The Hip Flashcards
What are the two main components of the hip joint complex?
The coxafemoral joint and the pelvic girdle
How important is the hip joint’s role in human movement?
“paramount” to mobility and stability during functional tasks
What is considered the “epicenter” of the hip joint complex?
coxafemoral joint
Compare/contrast the CFJ and the GHJ
Similar:
- spheroid
- “ball and socket”
- rotary movements during functional tasks
- move in multiple planes
- proximal, so it can refer pain down the limb
Different:
- CFJ is less mobile, more stable
- GHJ relies on ligamentous stabilization,
- CFJ gains mobility via weight-bearing structures, bony anatomy, and capsuloligamentous components
How does the structure of the CFJ affect the hip joint complex’s capacity for loading?
“stable arrangement of the CFJ allows the hip joint complex to manage tremendous forces and loads imposed during weight-bearing activities.”
How does the structure of the CFJ affect the hip joint complex’s capacity for loading?
“stable arrangement of the CFJ allows the hip joint complex to manage tremendous forces and loads imposed during weight-bearing activities.”
Why does it matter that the CFJ has numerous growth centers in its architecture?
Allows for structural adaptations throughout life
What is the hemipelvis?
Half of the pelvic bone complex. Ilium, Ischium, and Pubis
What does the structure of the ilium tell us about it’s role in human movement?
Large size and multiple attachment points mean that the ilium serves as a mechanical lever for the muscles that control movement and stability of the trunk
What injury commonly occurs at the ASIS? What population is most at risk?
avulsion fracture involving sartorius; adolescent (under 20) athletes
What is the proximal attachment point for the Tensor Fascia Latae
lateral anterior 1/3 of iliac crest
Describe the variability of the pubic bone structure.
Highly variable (race, sex, height, etc.)
What is the connection between the ilium and the pubis, and why is it clinically relevant?
Iliopubic Eminence; the iliopsoas courses over the IPE on its way down to the lesser trochanter of the femur
What is the Pectin Pubis and why is it clinically relevant?
top of the superior pubic ramus (pubis bone) that makes up part of the pelvic brim; serves as the attachment point for the pectineus muscle.
What is the Pectin Pubis and why is it clinically relevant?
top of the superior pubic ramus (pubis bone) that makes up part of the pelvic brim; serves as the attachment point for the pectineus muscle.
Why is the pectineus muscle clinically relevant?
Pectinus attaches to the superior pubic ramus, is an important adductor, and insertional tendinopathy can cause groin pain
List 3 important structures that attach at the Pubic Tubercle. Why is this important to know?
- Rectus Abdominis
- Adductor Longus
- Ilioinguinal Ligament
Patients can present with insertional tendinopathy or ligament injury, leading to pubic/groin pain
Where is the Pubic Tubercle located?
anterior superior aspect of the Pubic Body
Aside from the Pubic Tubercle attachments, what other structure attaches to the Pubic Body? Why is that relevant?
Adductor Brevis; can be a contributor to groin pain
What is the clinical relevance of Adductor Magnus attachment contrasted with other nearby muscles?
musculotendinous attachment is usually too broad to be a source of tendinopathy, but it is predisposed to avulsion fractures of its ischial attachment
What attaches on the ischial tuberosity?
Medially - Adductor Magnus
Laterally - Semimembranosus (most lateral), Semitendinosus, & the long head of Biceps Femoris
What ligament attaches at the Posterior Superior Iliac Spine?
Long Dorsal Sacroiliac Ligament
What is the sacral hiatus? What are important landmarks nearby?
bony tunnel of the sacrum (like central vertebral canal, it protects nerves which exit via the hiatus; sacral horns (cornua) border the hiatus
What type of tissue covers the sacral hiatus? Why is this clinically relevant for epidural injections?
thick, leathery fascia; the fascia needs to be pierced when administering a caudal epidural at the hiatus
What attaches at the lateral anterior border of the Midsacrum?
sacrospinous ligament
What are the attachments of the sacrospinous ligament
lateral anterior border of midsacrum to ischial spine
What structure is at the same level as the ischial spine?
acetabulum
Describe how the shape of the acetabulum changes over time.
starts as an imperfect spheroid concavity, over time and due to forces via the head of the femur, it adapts and becomes more spherical, coming into greater surface contact with the femoral head.
What is the orientation of the acetabulum?
forward (ventral/anterior), lateral, and downward (caudal/inferior)
What is the shape of the femoral head?
2/3 spherical
What tissue covers the femoral head?
