MSK hip Flashcards
approximate forces at hip
standing .3 x body weight
single leg stance 2.4-2.6 x BW
walking 1.3-5.8 x BW
stairs 3 x BW
running >4.5 x BW
describe the hip joint
synovial
vex on cave
max congruency - quadruped (90 flex, abd, ER)
what is the normal anteversion angle of the hip?
8-20 deg
coxa valga
above 139
coxa varum
below 125
what attaches to greater troch
glute min/med
what attaches to lesser troch
iliopsoas
describe the acetabulum
vinegar cup
fusion of ilium, ischium, pubis
oriented anterior, laterally, inferiorly
anterior sublux rare
what is the center edge angle of the hip?
angle from the center of femoral head vertically to center of femoral head to acetabular rim
normal: 30 deg
excessive coverage: > 44 deg can lead to impinge
undercoverage: < 25 deg, dysplasia
what is the acetabular labrum?
horseshoe fibrocartilage
only deepens it by 10%
provides stability and distributes forces
poor vascularity
what are the 3 extracapsular ligs
ilifemoral
pubofemoral
ischiofemoral
what are the 2 intracapsular ligs
ligamentum teres
transverse acetabular lig - depth, THA
what muscles flex the hip?
primary:
iliopsoas
rectus femoris - aversion fx, AIIS
secondary:
pectineus
TFL
sartorius
add brev/longus
what are the muscles that extend the hip?
pri:
glute max
sec:
biceps femoris
semiten
semimem
portions of add mag and glute med
what muscles abduct the hip?
pri:
glute med and min
sec:
TFL
piri
sar
what muscles adduct the hip?
pri:
add long/mag/brev
gracilis
pectineus
sec:
quatratus femoris only when hip is neutral
which muscles primarily IR the hip?
none
describe the trochanteric bursa
minimizes friction
greater trochanteric pain syndrome
describe the femoral nerve
L2,3,4
largest branch of lumbar plexus
common sites of entrapment:
ilipsoas tendon
inguinal lig
add canal
describe the lateral femoral cutaneous nerve
L2,3
sensory only
meralgia peristhetica (tight pants syndrome) or burnheart roth syndrome
describe the sciatic nerve
mixed
beneath piri
largest nerve in human body
anatomical variations:
through and below
through and above
how do you palpate the psoas?
1/2 distance between ASIS and umbilicus
direct pressure towards spine
how to palpate the gluteus medius?
two finger widths below iliac crest to lateral greater trochanter. side lying with hip extended, have pt resist abduction.
what is the self report for the hip?
the lower extremity functional scale
screening for referral in RA
bilateral, symmetrical, other joints affected
stiffness > 1 hr
constitutional symptoms
screening for referral in ankylosing spondylitis
stiffness > 1 hr
age < 40 yrs
screening for referral in septic joint or psoas abscess
recent surgery
constitutional symptoms
screening for referral in appendicitis
RLQ pain
constitutional symptoms
mcburney’s point
1/3 distance between ASIS and umbilicus
RIGHT SIDE
hold for 15-30 sec then release
+ sharp pain
testing for appendicitis
iliopsoas test
resisted SLR
+ pain
testing for abscess
obturator test
hip flexion, knee flexion, hip ER
+ pain
testing for abscess
cyriax’s sign of the buttock
limited SLR *
limited hip flexion to same extent as SLR *
limited trunk flexion to same extent as hip flexion
painful weakness of hip extension
non-capsular pattern of restriction at hip *
swollen buttock
empty end feel with flexion
*** REFER
possible pathologies that Cyriax points to
osteomyelitis of upper femur
neoplasm of upper femur
neoplasm of ilium
fractured sacrum
ischiorectal abscess
septic sacroiliitis
septic or rheumatic bursitis
osteonecrosis of the femoral head
avascular necrosis: corticosteroids, sickle cell
legg calve perthes disease: pediatric, pain with abd/ir
slipped capital femoral epiphysis
pediatric hip disorder: adolescents, growth spurt
overweight ados with groin pain with WB
inguinal hernia
athlete
unresolved groin pain exacerbated by coughing, sneezing, resisted sit ups
transient synovitis
insidious
viral infection
self limiting
how to screen for yellow flags at the hip
optimal screening for prediction of referral and outcome yellow flags (OSPRO-YF)
17 items
what does throbbing mean?
vascular issues
correlation between limp and hip disorder
pts who limb are 7x more likely to have a hip disorder
patellar pubic percussion test
pt supine
pt assists with steth placement
listen while tapping on patella
+ lack of sound on asymp side
testing for hip/pubic fracture
how does PT on the hip vs spine impact low back pain?
