Non- arthritic hip joint pain

Question 1

What are the best diagnostic criteria to rule in/ out a specific hip condition?

Answer 1

Combo of imaging and clinical fundings- no consensus on diagnostic criteria

Question 2

What is the normal angle of inclination?

Answer 2

120-125

Question 3

What is normal anteversion of the demur?

Answer 3

14-18

Question 4

Name the ligaments supporting the hip, as well as other passive structures that help provide its stability

Answer 4

Iliofemoral, ischiofemoral, pubofemoral
Labrum and joint capsule
Ligamentum Teres

Question 5

Describe the musculatures role in hip stabilization

Answer 5

Glute med- primary dynamic stabilizer
Iliopsoas- anterior stability
Hip rotators- more critical when labrum is torn

Question 6

Describe femoroacetabular impingement

Answer 6

Abnormal contact between the femoral head/ neck and the acetabular margin
Has been associated with labral and chondral damage

Question 7

Describe the 3 classifications of FAI

Answer 7

Cam- result of asphericity of the femoral head, often related to SCFE or protrusion of head/ neck junction
Pincer- result of acetabular abnormalities (protrusia/ retroversion)
Combination- Cam and pincer

Question 8

What can FAI contribute to?

Answer 8

Labral lesions, cartilage damage, secondary hip joint OA

Question 9

Describe the gender differences for cam/ pincer lesions

Answer 9

Cam- 2X prevalence in males

Pincer- middle aged active women

Question 10

Describe hip instability and its causes

Answer 10

Extraphysiological hip motion that causes pain
Traumatic, nontraumatic, or due to bony/ soft tissue abnormality (shallow acetabulum or excessive anteversion, neck shaft > 140)
Can lead to labral tears

Question 11

Differentiate between anteversion and retroversion

Answer 11

Anteversion- increased femoral IR, limited ER
Retroversion- increased ER, decreased IR
Both can increase risk for OA/ labral injury

Question 12

What is the function of the labrum?

Answer 12

deepens the hip socket, decreases forces transmitted to the articular cartilage

Question 13

Describe the MOI for labral tears

Answer 13

• Traumatic- rapid twisting, pivoting, falling motions, forceful rotation with hyperextension
• Insidious
• Due to anatomical variants

Question 14

What are the 4 classifications for labral tears?

Answer 14

1. Radial flap- Most common, free margin of labrum is disrupted
2. Radial fibrillated- fraying of the free margin
3. Abnormally mobile- partially detached from labral surface
4. Longitudinal peripheral- tear along acetabular labral junction

Question 15

Describe attachment points for the ligamentum teres

Answer 15

Edges of the acetabular notch and transverse acetabular ligament and attaches at the fovea capitus of the femoral head

Question 16

What is the role of the ligamentum teres?

Answer 16

Stabilization particularly when hip is ER in flexion or IR in extension

Question 17

What have anterior/ superior condral lesions been associated with?

Answer 17

Dysplasia
Anterior joint laxity
FAI
Traumatic- blow to greater trochanter

Question 18

Why might you see loose bodies in the hip joint

Answer 18

Single- Dislocation/ Osteochondritis dissecans

Multiple fragments- Synovial chondromatosis

Question 19

Describe the clinical findings associated with FAI- subjective and objective

Answer 19

Pain in anterior hip/ groin, and/ or lateral hip/ trochanter
Aching/ sharp
Agg by sitting
Mechanical symptoms- popping/ locking snapping
+ FADIR
Hip IR < 20
Flexion/ abduction also limited

Question 20

What are the radiographic findings with FAI

Answer 20

1. Cam impingement- increased femoral neck diameter
2. Pincer impingement- increased acetabular depth
3. Decreased acetabular inclination- tonnis angle < 0
4. Acetabular retroversion- ischial spine projects into pelvis, crossover sign

Question 21

Describe the clinical findings with structural instability of the hip- subjective/ objective/ imaging

Answer 21

Anterior groin, lateral hip, generalized hip pain
Mechanical symptoms
+ Hip apprehension sign (Hyperextension/ ER test)
+ FADIR/ FABER
Hip IR > 30
Radiographic- increased acetabular inclination
Tonnis angle > 10
Decreased femoral head coverage