Hyaline cartilage
Describe the hyaline cartilage that lines the articular surfaces of the coxafemoral joint.
“glass-like” translucent tissue that surrounds the bone; lots of collagen II fibers (one layer with fibers oriented parallel to the bone resists sheer forces & another layer perpendicular to bone surface resists compressive forces; hyaline cartilage is bathed in synovial fluid produced by the synovial membrane that lines the inner surface of the joint capsule
What is the collodiaphyseal angle? What is the average CD angle in adults?
angle of femoral neck and diaphysis (shaft) in the frontal plane; 120 degrees (normal can range from 120-140 degrees)
What is the CD angle that results in coxa vara? How does this apply to joint forces and pathology?
less than 120 degrees; results in increased sheering forces and damage to the formal head (epiphyseal plate)
How does the collodiaphyseal angle change throughout the course of development?
Starts at around 150 degrees, and decreases to 120 degrees
What is the collodiaphyseal angle that results in coxa valga? How does this apply to joint forces and pathology?
greater than 150 degrees; results in “altered muscle activity and intraarticular forces as well as altered cartilage response”
What is the angle between the femoral shaft (diaphysis) and the neck of the femur in the frontal plane?
collodiaphyseal angle (120 deg)
What is the central edge angle? What is the average angle in adults?
vertical line through the femoral head vs acetabulum in frontal plane; less than 30 degrees signifies “dysplastic changes in the CFJ”
What is the angle between a vertical line through the femoral head and the acetabular edge?
central edge angle
How does the anterior rotation of the femoral neck change throughout development?
starts at 40 degrees from a line between distal femoral condyles, decreases throughout development to around 9 degrees
Too much anterior rotation of the neck of the femur in the transverse plane results in what condition? What would you expect to see clinically? What is the explanation for this presentation? Why is this considered pathological?
hip anteversion; causes increased IR and decrease ER; hip still maintains total 90-100 degrees of total rotation; causes increased compression forces on CFJ cartilage and nearby tendons (tendinopathy)
What is the relationship between transverse orientation of the femoral neck and tendinopathy?
increased anterior rotation (anteversion) of the femoral neck causes increase compression forces on CFJ cartilage and local tendons
Why is is better to catch femoral neck anteversion early?
it’s better to correct the rotation of the femoral neck before puberty when the epiphyseal plates close up; otherwise, the patient may need a “derotation osteotomy”
What is femoral neck retroversion? How would someone with this condition present clinically?
decreased angle between neck of femur and line between femoral condyles in the transverse plane (less than 9 degrees); decreased hip IR and increased hip ER
If someone presents with limited hip IR, what can their hip ER tell us about the lack of IR?
If there is extra hip ER, it may be due to bony structure (femoral neck retroversion); If ER is normal or decreased, it’s more likely that the lack of IR is due to a true capsular limitation
What is another term from femoral neck retroversion?
Retrotorsion
How does femoral neck retroversion affect CFJ forces and pathology?
retroversion can produce “early degeneration” in the Anterior Superior Labrum, because the femoral neck can come into contact with the labrum’s cartilaginous ring
How does femoral neck retrotorsion affect the development and structure of the acetabulum?
Acetabular torsion takes place in some cases to compliment the decreased rotation angle of the femoral neck.
Why are the greater and lesser trochanters clinically relevant?
they serve as attachment points for several tendons (gluteus min & med, iliopsoas)
What attaches at the greater trochanter?
gluteus medius & gluteus minimus
What attaches at the lesser trochanter?
iliopsoas
What is the distal attachment for the gluteus medius?
greater trochanter
What is the distal attachment of the gluteus minimus?
greater trochanter
What is the distal attachment of the hip flexor?
lesser trochanter
Where is the gluteal tubercle located? Which muscle attaches there?
posterior line that runs parallel to the shaft of the femur, between greater and lesser trochanters; gluteus maximus
What are the distal attachments of the gluteus maximus
gluteal tubercle of the femur & IT band
How much of the femoral head is covered in cartilage? Why not the whole thing?
2/3 covered in hyaline; insertion of teres ligament (ligamentum teres) / neurovascular supply
What is the Pulvinar Acetabuli?
layer of fat on the floor of the acetabulum; moves with changes in pressure inside the CFJ
In which areas of the acetabulum is the hyaline cartilage most developed? Why?
posterior & anterior superior surfaces; most contact with femoral head / highest areas of loading during walking
What is the difference in the stress on acetabular cartilage between sexes?