PT to hip had greater impact
lumbar quadrant test
pt sitting
passive motion into full ext with rotation in both directions
can do standing as well: slide hand down thigh
+ sympt reproduced
rules out pain from lumbar facet
posterior shear test
pt supine with hip flexed to 90
towel under sacrum
push down on femur for 30 sec
if not pain reproduced, up to 5 thrusts
+ sympt reproduced
clearing SI joint
difference between hip IR and ER
hip IR is when tibia moves outward
hip ER is when tibia moves inward
lateral distraction
pt supine with knee flexed
fasten mobilization belt around proximal thigh and therapists hips
use body weight to “sit down” into belt while stabilizing knee
straight leg raise
for sciatic nerve
hip flexion, add, IR, knee ext, ankle dorsi, cervical flexion
stenosis hates it
slump test
slouch, cervical flexion, raise leg, cervical extension
disk injuries dont like it
neurodynamics for femoral nerve
prone
flex knee, extend hip while stabilizing lumbar, add hip
cervical ext decrease sym
plantarflexion should increase sym
can also do this sidelying
LQ Y balance
limb length: ASIS to med mall
R/L anterior
R/L posteromedial
R/L posterolateral
anterior labral tear test
supine
flex hip to 90, abd and ER
slowly add, IR and extend
+ pain with or without click
testing for impingement, labral, internal snapping hip
FADIR (flexion adduction internal rotation)
supine
flex hip to 90, add, IR
+ anterior hip or groin pain reproduced
testing for FAI or labral pathology
flexion abduction external rotation test
supine, heel superior to patella
passively ER and abd hip
stab pelvis and put pressure on test knee
+ lack of motion and concordant pain
testing for:
anterior hip pain: nonspecific hip involvement
SI joint: SI involvement
lateral hip: GTPS
quantity of motion: muscle tightness
scour test
pt supine
therapist on side to be tested
maximally flex hip and adduct. move hip from 10:00 - 2:00 a minimum of 2 times. if not pain - apply compressive force and repeat.
+ grinding, catching, pain, apprehension
testing for: hip OA, labral tear, AVN
CPR of hip OA
+ hip scour
hip pain with squatting
active hip flexion causes lateral pain
passive hip IR less than or greater to 25 deg
pain with active hip extension
3 or more present = sp fo 0.86
stinchfield test
supine with hip flexed to 20-30 deg
therapist resists hip flexion - distally
+ reproduction of pts symptoms
testing for: intra-articular hip pathology
log roll test
pt supine
hips neutral, passively fully IR and ER the UE
one hand on femoral condyles, one on tibial tub
+ side to side differences in ROM and has clicking
testing for: click - labral tear, increased ER on symptomatic side - laxity of iliofemoral ligament
craig’s test
prone with knee flexed to 90 deg
palpate greater troch, the passively IR and ER until most prominent part is parallel to table
deg of anteversion assessed
stationary arm: parallel to table
movement arm: tibia, bisecting the ankle
normal is 8-15 deg
increased ante: > 15
retroversion < 8
adductor squeeze test
pt supine with knees up
place fist between pt’s knees and have them squeeze
45 deg hip flexion is best
+ symptoms reproduced, symptoms at 0 deg is contraindication for return to sport
testing for: groin pain secondary to adductor muscle
bent knee stretch test
pt supine
passively maximally flex both the hip and knee
slowly straighten knee
+ reproduction of concordant pain
testing for: hamstring tendinopathy
resisted 90-90 hamstring test (hamstring syndrome)
pt supine with hip and knee flexed to 90 deg
therapist sitting on table with pt’s distal lower leg resting on their shoulder
“push your lower leg into my shoulder”
+ symptoms reproduced
testing for: to differentiate hamstring syndrome from other causes of buttock and posterior thigh pain
gluteal de-rotation test (resisted ER de-rotation test)
pt supine with hip flexed to 90 and pain free ER
place on hand on med knee and other on lateral ankle
therapist applies force into IR at ankle as pt resists
test again in prone with knee flexed
