PT3 - Hip In Locomotion Flashcards
What are the functions of the hip during locomotion?
- stability for weight baring in single leg
- stability + ROM to transmit and increase forces from spine and pelvis to lower limb
- stability + ROM to dissipate + transmit forces from ground contact to spine
What is the trendelenberg test?
- hip on contralateral side drops when one leg is lifted
- glute medius/minimus/tfl and trunk on contralateral side not strong enough to hold side up
What is reverse trendelenberg?
- contralateral hip hike
- might see a trunk lean to opposite side during gait
- seen in OA => lean towards painful hip to avoid trendellenberg in hip that’s not very comfortable
Where does force initiation of the hip movement come from?
- trunk and spine
- step forwards with right leg results in contralateral side rotation towards hip and thigh
What happens to the pelvis and hip as the trunk accelerates?
- pelvis and hip lengthen out
What happens when the pace of walking slows down?
- trunk and pelvis go together
Which age group do you see trunk and pelvis movements happening together?
- older people + coordination movement issues e.g. parkinsons
- thorax and spine looses mobility
- shift to sync gait
What generates energy in the gait sequence and what effect can this have on the head?
- trunk and spine
- force comes down from trunk + spine
- ground reaction force comes up from foot
- need to dissipate forces to stop head nodding during gait
What movements happen to the hip at heel strike?
- hip flexion
- hip abduction
- hip internal rotation
What happens to the hip in stance phase?
- hip flexion
- hip adduction
- hip internal rotation
What happens to the hip in swing phase?
- hip extension
- hip adduction
- hip external rotation
What is the q-angle of the hip?
- line between ASIS + patella
What are the key factors around q-angle?
- shape and size of pelvis
What happens to the q-angle in women?
- increased angle in women
- increased load through hip => requires stronger adductor force
- lateral hip structures work harder to stop knee coming in (trendelenberg action) => more difficult to control hip
- results in increased loading of lateral hip and medial knee
What is anteversion/retroversion?
- measures the shape/direction of rotation in the femur compared to the shape/direction of the femoral condyles
Describe how the increased q angle in women affects the pelvis, femur and knee
- increased q angle due to wider pelvis
- increased femoral anteversion
- relative knee valgus angle
What happens to femoral version/torsion in a baby?
- femur is anteverted
What happens to version/torsion as we grown into an adult?
- lateral hip muscles work, twisting femoral neck outwards compared to femoral condyles
- normal femoral neck anteversion
- hip hasn’t come out of baby stage of anteversion
What happens to the femoral neck in retroversion and what impact does this have on the leg?
- femoral neck becomes parallel with femoral condyles
- results in bowed knees when femur is in neutral
Anteversion and which disease of the hip have a high correlation?
- OA
Which test do you perform to identify femoral version/torsion?
- Craig’s test
- find greater trochanter in neutral and then look at foot
- foot internal rotation => anteversion
- foot pointing up => neutral anteversion
- foot pointing out => retroversion
What happens with an aging hip?
- aging is a natural process that occurs in all people to some degree
- acceleration => pathological OA of hip => inappropriate degeneration
- hip common joint for OA
How do you assess the aging hip?
- individual agency => social, sport, occupation => requirements and effect on structure/function
- local tissue changes => how has NMS changed?
- global effect of changes on NMS
Give examples of how individual agency can be affected by an aging hip (how does this impact life?)
- sit to stand => prolonged sitting => difficult to get going after long sedentary period of time
- weight baring e.g. walking issues
- cannot put socks/trousers on easily as have to take hip through EROM => painful
- loss of hip extension early on
- weight baring with impact e.g. stepping off of curb
What local tissue changes would you see at the hip that might contribute to symptoms?
- surface of the hip becomes less congruent
- gluteal tendonopathy
- capsule starts to break down
- FIA might appear due to cams or pincers around the femur
- ligaments start to wear/bear more load
- muscle wasting as not able to use them as much
- anterior hip change due to irritation of synovial capsule and inflammatory process
What is the global effect of an aging hip?
- patient might hike OA hip to assist in gait (reverse trendelenberg)
- use of trunk and pelvis flexion more => more kyphosis in thoracic spine
- movement of pelvis and leg in unison, rather than in opposition
- slowing down of movement
- lack of hip extension => maybe less adduction + external rotation during swing phase
What is dysplasia of the hip?
- might be the result of a shallow acetabulum
How does secondary osteoarthritis of the hip occur?
- incongruity of articular surfaces e.g. from development or fracture to acetabulum
- instability => abnormal mechanical friction e.g. dysplasia or shallow acetabulum
- avascular necrosis => hip cannot withstand forces
- concentrated pressure loading => femoral deformity e.g. retained anteversion
- direct injury => infection/trauma
- constitution => obesity, hypothyroidism, pituitary dysfunction
What are the symptoms of OA of the hip?
- pain in buttocks/glutes, groin/adductors, knee or lower back
- pain on weight bearing, esp. following misstep/twisting strain
- pain in the morning + stiffness; eases with gentle activity
- progressive stiffness + limp
- pain referral to below knee into shin
- dressing difficult, stairs + in/out cards
- shortening of leg => appears as a flexed + adducted hip posture
- contracture of hip capsule + ligaments + muscles or from deformation of femoral head + neck
What changes in the hip might you observe during location in OA?