Woman incur greater stress on cartilage than men
Describe the relationship between acetabular coverage and the shape of the femoral head in someone with hip dysplasia.
Dysplastic hips end up creating “elliptical” femoral head
What are some examples of pathology that result from hip joint dysplasia?
joint ligament laxity, instability, and early degenerative femoral head flattening & notching
What is the hip joint labrum?
cartilaginous ring that covers the outer margin of the acetabulum
What are the functions of the hip joint labrum?
- acts as an attachment for the joint capsule
- assists in maintaining fluid pressurization
- provides proprioceptive sensory info for hip position & movement (free nerve endings -> nociception?)
Describe the attachment of the hip joint labrum and the acetabular hyaline cartilage.
about 1-2mm zone of blending (labrum is “rubbery” fibrocartilage)
The hip joint labrum is composed primarily of what type of cartilage?
Fibrocartilage (“rubbery”)
What issues are caused by a decrease in the structural integrity of the hip joint labrum?
- decrease in articular seal
- decrease in load support
- decrease in fluid pressurization
- decreased joint lubrication
List five types of sensory endings contained in the hip joint labrum.
- Ruffini endings (stretch, warmth)
- Pacinian corpuscles (pressure, vibration)
- Golgi-like organs (tension)
- Krausse endings (cold)
- free nerve endings (nociception)
Describe the blood supply to the hip joint labrum.
Similar to menisci; outer areas are well-supplied; superior region less vascularized
Which region of the labrum is less vascularized? What are the clinical implications?
superior region; this area is more susceptible to traumatic or degenerative tears
Describe the structure of the coxofemoral joint capsule.
runs from the labrum to the base of the neck of the femur; it narrows as it gets closer to the neck and creates a “collar” to keep the head of the femur in the acetabulum (during walking)
Describe each of the 3 fiber systems of the CFJ capsule.
Longitudinal - runs proximal to distal, provides tensile constraint;
Transverse - circular around the diameter of the femoral neck, create Zona Orbicularis;
Arcuate - loops at proximal insertion (at labrum), reinforces attachment of CFJ capsule and labrum
What are the three main articular connective tissue structures that hold the femoral head in the acetabulum?
joint capsule, labrum, ligamentum teres
How do developmental changes affect the orientation of the coxafemoral joint capsule fibers?
fibers take on spiraled orientation once we start standing upright (hip joint is more stable in upright position)
Describe the structure of the synovium of the coxafemoral joint capsule.
lines the inside of the joint capsule, occasionally folding in on itself (plica folds)
What are plica folds of the CFJ capsule? Why is this clinically relevant?
folding over of the synovium; plica folds can swell after trauma, constricting the blood supply to the femoral head (recurrent from Femoral Artery)
Describe the Ligamentum Teres. What is its function?
arises from Transverse Acetabular Ligament / inferior margin of the Acetabulum; “maintains reduction” of femoral head and serves as conduit for neurovascular supply to femoral head
How has current thinking changed regarding the clinical relevance of the Ligamentum Teres?
We used to think that the Ligamentum Teres was vestigial, but we now recognize it as a significant potential source of pain and/or mechanical symptoms in the hip joint.
What are the three main extra-articular ligaments of the coxofemoral joint?
iliofemoral ligament, pubofemoral ligament, ischiofemoral ligament
What are the two branches of the Iliofemoral Ligament? What does the Iliofemoral Ligament check in different hip positions?
Pars Inferioris and Pars Superioris; has duel control of external rotation (when CFJ is in flexion) and both internal/external rotation (when CFJ is in extension)
What is the Pars Inferioris and what motion(s) does it check?
branch of Iliofemoral Ligament; checks extension
What is the Pars Superioris and what motion(s) does it check?
branch of Iliofemoral Ligament; checks extension, abduction, and external rotation
What motion(s) does the Pubofemoral Ligament check?
checks extension, abduction, and external rotation (when the CFJ is in extension)
What hip ligaments check external rotation in extension?
Iliofemoral Ligament and Pubofemoral Ligament
Describe the location and function of the Ischiofemoral ligament.
posterior hip joint; tight in upright position and provides stability during “quiet standing”
What do the Ischiofemoral Ligament and the Arcuate Ligament have in common?
both reinforce the posterior capsule
How does the structure of the hip joint ligaments affect traumatic injury and movement of the femoral head?
trauma causes antero-inferior or posterior dislocation due to capsular weak spots
What two cavities does the Inguinal Canal connect in males vs females?
connects the abdomen and the scrotum (males) / labia majora (females)
What does the Inguinal Canal contain?