+ symptoms reproduced
testing for: GTPS, gluteal tendinopathy
active piriformis test
pt lying on contralateral side
place foot of unaffected side on table behind other
palpate piri while resisting abd and Er
+ increased symptoms in gluteal region or post thigh
testing for: piriformis syndrome
single leg stance test
pt standing on affected side for 30 seconds
+ reproduction of lateral hip pain indicated gluteal involvement
testing for: GTPS
trendelenburg’s sign (greater trochanteric pain syndrome)
pt stands on one leg while PT watches for pelvis drop
+ pelvis on non stance side drops when pt stands on affected leg
testing for: GTPS
thomas test: iliopsoas
thigh should touch table
if not, extend knee
one joint tightness
thomas test: rectus femoris
knee should flex to 80 deg
two joint stiffness
thomas test: TFL
any deviation from 0 is positive
ely’s test
NO PILLOW
pt prone with legs extended
therapist passively flexes knee
look for involuntary hip flexion
+ if hip flexes when knee flexes
testing for: rectus femoris extensibility (contracture)
passive supine 90/90 position assessment
pt supine with hip flexed to 90 deg
stationary arm: lateral midline of femur
fulcrum: lateral epicondyle of knee
moving arm: lateral malleolus
normative value across sexes: 75 deg
tripod sign
pt seated with knees over edge of table
therapist passively moves pt’s knee into extension
COMPARE BOTH SIDES
+ pt slumps or leans backward while knee extended
testing for: hamstring extensibility
false positives: bad posture, sciatic nerve involvement
ober’s tet
pt side lying with test side up and bottom knee bent
therapist stabilizes pelvis with one hand and hold under knee with other (flexed to 20 deg)
clear greater troch by abd and extending to hip and slowly lower the leg while maintaining stable pelvis
COMPARE BOTH SIDES
+ less than 10 deg below horizontal
testing for: tightness in TFL and ITB
flexion adduction internal rotation test (FAIR)
pt lying on contralateral side
with hip flexed less than 60 deg, add and IR the hip
+ increased symptoms in lateral hip and glute or down lateral thigh
testing for: piriformis syndrome and sciatic nerve entrapment
piriformis test
similar to FAIR
overpressure applied to lateral knee and IR component is not performed
hip arthrokinematics
convex on concave - roll and glide opposite
exercises to promote hip flexion and extension flexibility
supine hamstring: knee to chest then straighten
seated hamstring: hinge at hips, straight leg
side lying quad
standing quad stretch
exercises to promote hip abd and add flexibility
butterfly stretch
standing adductor: side lunge
TFL: cross legs, push hip into wall, outside is stretched
piriformis stretch variations
supine piri: cross one leg over, towel pulls other
seated piri: cross one leg and hinge into it
standing piri: leg crossed on table, lean into it
self MFR and foam rolling
psoas: lay on ball
IT band: on lateral side of thigh
piri: over butt
hamstrings
quadriceps
adductors: army crawl, medial thigh
hip AROM controlled articular rotations (CARs)
neutral
flexed hip
abduction
extend hip
back to neutral
do this forwards and backwards
neurodynamics
supine sciatic: strap on ankle, pull hip into flexion
sidelying sciatic: nue hip, flexed hip, ankle pumps
seated sciatic: PF ankle and extend knee
prone femoral: pull knee into ex with strap and ex cer
knee extension stretching
supine/sitting: towel under ankle, use gravity
prone knee hang: towel under thigh, use gravity
knee flexion stretching
heel slides
wall slides
assisted flexion
calf stretching
gastroc: leg straight
soleus: knee bent
hip isos
hip flexion: push into hands
glute set: supine, press glutes together
hip abd: use belt and push out
hip add: push into ball
4 way straight leg raise
hip ext
straight leg raise: flexion
abd: on side, top leg up
add: bottom leg up
glute med progression
supine/side-lying clamshell
side-lying glute med lift: sidelying SLR
side-bridge leg lift: body off ground
side lunge
pelvic elevation/depression: basically a hip hike
