Surgery: 2 tendons ≥ 2cm retrac1on or 3 tendons 3. Distal Inser1onal injuries
• Biceps Femoris (most common) (varus hyperextension MOI)
Hamstring Tendinopathy
Distal or Proximal (high hamstring tendinopathy or “high-up syndrome”)
• Uncommon, but very problema1c to treat!
• Overuse injury in distance runners
• Pa1ents report deep buWock or post thigh pain
Hamstring tendinopathy- treatment
Conservative
• STT
• Therapeutic modalities
• Rehabilitation
More Invasive
• Cor1costeroid injec1ons
• Autologous blood injec1ons
Meralgia Paresthetica
Lateral femoral cutaneous nerve entrapment
• Compression occurs as it passes under the inguinal ligament
• Causes:
– Large belly
– including pregnancy 3rd Trimester
– Pressure directly over the ligament
• Presentation:
– Numbness over the anterolateral
thigh (see next slide)
Femoral nerve stretch test
Prone Knee is flexed
– Pain in L/S or anterior thigh is +ve for upper Lumbar nerve root lesion (L1-3)
Dynamic stabilisers of the hip joint
Capsule divided in 4 distinct bands
• Medial iliofemoral ligament (Y / Bigelow)
– Limit extension and external rota1on assist static posture
• Ischiofemoral ligament
– Limit internal rotation and hip adduction with flexion
• Arcuate ligament (confluent with the posterior hip capsule)
– Limit abduction and external rotation
• Pubofemoral ligament
– Limit hip extension and abduction