Ilioinguinal Nerve and the testes/spermata cord (males) / round ligament of the uterus (females)
What tissue forms the Inguinal Canal?
Aponeurosis of External Abdominal Oblique Muscle
Describe the structure and attachment of the Inguinal Canal.
External Oblique Aponeurosis folds over onto itself and attaches the to front of the Iliac Crest and Pubic Tubercle
What is the Superficial Inguinal Ring? Why is this clinically significant?
The Superficial Inguinal Ring is the inferior exit of the Inguinal Canal. It is the site of Inguinal Hernias and Entrapment of the Ilioinguinal Nerve
What tendon makes up the posterior wall of the Superficial Inguinal Ring? Why is this clinically relevant?
The Conjoint Tendon; This reinforces an area that would be weaker otherwise. If there are structural deficits, hernias occur here.
What tissues form the Conjoint Tendon?
fibers of the Internal Abdominal Oblique and Transversus Abdominis
Does the Iliopsoas Tendon pass over or under the Ilioinguinal Ligament?
under
Describe the innervation of the Coxafemoral Joint.
Anteriorly: sensory branches from Femoral and Obturator Nerves
Posteriorly: sensory branches from the Sacral Plexus
What is the nerve supply to the posterior Coxafemoral Joint? How does this present clinically?
sensory branches from the Sacral Plexus; presents as buttock or lateral trochanteric pain
What is/are the nerve(s) that supply the anterior Coxafemoral Joint? How does irritation of this neural tissue tend to present clinically?
sensory branches from Femoral and Obturator Nerves; presents as groin pain
How do you locate the Iliopsoas Tendon? What is significant about this area of the tendon?
distal to Ilioinguinal Ligament, between ASIS and Femoral Pulse; this is where the Psoas Major and Iliacus tendon fibers blend
Describe the attachments of the Psoas Major.
travels from anterolateral bodies and transverse processes of T12-L5 to combine with Iliacus and attach at Lesser Trochanter of the Femur
Describe the attachments of the Iliacus.
travels from anterior fossa of the Iliac Crest to the Lesser Trochanter of the Femur
Describe the relevant structures that the Iliopsoas passes as it travels from the spine to the femur.
Iliopsoas travels over the Iliopectineal Eminence / acetabulum and under the Inguinal Ligament
What is special about the distal fibers of the Iliopsoas tendon?
the tendon is reinforced / laced with fibrocartilage that increases its tolerance for tensile forces.
Describe the attachments of the Rectus Femoris
travels from AIIS to Patellar Tendon
How do you locate the Rectus Femoris Tendon?
2 cm distal and 1 cm medial to ASIS, deep to the Sartorius attachment
Where do the Rectus Femoris and Sartorius attach, and what do the two sites have in common?
Rectus Femoris attaches at the AIIS, Sartorius attaches at the ASIS; These are both common sites of avulsion fractures in adolescents
Describe the attachments of the Pectineus.
travels from Pectin Pubis (top/front of Pubis) to the Pectineal Line of the Femur (posterior/medial)
How do you locate the Pectineus?
distal to Inguinal Ligament and medial to Femoral Pulse
Describe the attachments of the Adductor Longus.
travels from Pubic Tubercle (superior/medial) to mid-posterior Femur
Describe the attachments of the Gracilis.
travels from Inferior Pubic Ramus to join Pes Anserinus Superficialis on the medial proximal anterior Tibia
Describe the attachments of the Adductor Brevis.
travels from the anterior Pubis to the Linea Aspera (medial lip) of the Femur
Describe the attachments of the Adductor Magnus.
travels from the Inferior Pubic Ramus / Ischial Ramus / Ischial Tuberosity to the Linea Aspera (medial lip) of the Femur / Adductor Tubercle of the Medial Condyle
Why is/isn’t the Adductor Magnus a common site for tendonopathy?
expansive tendon distributes forces, but large muscle means large forces and avulsion fractures can occur at its proximal attachments (Inferior Pubic Ramus / Ischial Ramus / Ischial Tuberosity)
Describe the muscle group of the hip that is most similar in structure and function to the Rotator Cuff of the Shoulder. In what way are the two muscle groups similar?
posterior hip musculotendinous structures (Gluteus Maximus, Medius, and Minimus; Piriformis; Superior and Inferior Gemellus; Obturator Internis and Externis; Quadratus Femoris); Both muscle groups promote “coaptation” (drawing together) of the ball and socket joint and optimize load-bearing across the joint surface
Describe the attachments of the Gluteus Maximus.