single leg squat
banded stepping exercies
big step then small step
30 deg hip flexion
prog: squatting, band lower, harder band
glute max prog
bridge
single leg bridge
weighted hip thrust
forward-lean lunge
lateral step up
forward step up
quad prog
quad sets: press quad down
short arc quads: towel under knee, raise leg
reverse lunge
SLR
long arc quads: in chair and raise leg
wall lean: good leg on wall
hamstring curls
prone
standing
can do toe in or toe out
calf raises
can do it on a step
can do toes in or toes out
squat prog
wall squat
squat
bulgarian: one leg on bench
single leg squat
deadlift prog
tall-kneeling hip hinge
hip hinge
romanian deadlift: straight legs, hinge at hips
single leg deadlift
lunge prog
reverse lunge
forward lunge
multi-directional
step up/down prog
anterior
lateral
anterior slide out
step downs
balance prog
feet apart
feet together
semitandem
full tandem
single leg
each try airex, closed eyes, head rotation
circle stability co-contraction
4 inch circle
8 in
12 in
trace with foot
rotational step out
foam roller between knee and wall
step out with other leg
dont move hips or shoulder of wall side
hop prog
feet together = jump
single leg = hop
forward/backward
left/right
add distance
add height
exaggerated running
bounding: giant steps
skipping: arm to sky
heiden hop: skiers, side to side
pin and stretch - hip
indications - increased tone or decreased length
pt prone, knee flexed, hip abd
with elbow, sink into glute and apply pressure towards sacrum
provide passive IR of hip
passive stretching - hip
indication - hypo, limited ROM
lengthen muscles and hold for 15-30 sec, 2-4 reps
hamstrings - hip flexion w/ knee straight
quads - prone, neutral hip, knee flexion
piri - supine, hip and knee flexion, provide add
hold relax - hip
indications - restricted ROM
submax isometric contraction held for 5-10 sec
passively move through new ROM
repeat 4-6 times or until no more gain
ischemic compression - psoas
indication - active trigger point is source of pain or lack of ROM
duration: high pressure for 30 sec, lower pressure for 90 or until 50% reduction in referred pain
dry needling
indication: active MF trigger point is source of pain
situ, pistoning, winding
hip distractions
long axis distraction glide
lateral distraction glide (with belt)
hip anterior glide
prone, knee bent and LE supported by therapist
ant force to hip joint
to promote hip ext and ER
hip post glide
supine, hip flexed and LE resting on therapist’s shoulder
therapist pulls toward themself
to promote hip flexion and IR
hip inferomedial glide
pt side lying with bottom leg bent
therapist holds top leg in abd. force is infermedial
promotes hip abd
prevalence of hip OA
9% of older adults have it
20% have radiographic changes
MOI for hip OA
progressive loss of joint space
followed by mobility and functional deficits
impairments for hip OA
altered gait
pain with WB
pain pattern for hip OA
gluteal, groin, ant. thigh
worse with WB
hip stiffness lasting < 60 min
risk factors for hip OA
> 50
history of physical labor
congenital deformity prior to injury
possible link to higher BMI
observation for hip OA
trendelenburg gait
hip held in flexion, abd, and ER
exam of hip OA
decres ROM in cap pattern
crepitus with ROM
glute med/max weakness
+ scour, FABER, IR with OP, Stinchfield
pt ed for hip OA
joint protection
activity mod
assistive devices
weight reduction
manual therapy for hip OA
mobs grad 1-2 for pain, gr 3-4 for mobility
STM/MFR for glutes, piri, deep hip rotators, flexors
hold/relax may increase muscle extensibility
ther ex for hip OA
self mobs and stretching
strengthen abd, ext, ERs
start with table isos and progress to AROM/SLR
progress into squats, lunges
balance, proprioceptive, gait activities
maybe aquatic
MOI for femoroacetabular impingement
structural variations of femur/acetabulum
classified as pincer, CAM or both
may be a precursor to OA
pincer: coverage of ace
CAM: wider femoral neck, more femur exposed
impairments for FAI
pain at end ROM
weakness of abd, rotators