Question 22

Describe the clinical findings of intra-articular injury (labral tear, osteochondral lesion, loose bodies, ligamentum teres rupture)

Answer 22

Anterior/ generalized hip pain
Mechanical symptoms of hip
Reported feelings of instability/ sensation of instability with squatting
+ FADIR/ FABER

Question 23

What are the differential diagnoses for nonarthritic hip joint pain

Answer 23

Referred pain from lumbar- facet/ disc/ stenosis
SIJ dysfunction
Pubic symphysis dysfunction
Nerve entrapment- lateral femoral cutaneous, obturator
Hip OA/ Septic Arthritis/ RA
Hernia- inguinal, athletic pubalgia
Strain- iliopsoas, adductor/ psoas abcess
Osteonecrosis, Osteomyeltis
Myositis Ossificans/ Heterotopic ossificans
Avulsion injury- Sartorius/ rectus femoris
Leg Calve Perthes
SCFE
Metabolic bone disease
Prostatitis
Neoplasm
Gynecological disorders

Question 24

What imaging studies are recommended for diagnostics of non arthritic hip joint pain

Answer 24

XR- first, can detect femoral/ acetabular abnormalities

MRA- intra-articular structures, articular cartilage integrity

Question 25

Describe the clinical course for treatment of non- arthritic hip joint pain

Answer 25

Non surgical management for 8-12 weeks- PT, medication, and U/S guided injection Arthroscopic procedures- labral tear resection (most support)/ repair, capsular modification, osteoplasty for FAI, ligamentum teres debridement, loose- body removal

Question 26

Which validated outcome measures should you use

Answer 26

A evidence- HOS- Hip Outcome Score HAGOS- Copenhagen Hip and Groin Outcome Score iHOT- 33- International Hip Outcome Tool

Question 27

What physical impairment measures should you assess

Answer 27

``` Trendeleberg FABER/ FADIR Log roll test Passive hip IR/ ER - sitting/ prone Passive flexion/ abduction Hip Abductor/ posterior glute med muscle strength Hip IR/ER strength in flexion (sitting) and extension (thomas test, supine- take into end range- hold) Hip flexor strength ```

Question 28

Describe a positive Trendelenberg

Answer 28

Raise non-stance pelvis as high as possible 1. Unable to hold elevated pelvic position for 30 sec 2. No elevation noted 3. Stance hip adducts , allowing non stance pelvis to drop below stance leg pelvis

Question 29

Describe the log roll test

Answer 29

For determining ligamentous laxity Passive IR/ ER in supine +. > ER than non- involved side

Question 30

What instruction/ patient education should you provide for FAI

Answer 30

Avoid activities that create pinching | Avoid end- range flexion, IR and sometimes abduction

Question 31

What instruction/ patient education should you provide for Structural instability

Answer 31

Avoid repetitive strain on passive restraints on hip- extension and rotational loading

Question 32

What activities should you be assessing to determine if any modification should be provided?

Answer 32

Sitting- avoid low/ soft chair, changing work positions Sit to stand Ambulation- assistive device? increase plantar flexion at terminal stance Stairs Sleep positions Flexibility routine- avoid end- range aggressive flexion/ IR stretches or hip flexor stretches

Question 33

What manual techniques are contraindicated for FAI, for structural instability?

Answer 33

FAI- end range flexion/ IR | Instability- joint mobilization (with exception of pain modulation)

Question 34

What recommendations are made for manual therapy for non- arthritic hip joint pain?

Answer 34

F evidence- joint mobilization for capsular restriction impairing mobility STM- for muscles impairing hip mobility

Question 35

What can be said about stretching and structural instability? For general non- arthritic hip pain?

Answer 35

Contraindicated for instability Can use contract/ relax stretching and prolonged stretching that does increase symptoms otherwise ASK WHAT THEYVE TRIED- usually they have tried stretching already

Question 36

Which muscle groups are important to strengthen with structural instability

Answer 36

Hip abductors and rotators

Question 37

What recommendation can be made about Neuro re-ed and hip pain

Answer 37

F- evidence May be used to decrease movement coordination deficits dynamic stabilization may be beneficial for those with compromised labrum