travels from the complex attachment at the Posterior Iliac Crest / PSIS / Dorsal Sacrum / Coccyx to the posterior aspect of the Iliotibial Band / Gluteal Tuberosity (distal to Greater Trochanter) of the Femur
What is the relationship between the Gluteus Maximus and the lumbosacral spine?
fibers of the proximal attachments blend with the Thoracolumbar Fascia and dorsal Sacroiliac Ligament System
What is the role of the Gluteus Maximus in Sacroiliac Joint function?
fibers of the proximal attachment blend with the dorsal Sacroiliac Ligament System, so the Gluteus Maximus helps with dynamic stability of the Sacroiliac Joint.
Describe the attachments of the Piriformis.
travels from the anterior Sacrum to the posterior proximal Greater Trochanter of the Femur
What are the actions of the Piriformis?
externally rotates the hip joint; extends and abducts the flexed thigh
What muscles travel from the posterior Ischium / Obturator Membrane to the Trochanteric Fossa of the Femur?
Superior Gemellus, Obturator Internis, Inferior Gemellus, Obturator Externis
Describe the muscles that attach to the Intertrochanteric Fossa in descending order of location.
Piriformis, Superior Gemellus, Oburator Internis, Inferior Gemellus, Obturator Externis
Describe the attachments of the Quadratus Femoris.
travels from the Ischial Tuberosity to the Intertrochanteric Crest of the Femur (posterior surface)
Describe the attachments of the Gluteus Medius.
travels from the posterior Ilium (between Anterior and Posterior Gluteal Lines) to the postero-lateral aspect of the Greater Trochanter of the Femur
Describe the attachments of the Gluteus Minimus.
travels from the posterior Ilium (between Anterior and Inferior Gluteal Lines) to the anterior Greater Trochanter
Describe the structural variance and clinical relevance of the distal Gluteus Medius and Minimus “tendon complex”
one study (LaBan, 2004) found that the fibers blend together at their distal attachments on the Greater Trochanter. The tendon complex can develop a calcific reaction that causes chronic tendonitis/osis and create a “mechanical deficiency” that leads to an increased risk of tear.
Describe the process of a Gluteal Tendon Complex tear due to tendonitis
calcific tissue isn’t as good at transmitting tension and friction loads, and tissue failure (degenerative or traumatic tears) can occur
What percentage of people over 60 have asymptomatic gluteal tendon complex tears? Why is this clinically relevant?
1 in 10; But any degenerative tear can lead to inflammation of nearby bursae (Trochanteric Bursa)
What structural change in the gluteal musculature (aside from tendonitis) can occur in people over 65 that affects their mobility and health?
Fatty degeneration of the Gluteus Minimus tendon has been correlated with falls in people over 65 (Kiyoshige, 2015)
Name the most relevant Bursae of the Hip Joint Complex
Trochanteric, Ischiogluteal, Iliopectineal
Where is the Trochanteric Bursa located? What is its relationship to local musculature?
posterior Greater Trochanter; one or more connected or separate layers between Gluteus Medius and Gluteus Minimus (lots of variation)
Where is the Ischiogluteal Bursa located?
under Gluteus Maximus, just posterior to Ischial Tuberosity
Where is the Iliopectineal Bursa located?
deep to Iliopsoas Tendon, just in front of the Iliopectineal Eminence on the front lateral rim of the pelvic cavity
Describe the structure of the Interpubic Disc and its clinical relevance.
Symphyseal fibrocartilage disc that separates the Pubic Bodies, but it has a fissure at the top lined with synovium, so it’s susceptible to inflammation and swelling
Which 2 soft tissue structures stabilize the Pubic Symphysis?
Superior Symphyseal Ligament (across the top), Arcuate Ligament Complex (across the front)
What spinal levels are associated with sensation from the Anterior Pubic Symphysis? How does this present clinically?
sensory/afferent neural information goes to L2-L4; presents as groin pain
What is the nerve supply to the Posterior Pubic Ramus? How does this present clinically?
sensory/afferent neural information goes to S3-S5; presents as genital pain
How does the orientation of the acetabulum affect arthrokinematic movements vs osteokinematic movements of the hip joint.
Because the acetabulum is oriented obliquely (forward, lateral, and downward), the hip joint moves in 3D during cardinal plane movements
What movements of the Femoral Head occur during anatomical hip flexion?
Flexion, Abduction, and Internal Rotation
What movements of the Femoral Head occur during anatomical hip extension?