anterior pelvic tilt
pain pattern for FAI
c sign or groin pain
pain at end ROM (squatting)
less pain in WB than OA
risk factors for FAI
25-50 yo
sports with end ROM, twisting, pivoting
observation for FAI
anteriorly rotated pelvis
exam for FAI
may have locking, clicking
weakness of affected side
poor control with step down or SL squat
+ FADIR, FABER (ant hip, groin pain)
pain at end ROM
limited in IR and Flexion
decrease hip flexor length
pt ed for FAI
avoid end ROM activities
avoid repetitive flexion - squats, stairs, inclines
manual therapy for FAI
joint distraction
mob in mis range where hypomobile
STM - flexors, deep rotators
ther ex for FAI
stretch hip flexors to minimize pelvic tilt
avoid vigorous stretching
start with iso and controlled strengthening
bridges, clamshells on table
squats, lunges, hip hikes, lateral banded walks
lumbopelvic strength/endurance
balance retraining for control; can add perturbations
MOI for hip labral pathology
trauma
FAI
capsular laxity/hip hypermobility
dysplasia
degeneration
impairments for labral
ant: anterosuperior quadrant of hip
post: deep buttock pain
clicking in hip
pain pattern for labral
clicking, popping, catching
ant hip and groin pain
pain with squatting or end ROM
risk factors for labral
hypermobility, laxity, dysplasia
hx of FAI
male: traumatic, fe: atraumatic
sports with end ROM mvmts in ext/ER
observation for labral
may have inc/dec ROM
flexed knee gait
dec step length
exam for labral
similar to FAI; can co-occur
hip muscle weakness
+FADIR, FABER
possible beighton’s
pt ed for labral
avoid extreme ROM
do not stress passive stabilizers
manual therapy for labral
avid anterior glides
no mobs if hypermobile
STM - hip flexors, deep hip rotators
ther ex for labral
avoid vig stretching
start with isos and controlled mvmts - no end ROM
bridges and clamshells on the table
squats, lunges, hip hikes, lateral band walks
lumbopelvic strength/endurance
balance re-training from proximal and distal control
MOI of hip stress fracture
abnormal stress on normal bone (insuff/fatigue)
normal stress on abnormal bone (pathologic)
intertrochanteric fracture may be due to a fall
impairments with hip stress fracture
pain in hip, groin, thigh with loading or impact
pain at end ROM esp IR
which hip fractures are intracapsular?
femoral head
subcapital
femoral neck
which hip fractures are extracapsular?
intertrochanteric
subtrochanteric
shaft
pain pattern for hip stress fracture
insidious, gradual onset and worsening of hip/groin/thigh pain
pain with activity, relieved with rest; pain at night
pain poorly localized
risk factors for hip stress fracture
long distance runners
recent, sharp increase in activity
female, history of previous stress fracture
corticosteroid use; NSAIDs
observation of hip stress fracture
antalgic
examination for hip stress fracture
+ patellar pubic percussion, log roll, fulcrum test, hop test
limited P/AROM
diagnostic imaging (MRI)
cannot rely on palpation to assist in diagnosis
pt ed for hip stress fracture
activity mod
WB restriction for 6-8 weeks, possible longer
manual therapy in hip stress fracture
joint mobs in latter phases of rehab
STM
ther ex for hip stress fracture
aquatic therapy
start with NWB - caution with supine and sidelying SLR
gradually increase ROM and strengthening until cleared to RTS
balance training, esp in older adults at risk of falls
posterior vs anterior hip dislocations
85% are posterior
posterior force through flexed and adducted hp
MVA
tackled with flexed hip and knee
anterior is rare
anterior force with hip in ext and ER
what does dislocation put pt at a premature risk of?
OA
MOI for hip osteonecrosis
traumatic vs atraumatic - diminished blood supply
atraumatic: insidious onset of hip pain > 6 weeks
middle aged adults
legg-calve-perthes in peds
risk factors for ON
corticosteroid use
alcoholism
sickle cell anemia
trauma (dislocation)
impairments for ON
can mimic OA with WB and ROM impairments
click in front of hip from sit to stand
no relief with PT
what is hip dysplasia?
