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MSK II > Pelvis and Hip 3 > Flashcards

Pelvis and Hip 3 Flashcards

1
Q

etiology of hypermobility at the hip

A

traumatic like fx, ligament tear, or labral tear

atraumatic from extreme motions in sports, labral tear with FAI/IPI, and systemic connective tissue disorders

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2
Q

if there is a bony abnormality, what factors may contribute to hypermobility of hip

A

shallow acetabulum

inferior acetabular insufficiency

excessive femoral torsion or version (only one we can pick up clinically)

excessive femoral neck angle

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3
Q

what is femoral torsion

A

in transverse plane

angle between femoral condyles and femoral head and neck

excessive anteversion = toeing in

excessive retroversion = toeing out

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4
Q

what is the femoral neck angle

A

in frontal plane the angle between the shaft and neck

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5
Q

what is coxa valga

A

larger inclincation angle

leads to genu vara or bow legged

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6
Q

what does valgus mean

A

distal segment moves laterally

i.e. coxa valga = bow legged stature

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7
Q

what is coxa vara

A

smaller inclination angle

leads to genus valga or knock kneed position

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8
Q

prevalence of hypermobility at the hip

A

inconsistent with gender differences

5-35% of those with hip pain

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9
Q

risk factors for hypermobility

A

genetics
injury
nature of pts activities
-running
-ballet
-golf
-hockey
-soccer
-excessive RT, FLX, and hyper EXT

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10
Q

symptoms of hypermobility of hip

A

like impingement due to hypermobility plus:

anterior groin or lateral hip pain
popping, locking, or snapping
feeling of instability, especially when squatting

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11
Q

signs of hip hypermobility

A

like impingement plus

ROM: hip IR>30 at 90 flx

combined motion: possibly inconsistent

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12
Q

special tests for hip

A

hip apprehension

abnormal femoral version or torsion

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13
Q

what is the hip apprehension test

A

in prone

move hip into ext and abd while applying anterior inferior force on femur

specific to pubofemoral ligament test

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14
Q

PT Rx for hypermobility of hip

A

primary focus on cartilage integrity and stabilization

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15
Q

predominant innervation to the L4-S1 Z joints

A

L4 dorsal Rami

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16
Q

predominant and most consistent innervation to the L4-S1 discs

A

L1, 2 dorsal root ganglia

L4 and L5 sinuvertebral nn

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17
Q

iliolumbar ligaments are innervated by

A

L1-4 spinal nn

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18
Q

if there is a instability at L4-S1, what muscle groups would be more likely to excessively recruit due to the predominance of L1-L4

A

hip flexors (L1/2)
hip adductors (L3)
knee extensors (L3/4)
Ankle DF (L4/5)

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19
Q

main function of iliopsoas and where does it attach

A

primarily a hip flexor and trunk stabilizer

attaches to iliocapsularis

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20
Q

functions of iliocapsularis and where does it attach

A

primarily a dynamic stabilizer for capsule

also a hip flexor

attaches to iliopsoas, anteromedial capsule, and rectus femoris

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21
Q

rectus femoris attaches to

A

the capsule

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22
Q

the capsule attaches to

A

the labrum

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23
Q

nerve roots for iliopsoas, iliocapsularis, and rectus femoris

A

iliopsoas= L1-4

iliocapsularis = L2-4

rectus femoris = L2-4

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24
Q

simplify the hip consequence of excessively recruited hip flexors

A

muscles are overrecruited and pull on attachment to capsule that ultimatley pulls on the labrum as well

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25
Q

etiology of L4-S1 regional interdependence

A

L4-S1 hypermobility instability

most common segments

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26
Q

pathomechanics of L4-S1 regional interdependence x5

A

1-excessively recruited hip flexors that attach to capsule/labrum

2-this causes excessive traction on anterior medial portion of capsule and labrum (3/9 oclock)

3-this can lead to labral attrition WITHOUT bony changes

4-also inhibited hip extensors and abductors

5-these things lead to imbalnce of optimal axis of motion and joint support as well as easily overworked muscles due to lowered recruitment so overuse/lower supply occurs

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27
Q

hypertonicity of hip extensors and abductirs is due to what

A

being overworked even without overuse

often reported as tightness that stretching helps short term but doesnt resolve

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28
Q

describe why L4-S1 regional interdependence is self perpetuating without address of lumbar stabilization