Extension, Adduction, and External Rotation
What movements of the Femoral Head occur during anatomical hip abduction?
Abduction, Flexion, and External Rotation
Give two examples of the symbiotic relationship between the Coxofemoral Joint and other biomechanical joint mechanisms in the axial skeleton. Why is this symbiotic relationship clinically relevant?
- bilateral hip flexion causes innominate posterior rotation, and 2. hip movements during gait cause lumbar vertebrae rotation; Limitations at the CFJ may have an effect on pathology in other regions
What are the peak forces through the hip joint surfaces during gait? What structural abnormality changes this force significantly.
1.8-3.8 x bodyweight; Femoral anteversion increases these forces
Describe the areas of highest pressure on the cartilage of the hip joint surface during gait.
during loading/weight acceptance, dorsolateral articular cartilage; during propulsion, ventrolateral articular cartilage
Where does most of the pressure occur on the articular cartilage of the hip joint?
superolateral portion of the joint surface
Describe the relationship between intra-articular joint forces, muscle function, and hip joint degeneration
“Any force greater than 3x body weight increases risk of early degeneration. If even one muscle decreases its function across the joint, the compression force across the cartilage can exceed 4x bodyweight.”
What is Acetabular/Femoral Head Dysplasia? Describe its effect on hip joint structure and function.
decreased coverage of the femoral head and altered joint congruency; Locomotor performance is altered, compression forces change, and joint laxity/instability cause increased risk of femoral head “flattening” and “notching”
What age ranges have the highest incidence of Articular Osteochondritis Dessicans?
15-25 years old
What age ranges have the highest incidence of Ischemic Femoral Necrosis and Synovial Osteochondromatosis?
35-50 years old
What age ranges have the highest incidence of Hip Labral Lesions?
18-40 years old
What 3 hip pathologies are more common after the age of 40?
stress fracture of the pelvis/femur, labral cysts, sacral pathology
What is the “Female Triad”? How does this apply to the hip joint?
Eating Disorder, Dysmenorrhea, Osteoporosis; stress fractures of the proximal femur in young athletic females
Is pain location and description useful in diagnosing hip pathology?
Not always. There are lots of referral patterns to/from the hip region
Hip pain described as “aching” is more likely to be…
bursitis, tendinopathy, athritis, arthrosis
Hip pain described as “sharp” is more likely to be…
labral tear, loose articular body (often accompanied by clicking, giving way, and joint catching/locking)
Hip pain described as “burning” is more likely to be…
nerve entrapment (Femoral, Lateral Femoral Cutaneous, Ilioinguinal, Genitofemoral, Obturator, or Sciatic Nerve)
What are five clinically relevant nerves that can cause hip pain with entrapment?
Femoral, Lateral Femoral Cutaneous, Ilioinguinal, Genitofemoral, Obturator, Sciatic
What are some signs aside from pain that may result from nerve entrapment at the hip?
sweating, hair loss, foot/nail changes, paresthesia, numbness, weakness
List 9 musculoskeletal / non-musculoskeletal pathologies that might cause groin pain specifically.
1. CFJ injury 2 labrum injury 3. symphysis pubis lesion 4. adductor tendinopathy 5. iliopectineal bursitis 6. incompetent abdominal wall 7. urological/gynecological pathology 8. neurovascular pathology 9, lumbosacral referral
What are some pathologies that would cause Posterior Hip / Buttock pain specifically?
lumbosacral referral, gluteal bursitis, hamstring tendinopathy, hamstring syndrome, CFJ/labrum lesion, posterior pubic symphysis lesion
List 5 of the more common pathologies that can cause Posterolateral Hip pain specifically
- trochanteric bursitis
- gluteal insertion tendinopathy
- disruption/component loosing post-THA
- lumbar referral
- T12 dorsal ramus
What can cause groin pain that increases with coughing/sneezing?
hernia, pubic symphysis lesion, tendinopathies (adductor longus / rectus abdominis)
What can cause buttock pain that increases with coughing/sneezing?
lumbar nerve root (prolapsed/extruded disc)
If the patient reports that their hip pain only hurts at night, what are the next steps to take? Give an example of a condition that might cause this and how to detect it.
Rule out systemic disease or tumor; Osteoid Osteoma can be temporarily relieved with Aspirin
If the patient sits all day, what may be causing their groin pain?
anterosuperior acetabular labrum
If the patient reports buttock pain worsens with sitting, what are the 3 most likely conditions that might be present?