shallow hip sockets which lead to dislocation of the femoral head
pt may go onto develop OA
leading cause in OA before age 50
MOI of hip dysplasia
congenital
impairments of hip dysplasia
true feeling of giving way
ROM WNL but painful
weakness
pain pattern for hip dysplasia
insidious onset of hip/groin/thigh pain
adults: catching, popping, apprehension
risk factors for hip dysplasia
fe > males
possible family history
observation for hip dysplasia
+ trendelenburg
exam for hip dysplasia
LCEA < 20 deg
shorter leg on affected side
normal but painful ROM
weakness of flexors and abductors
+FADIR
+ortolani and barlow maneuvers (infants)
pt ed for hip dysplasia
activity mod
weight management
bracing and orthotics in peds
manual therapy for hip dysplasia
joint mobs and STM as indicted by impairments
what CONTRAINDICATIONS for mobs
ther ex for hip dysplasia
regular low or no impact exercises can be helpful
what is legg-calve-perthes disease?
transient disruption of blood flow to the femoral head, resulting in necrosis
MOI for LCPD
insidious onset of hip pain and AVN, which flattens femoral head
what are the four phases in LCPD
necrosis
fragmentation
reossification
remodeling
impairments with LCPD
decreased IR and abd
hip muscle weakness
pain pattern with LCPD
pain in hip, knee, thigh with activity
risk factors
4-10 yo
male > fe 5:1
history of blood clotting disorder
observation for LCPD
trendeleburg gait
thigh/glute atrophy
leg length differences
exam with LCPD
limited ROM - abd and ext
pt ed with LCPD
activity mod
protective WB until reossification
manual therapy for LCPD
mobs and STM as needed post op
conservative treatment more successful in younger pt
femoral or pelvic osteotomy
ther ex for LCPD
no bracing
ROM, stretching throughout
abd and ext strengthening
endurance activities
aquatic therapy
what is slipped capital femoral epiphysis?
slippage of the proximal femoral epiphysis on the metaphysis through the growth plate
what is the most common adolescent hip disorder of unknown etiology?
SCFE
MOI of SCFE
insidious onset
periods of rapid growth
impairments with SCFE
ROM restriction
vague hip/thigh pain
antalgic gait; leg in ER
pain pattern with SCFE
intermittent groin pain, possible hip and thigh
risk factors with SCFE
ados
overweight or obesity
males 10-17 > females 8-15 (2:1)
family history
metabolic disorder
observation of SCFE
possible LLD
limb held in ER
antalgic gait ot trendelenburg gait
exam for SCFE
weak hip abd
limited abd, flex, IR ROM; muscle guarding
diagnostic imaging (plain radiographs)
pt ed with SCFE
weight management
surgery in primary treatment (in situ vs ORIF)
manual therapy for SCFE
joint mobs and STM as needed postop
ther ex for SCFE
NO SPICA CASTING - high complications
POSTOP - dictated by surgeon
early:
swelling and pain reduction
passive mobility
PWB
intermediate:
functional strengthening
increasing ROM
aerobic conditioning
late:
RTS
where can hamstring strains occur?
myotendinous junction or muscle belly
80% in long head of biceps femoris
in what population are hamstring strains common?
athletic population
MOI for hamsting strain
relative overuse
repetitive eccentric loading
if trau - refer to rule out avulsion from isch tub
impairments with hamstring strain
decreased hamstring force production, length
antalgic gait
pain pattern for hamstring strain
posterior thigh pain
risk factors for hamstring strain
prior injury
increasing age
weakness; poor quad to ham ratio
asymm strength R/L
reduced quad flexibility
observation in hams strain
unremarkable; possible antalgic gait
ecchy if muscle belly is affected
exam in ham strain
tenderness in hamstring
+ bent knee stretch test, taking off shoe test, SLR
slump test to r/o neural issue
pt ed in ham strain
address modifiable risk factors!!
manual therapy for ham strain
mobs as needed
STM: CFM, hold/relax, IASTM
ther ex for ham strain
actue:
hip ROM midrange and submax strengthening
sciatic nerve glides if needed
intermediate:
end ROM and eccentrics
single limb balance control
late:
perturbations and reactive tasks
sport specific plyometrics
higher velocity mvmts
agility and core strength > isolated hams strength and flexibility
what is piriformis syndrome?
buttock pain with or wo sciatica
MOI for piri syn
anatomic variants - early branching of sciatic n.