A

iliopsoas is a stabilizer of LORDOSIS in standing

iliopsoas maintains its size or grows in those with LBP indicating continued/excessive recruitment

excessive recruitment can further add to the anterior shearing most often occurring with lumbar hypermobility/instability

excessive recruitment = more pull = more anterior shear = more LBP = more recruitment (cycle)

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29
Q

what is iliopsoas impingement

A

impingement without dysplasia or bony changes

30
Q

etiology of iliopsoas impingement

A

not fully clear

conditions that lead to excessive hip flexor recruitment

lumbar hypermobility/instability with regional interdependence

31
Q

symptoms of iliopsoas impingement

A

like FAI

possible lumbar hypermobility/instability symptoms if aggravated

32
Q

signs of iliopsoas impingement

(PROM, tracking, inhibited muscles, neuro, palpation, and thoracolumbar scan/BE)

A

like FAI plus:

-IR limited at 90 flexion with elastic end feel

-hip maltracking at 90 flx (hip deviated into abd while passively flexing)

-possible hip ER inhibition at 90 with RST

-possible inhibition of extensors and abductors

-possible hypersensitivity with neuro

-TTP over ant hip (3/9 oclock)

-thoracolumbar scan/BE findings for lumbar hypermobility

33
Q

explain why IR is lost in PROM at 90 flexion

A

because of the inhibition and hypertonicity of extensors; primarily glut max inhibition which is also the main external rotator at 90 flexion

34
Q

explain why jip maltracking at 90 flx occurs with iliopsoas impingement

A

due to inhibition and hypertonicity of piriformis that is an abductor at 90 flx; draws hip out and wont let it stay in line

elastic end feel into flexion if deviation is not allowed

35
Q

why might there be inhibited ER at 90 flx with iliopsoas impingement

A

due to glut max inhibition bc it is the main ER at 90 flx

36
Q

if a pt has iliopsoas impingement and you ask them to squat what might you see

A

quad dominant squat pattern

knees over toes

due to inhibited hip ext and excessive knee ext

37
Q

PT Rx for iliopsoas impingement

A

“culprit Rx” for lumbar hypermobility/instability

“victim Rx” like FAI Rx

38
Q

MD Rx for iliopsoas impingement

A

iliopsoas surgical release

39
Q

Describe gluteal tendinopathy

A

lateral hip P!

usually diagnosed as greater trochanteric bursitis

called tendinopathy b/c usually there are already structural changes (more accurate description)

aka GTPS

40
Q

prevalence of gluteal tendinopathy

A

most prevalent in LE

women > men

> 40

sedentary > athletic

41
Q

risk factors for gluteal tendinopathy

A

female

BMI

excessive hip ADD

weak hip ABD

coxa vara

plyometric overuse

42
Q

structures involved with gluteal tendinopathy

A

primarily greater trochanteric bursa

primary muscle = glut med

secondary muscle = TFL/IT band

43
Q

describe insertions in releation to the R greater trochanter

A

12 oclock = Gmed

11= piriformis

10 = GOGOs

9 = QF

44
Q

etiology and pathomechanics of gluteal tendinopathy

A

abnormal mechanical loading is the primary driver

excessive loads may be applied longitudinally or perpindicularly

excess loads can also occur with impaired LE control including but not limited to excessive femoral ADD

45
Q

when do tensile loads occur

A

with concentric loads

46
Q

when do tensile and compressive loads occur

A

with eccentric loads

particularly in lengthened ranges

47
Q

how does L4-S1 rehional interdependence play a role with gluteal tendinopathy

A

TFL/IT band overrecruitment

known to hypertrophy indicating excessive recruitment

48
Q

symptoms of gluteal tendinopathy

A

gradual and unknown onset but possible overuse/lower supply

increasing lateral hip pain and maybe lateral thigh

decreased pain with rest

possible lumbar hypermobility/instability symptoms if aggravated

49
Q

when are symptoms increased with gluteal tendinopathy

A

walking, running, stairs, any single leg loading

prolonged sitting, especially crossing legs as IT band tension increases thru Gmax lengthening, particularly in lower seat and then first few steps

lying on involved side

50
Q

observation/functional tests for gluteal tendinopathy

A

possible antalgic and or trendelenburg gait

impaired LE control
-pain/weak with 30 sec SLS
-may need to assess higher level ADLs like jumping/running

51
Q

ROM signs with gluteal tendinopathy

A

possible lateral hip pain and limitation with add and IR in neutral (lengthening fibers of glut med)