- ischiogluteal bursitis
- hamstring syndrome
- lumbar pathology
What are the components of a hip examination in standing?
forward flexion, trunk extension, lateral flexion, Trendelenburg
What are the dural tests that should be performed during a hip examination?
Slump test (distal initiation) in sitting, and Straight Leg Raise (distal initiation) in supine
What are the components of a hip examination
Standing, Dural Tests, SI Joint Provocation, Hip PROM in Supine, Resisted Hip Testing in Supine, Hip PROM in Prone, Hip Resisted Testing in Prone, Special Tests
What are the SI Joint tests that should be performed during a hip examination?
Dorsolateral Test in Supine, Thigh Medial Thrust Test in Supine, Ventromedial Test in Side-lying, Nutation Gaenslan Test, Counter-Nutation Gaenslan Test, Sacral Thrust in Prone
List the 5 most common components of the Hip PROM examination (and normal degree ranges) when the patient is supine?
- Flexion (120-140)
- IR at 90 deg (30-45)
- ER at 90 deg (40-50)
- Abduction with/without knee extended (30-50)
- Adduction (20-30)
What are the components of Hip exam manual muscle testing when the patient is supine?
Flexion, Adduction in Neutral, Adduction at 45 deg, Adduction at 90 deg, Abduction
What are the components of the Hip PROM examination when the patient is prone?
Extension (10-20) & IR (30-45)
What are the components of Hip exam manual muscle testing when the patient is prone?
Extension, IR, ER, Knee Extension, Knee Flexion
List 10 special tests might be performed during the Hip exam.
- ALSR/PSLR in Supine
- Drehmann Sign
- Femoral Fulcrum Test
- FABER
- FADDIR
- Trochanteric Bursitis Test
- Iliopectineal Bursitis Test
- Slump Test
- Modified Circumduction Test
- Additional Neural Tension Tests (Femoral, Lateral Femoral Cutaneous)
Why is it important to screen the lumbar spine and sacroiliac joints during the hip exam.
Pathology at these areas can refer to the glute, lateral hip, and groin
During visual assessment, what does swelling in the groin suggest?
inguinal hernia, lymphangitis, serious pathology
During the visual assessment, what does atrophy of the gluteal muscles suggest?
involvement of S1-S2 nerve roots
What is the clinical relevance of nodules found over the sacrum during the visual assessment?
usually benign lipomas
What can visual assessment tell us about coxofemoral joint intra-articular swelling?
usually can’t see it without imaging
What special tests would help to distinguish hamstring tightness from Hamstring Syndrome?
SDI and SLRDI
What is hamstring syndrome
entrapment of sciatic nerve as it courses laterally around the Ischial Tuberosity; the nerve is entrapped in a fascial envelope that emerges from the proximal attachment of Biceps Femoris.
What are the Sacroiliac Joint tests?
Dorsolateral Provocation, Thigh Thrust, Gaenslan’s (in supine), Ventromedial Provocation (in sidelying), Sacral Thrust (prone)
What findings from Sacroiliac Joint testing indicate a high likelihood of involvement?
at least 3 of the 5 tests need to recreate symptoms
What is the difference between pain provocation testing vs pelvic configuration / SIJ mobility assessment?
pain provocation testing is much more reliable and easier to reproduce than visual or tactile assessment
Describe how and why the ASLR test would be performed as part of the SIJ joint screen.
to investigate Pelvic Ring Instability; pt is supine & asked to raise the heel 20 cm off of the table with knee straight, (+) if weakness and/or pain limits movement & pain is reduced with compression of innominates
Describe Pelvic Ring Instability
decreased control of the pelvic floor muscles (Levator Ani) and the diaphragm; these two muscle groups stabilize the pelvic ring (sacrum and hip bones)
Name the Levator Ani muscles
pubcoccygeus, puborectalis, iliococcygeus, and coccygeus
What items of the Hip exam should be performed in supine?
passive flexion, adduction, abduction w knee extended (gracilis), abduction w knee flexed, IR at 90, ER at 90, Optional: labral tests like Scour & FADDIR; adductor resistance tests in 0, 45, and 90 deg; neurodynamics; Hip extension (bridge)
What tests are best for detecting tendinopathy? List the 5 most common movements/muscles for tendinopathy in the hip.
manual muscle / resistive testing
- hip flexion (iliopsoas)
- abduction (gluteus medius)
- adduction in neutral (adductor longus/gracilis), and adduction in 90 deg (pectineus)
- knee flexion / hip extension (hamstring)
- knee extension (rectus femoris)
What would produce pain with resisted hip adduction in 45 deg of flexion?
symphysis pubis pathology
What imaging modalities are most useful for detecting hip pathology?
radiographs for most fractures, MRI with contrast, MRI without contrast, CT scan for occult fracture or acetabular fracture
Describe the categories used for the interpretation and management of Hip pain
Disorders With Limitation (Capsular vs. Non-Capsular Pattern Limitations), Disorders Without Limitation (Buttock Pain, Groin Pain)
Describe the first step in diagnosing Hip pain.