something compromises muscle length or causes compression
impairments of piri
tenderness to palpation
types of piri variation
I - sci completely under - 87%
II - sci under and through - 13%
III - sci over and under - <1%
IV - sci completely through - <1%
V - sci over and through - <1%
VI - sci completely over - <1%
pain pattern for piri
buttock pain with or wo sci
worse with sitting or activation
risk factors for piri
prolonged sitting
anatomic variations
middle age, female (6:1)
observation for piri
excessive femoral add/IR during step down
exam for piri
tenderness to palpation of piri and great sciatic notch
concurrent lumbar/SI issues
+ FAIR, piri test
pt ed for piri
activity/posture mods
manual therapy for piri
mobs - lumbar/SI, hip as needed
STM - deep gluteal but stop is irritability increases post treatment
ther ex for piri
stretching:
gradual increase
avoid aggressive esp in high irri
strengthening:
hip abd and deep rotators
starting isometric and progress to isotonic then to WB and SLS
lumbopelvic strength and endurance
MOI for athletic pubalgia
imbalance between adds and abdos at the pubis
like add strain but with lower abdo issues
previous name for athletic pubalgia
sports hernia
impairments for AP
valsalva maneuvers may increase pain
five signs that are indicative of AP
- complaint of deep groin/lower abdo pain
- pain exacerbated with increased exertion such as sprinting, cutting, sit-up and relieved with rest
- palpable tenderness over pubic ramus at insertion of rectus abdominus &/or conjoined tendon
- pain with resisted hip add at 0, 45, &/or 90 deg of hip flexion
- pain with resisted abdominal curl up
pain pattern in AP
groin pain above inguinal lig with exertion
relieved with rest
risk factors in AP
younger males
athletes in sports with end ROM and twisting
ROM-limiting hip disorders (FAI)
insufficient training
observation in AP
no visible hernia
exam in AP
pain with resisted sit up
+ adductor squeeze test
pt ed for AP
activity mod
manual therapy for AP
mobs if hypomobile
STM - hip flexors, abdo, adductors
ther ex for AP
mobility to improve hip ROM
address abd/add muscle imbalances, lower abdo weakness
what is osteitis pubis?
common cause of groin pain in athletes
can be self-limiting
MOI for osteitis pubis
imbalance between abdos and adds
creates shearing force at pubis
impairments for osteitis pubis
tenderness of pubic symphysis
weakness
pain pattern for OP
groin, thigh, lower abdo pain
pain with exertion (kicking, running, quick direction changes, sitting up)
risk factors for OP
athletes; soccer, rugby, hockey, distance running
pregnancy
observation for OP
decreased hip IR
waddling gait
crepitus in severe cases
exam for OP
weakness, limited hip ROM
+ adductor squeeze, FABER
may have SI instability
pt ed for OP
rest
activity limitations
manual therapy for OP
mobs if hypomobile
STM - flexors, adds, other muscles as needed
ther ex for OP
stretching:
gentle
avoid adds in early phases
strengthening:
lumbopelvic stability
isometrics, progress to isotonics
eccentric hip exercises, side steps, squats, lunges
progress to sport specific
adductor strain/tendinopathy prevalance
can be present with OP and AP
longus > magnus > gracilis
MOI for add strain
acute, overuse or recurrent
running, kicking, training errors
impairments with add strain
hip add:abd ratio < 80% (add strong and abd weak)
limited hip joint ROM
pain pattern with add strain
inner thigh and/or groin pain
can radiate down leg
risk factors for add stain
males > fem
athletes
previous groin injury, hip weakness, poor off-season training
observation for add strain
may have swelling or bruising if acute
exam for add strain
variable
decreased hip abd ROM, add flexibility
+ add squeeze test
adductor weakness MMT
pt ed for add strain
protection in acute phase
activity mod
manual therapy for add strain
join mobs as indicated
STM - hold/relax, dry needling
ther ex for add strain
stretching:
cautious with involved muscles
stretch adjacent muscles
strengthening:
progression highly variable
lumbopelvic stab and iso of uninvolved muscles initiated early
partial to full ROM
isometric to isotonic, with eccentric strength improvements necessary esp in athletes
copenhagen eccentrics
what is snapping hip syndrome?