- mild => moderate changes in gait biomechanics unrelated to pain
- hiked unsupported hemi-pelvis + tilted pelvis tilts anteriorly
- more peak hip abduction + external rotation + less peak hip extension
- shorter stride => loss of extension + trunk flexion
What can you do to assist someone with OA if you know that they have lost hip extension and their trunk is in flexion?
- work on thoracic extension
Miss Jones is a 35 year old police officer who often spends the majority of her shifts on foot patrol. She has recently noticed some anterior knee pain when walking which seems to be worse in her work boots compared to the trainer she usually wears on days off.
Can you describe some potential maladaption of the hip that might contribute to this?
- development or fractures of articular surface => incongruity of articular surfaces
- dysplasia of hip or shallow acetabulum => instability causing abnormal mechanical friction
- hip is unable to withstand forces => avascular necrosis
- femoral deformity (cams/pincers/retained anteversion) => concentrated forces through specific areas of the hip, altering how the hip is loaded
- trauma to the hip e.g. infection or an impact
- changes caused by increased load such as obesity or metabolic changes from pituitary dysfunction (bone didn’t grown like it should) or hypothyroidism
- all of these can result in other structures becoming involved to adapt to these changes
Miss Jones is a 35 year old police officer who often spends the majority of her shifts on foot patrol. She has recently noticed some anterior knee pain when walking which seems to be worse in her work boots compared to the trainer she usually wears on days off.
Describe the potential biomechanical mechanisms that might be involved
- increased anteversion of the hip => shape of the acetabulum doesn’t allow for as much extension in gait, resulting to changes in the capsule, ligaments and musculature => osteoarthritic age related changes in the hip
- may see an increase in flexion of the spine and trunk to assist in leg acceleration => if reduced extension of hip, then body will become efficient at moving in flexed hip position. Leading to more external rotation and abduction to assist with movement
- altered hip surface => less congruent with articular surface of acetabulum => change in shape of the hip bone + less space around the head of the femur => contract of musculature around thigh (rectus femoris) and shortening of thigh bone which inserts into the tibial tuberosity pulling the patella superiorly causing some knee pain
Miss Jones was so pleased with your advice she has asked her 72 year old father to visit you about his groin pain. He recently visited his GP and following an X-ray was diagnosed with OA of the hip. His pain is most noticeable on walking.
Discuss how age related changes of the hip might impact on gait efficiency
- may result in a shorter strike due to less extension of the hip + muscle around the hip (rectus femoris + psoas + iliacus) tightening
- might need to slow down walking due to shorter strike => hip and pelvis move together rather than pelvis moving in contralateral rotation to dissipate forces
- thorax may come into more of a flexed position to assist with acceleration of the leg, reducing energy efficiency in all positions
- Hemi-pelvis hip hike on unsupported limb to assist in swing through
- more peak hip abduction + external rotation and less peak hip extension
Miss Jones was so pleased with your advice she has asked her 72 year old father to visit you about his groin pain. He recently visited his GP and following an X-ray was diagnosed with OA of the hip. His pain is most noticeable on walking.
What assessment strategies could you use to inform your treatment of a patient with hip pain from OA when walking?
- Craig’s test to understand what direction the hip is rotated in neutral => would inform whether musculature is tight or whether that is the patient’s normal
- trendelenberg => to understand if the pelvis hikes on the opposite side and the patient can be assisted with muscle strengthening exercises
- patients active ROM => identification of their awareness of what movement they have available => compare this to passive ROM to see whether their range is different from passive range => is it a coordination with cerebellum/extrapyramidal function that could be trained?
- Thomas test to understand whether the hip is in fixed flexed deformity
- scourer test to test for OA => may not need this as already have a diagnosis from an X-ray
- FADIR/FADER test to understand ROM available and see if that can be altered
What is the q-angle?
- angle between patella and ASIC
What is the difference between anteversion and retroversion?
- anteversion => neck of femur is internally rotated compared to condyles of femur; this is what happens as a baby
- retroversion => neck of femur has been externally rotated by hip muscles compared toe condyles of femur; this is what happens as a adult
What are the 3 key functions of the hip during locomotion?
- stability + ROM to transmit + increase motion of spine and pelvis to lower limb
- dissipate forces from ground and spine to make sure that head doesn’t nod
- stability for single leg weight bearing
Describe the key ranges of motion required of the hip for efficient locomotion
- heel strike => stance phase: flexion + abduction + internal rotation
- swing phase => extension + adduction + external rotation
Describe how age-rated changes of the hip may be maladaptive to efficient locomotion
- metabolic change e.g. obesity increasing pressure on the joint
- trauma to the joint e.g. injury to the joint from sports or repetitive movements where continuously being taken to the end range in yoga
- the surface may become less congruous and not move as effectively in the hip socket
- specific pressure on a certain point may result in a cam
- a shallow hip socket or hip dysplasia may result in more wearing of the labrum/tendons/ligaments to hold the hip in place