ER (glut med and min lengthening) and H. ADD (piriformis) in 90 flexion

52
Q

resisted/MMT for gluteal tendinopathy

A

possible weakness and pain with
-ABD (especially in ADD position)
-ER in neutral
-IR and H Abd in 90 hip flx
-ABD and ERs weak and atrophied

53
Q

special tests for gluteal tendinopathy

A

+ ER (G med and min lengthened) and H add (piriformis lengthened)

possible + Obers

54
Q

palpation findings for gluteal tendinopathy

A

TTP over bursa (hallmark sign) > Glut Med

55
Q

PT Rx for gluteal tendinopathy aside from MET

A

victim vs culprit?
-itis vs osis
-regional interdependence

pt edu
-soreness rule
-load management
-avoid provoking symptoms (i.e. lying on side/crossed legs)
-pillow between knees when on uninvolved side

POLICED

stretching not recommended (maximally lengthening and compressing structure)

56
Q

shockwave effectiveness with gluteal tendinopathy

A

shock wave therapy proposed but not substantiated in research

57
Q

primary MET focus for gluteal tendinopathy

A

tendon proliferation and stabilization (hip and lumbar)

58
Q

MET parameters for gluteal tendinopathy

A

isometric without compression from lengthening

isotonic without compression from lengthening

isotonic with compression from lengthening

isometric loading in WB (best place to start doing closed chain; should be able to do above first)

plyometric loading

59
Q

MD Rx for gluteal tendinopathy

A

corticosteroid injections
-inflammation not primary issue
-mainly acts as a analgesic
-may hinder tendon from responding to optimal loading
-may hinder response to optimal loading

platelet rich and other “regenerative” injections lack sufficient support for all soft tissue injuries

60
Q

describe hamstring tendinopathy

A

glute pain that is more often a tendinopathy

common in athletes; rare in general public

61
Q

risk factors for hamstring tendinopathy

A

prior injury

regional interdependence from L4-S1 lumbar hypermobility/instability

weak Gmax, Gmed, and or adductors

62
Q

explain how regional interdependence from L4-S1 can affect hamstring tendinopathy

A

excessive hip flexor recruitment leads to anterior pelvic tilt and adds to excessive tension/compression

inadequate ham/quad ratio
-excessive quad recruitment
-overuse/lower supply with hamstring inhibition

advanced age means less pliable tissue = greater tension/compression

63
Q

structures involved with hamstring tendinopathy

A

hamstring proximal tendon

adductor magnus = shared origin and fascial connections with hamstrings

ischial bursa

rarely sciatic n; possibly adhered if tendinosis

64
Q

etiology of hamstring tendinopathy

A

abnormal mechanical loading

-repetitive hamstring action with hip flexion (running, jumping, training errors)
-excessive prolonged stretching
-sedentary lifestyle
-muscle imbalances
-prior injury

deceleration - hamstrings eccentrically control knee ext

heel strike and foot flat - after lengthening hamstrings act in a lengthened position with hip in flexion

65
Q

symptoms of hamstring tendinopathy

A

posterior hip/butt pain (deep ache)

less symptomatic with warm up

worsened with activities that lengthen hamstring with or without m action

stiffness after prolonged position, particularly sitting

66
Q

signs of hamstring tendinopathy

A

observation = possible atrophy if long standing

functional tests = pain with activoty involving lengthening with muscle action (i.e. lunge, running, squat, etc)

ROM = possible limits/pain with hip flexion and knee extension especially if combined

RST/MMT = possible weakness/pain with hip ext and knee flex especially with lengthened position

neuro = possible dural mobility limits if sciatic involved

TTP over proximal tendon and bursa at ischial tuberosity

special test = bent knee test and shortened muscle length test

67
Q

describe the bent knee stretch test

A

hip and knee flexed

PT slowly straightens knee

mod to high reliability

68
Q

PT Rx for hamstring tendinopathy

A

follow general prinicples of gluteal tendinopathy and tendinosis Rx plus

pt edu to stand more than sit and avoid low seats/prolonged sitting

dry needling has limited support

neural mobs for sciatic involvement

69
Q

MET for hamstring tendinopathy

A

eccentric training to reduce pain and injury

lumbopelvic stabilization to improve hamstring activity that supports regional interdependence

70
Q

prognosis for hamstring tendinopathy

A

good out to at least 6 months with 8-10 weeks if PT

71
Q

MD Rx for hamstring tendinopathy

A

corticosteroid injections
-mainly act as a analgesic
-may hinder tendon from responding to normal loading

platelet rich other “regenerative” injections (lack support for ALL soft tissue injuries)

MSK II (18 decks)

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