iliopsoas over femoral head or ITB over greater trochanter - with or wo pain
MOI of snapping hip
overuse
short muscles
inadequate relaxation
impairments of snapping hip
audible or palpable snapping
what are the 3 types of snapping hip?
internal - iliopsoas issue
external - greater troch issue
intra-articular - loose body
pain pattern for snapping hip
may or may not be painful
pain/pop in groin or front of hip
risk factors for snapping hip
fe > males
activities involving extreme ROM or repetitive motion
observation for snapping hip
unremarkable
possible hypermobility
exam for snapping hip
+ thomas test, snapping hip
+ FADIR if intra-articular
popping with hip flexion/ext
pt ed for snapping hip
address posture or habitual motions
manual therapy for snapping hip
avoid hip mobs if HYPERmobile
lumbar or SI mobs as needed
STM - iliop, ITB, glute
ischemic compression
dry needling
ther ex for snapping hip
alt forms of endurance for athletes
stretching:
hip flexors
TFL
strengthening:
LP and hip
cautious progression of hip flexor, start w short lever
progress ROM, speed, eccentric loads to stim sports
former name for greater trochanteric pain syndrome (GTPS)
bursitis
can be chronic or non-inflammatory
MOI for GTPS
gradual onset
repetitive mvmts
impairments for GTPS
tenderness to palpation near greater troch
pain with sitting, WB, stairs, side-lying
pain pattern for GTPS
lateral hip pain worse with WB and side lying
risk factors for GTPS
ages 40-60
higher BMI
long distance runners
observation for GTPS
trendelenburg gait
exam for GTPS
pain with hip abd MMT
+ trendelenburg, gluteal derotation, SLS, FABER with lateral pain
no to minimal signs of OA
pt ed for GTPS
activity/posture mod
weight management if needed
manual therapy for GTPS
mobs if hypomobile
STM - hip abd, deep hip rotators, flexion
sometimes tissue compression increases symptoms
fry needling to gluteal muscles
ther ex for GTPS
strengthening muscles in frontal/transverse plane
stretching:
obtain optimal tissue length necessary for function
strengthening:
isometrics in acute phase
progress to isotonic
WB activities controlling add and frontal plane mvmt
what is meralgia paresthetica?
lateral femoral cutaneous nerve entrapment
SENSORY ONLY
MOI for meralgia paresthetica
obesity, pregnancy, ascites
tight-fitting clothes
post THA
entrapment at ingunial lig
impairments for mer paresth
tigling, numbness, burning of lateral thigh
+ neurody testing, tinel’s
treatment of mer paresth
STM
nerve glides
exercises for hip and pelvic muscles
what are corticosteroid injections used for in the hip?
trochanteric bursa
they are guided with US or fluoroscopy
what is another pathology that cortico injections may help but may not be effective with?
GTPS involving tendinopathy
describe platelet-rich plasma injections
treatment of tendinopathies and intra-articular hip disorders
not covered by insurance
post treatment restrictions
regenerative treatment
from individual pt, rich in growth factors
what is a hip arthroplasty
replacement of femoral head and acetabulum
partial vs total
who benefits from HA?
femoral neck fracture
severe OA that did not improve with conservative
posterolateral THA
hip is dislocated, external rotators detached and reflected
posterior capsule
no flexion > 90, adduction, IR
anterior THA
less disruption of muscles
lateral femoral cutaneous nerve
limit ext, ER, abd, but may have no precautions
ORIF
bony segments realigned and fixed with hardware
who benefits from ORIF
younger adults for nearly all fx
older adults with non or minimally displaced fx
rehab for ORIF
NWB for about 4 weeks
isometrics, A/AROM
progress to FWB by 8 weeks
may initially have ROM restrictions
labral debridement
50% WB for 7-10 days
90 deg flexion limitation for 10-14 days
labral repair
NWB or TTWB for 3-6 weeks
flexion, abd, ext ROM restrictions for 10-14 days
gentle ER/IR for 3 weeks
periacetabular osteotomy
reorientation of the acetabulum to improve femoral head coverage and normalize loading
reduced ROM, limits progression of OA
for pts with instability from hip dysplasia
osteochondroplasty
resection of part of the femoral head/neck or acetabulum
performed with or w/o labral repair
for pts with FAI who do not respond to conservative