Does the pt. present with a limitation of movement? Need to check out ROM and determine if it is limited in active movement, passive movement, or both. (Contractile vs. Inert)
If one isolated active movement is limited, what does this typically indicate?
neurologic disorder
If both active and passive ROM are limited in the hip, what is the next distinction to make?
Is it a capsular vs a non-capsular pattern?
What are some causes of Capsular Pattern Limitations in the Hip?
Arthritis (Synovitis), Arthrosis, R.A., Gout, Reiter Syndrome (arthritis from infection), Psoriasis, A.S., Legg-Calve-Perthes Disease, Necrotic Changes, Rheumatologic Disorders, Transient Synovitis, Septic Synovitis, Coxarthrosis
What are the 3 categories of causes of arthritis?
Disease (non-traumatic), Macrotrauma (irritation of the synovium), and Microtrauma (forceful/repetitive loading)
What type of hip joint arthritis is most common in those over 20 years old?
Traumatic arthritis (micro/macro) as a result of repetitive/forceful hyperextension, rotation, or some combination
Pain in which location(s) & with which positions / functional activities can indicate hip arthritis?
groin or anterior thigh pain with sitting, walking, ascending stairs
Which motion limitations are most common in a capsular pattern limitation?
look for painful and limited IR, limitations in flexion/extension/abduction or some combo
What hip limitation may predict hip joint arthritis?
IR
List the 5 components of the Hip Arthritis Clinical Prediction Guideline
- Squat, 2. AROM Flexion (lateral hip pain), 3. Sour Test w/ Adduction* (lateral or groin pain), 4. AROM Extension*, 5. PROM IR less than 25 deg; 3 or more reproduce symptoms
Which hip motions are less likely to be limited in a patient with Hip Arthritis?
Adduction and ER
What is the first step in the conservative management of micro-/macro-traumatic hip arthritis?
early mobilization to restore the limited range of motion; different techniques are used to restore specific limitations in motion
Describe a manual technique to restore Hip flexion in a patient with Hip Arthritis
Step 1: pt is in supine, hip passively held in loose-packed position, oscillatory traction is performed
Step 2: direct traction is performed at the limit of hip flexion w/ submax abduction and ER (leg over closest shoulder & direction of traction is towards your other shoulder, first oscillate then sustain traction
Step 3: Direct traction at hip flexion limit with submax abduction and IR (maximizes stretch on the capsule)
When performing a joint mobilization to restore hip flexion, what position would maximize the stretch on the capsule?
flexion limit, submax abduction, and IR
Describe a manual technique to restore Hip extension in a patient with Hip Arthritis
Step 1: pt is prone, indirect traction at hip extension limit w/ submax adduction and ER, oscillatory axial traction (decr pain & prepares joint); Step 2: once patient can extend to neutral, support under ASIS and pillows under leg to the point of hip extension limit, first oscillatory, the sustained traction in 45 deg ventral / 45 deg lateral / 45 deg caudal direction
Describe a manual technique to restore Hip abduction in a patient with Hip Arthritis
pt in supine, hip positioned at abduction limit with submax extension and ER
What are contraindications for Hip joint mobilization/manipulation?
joint instability w/ synovitis; degenerative bone disorders like osteoporosis, cancer, infection, osteogenesis imperfecta; present use of anticoagulants (cardiac disease, stroke, a-fib, etc.)
List 6 non-traumatic conditions may present with a capsular pattern of limitation similar to arthritis
- Rheumatoid Arthritis
- Gout
- Reiter Syndrome
- Psoriasis
- Ankylosing Spondylitis
- Legg-Calve-Perthes Disease
What is Reiter Syndrome and why is it clinically relevant when examining Hip pain?
arthritis caused by infection (chlamydia, trachomatis, salmonella, etc.); it can create a capsular pattern of limitation in the hip similar to traditional traumatic arthritis
If a younger patient presents with a nontraumatic onset of painful capsular pattern limitation of the Hip, what should be your next step?
seek further testing; pt may need imaging to rule out necrotic changes or blood testing to rule out rheumatologic disorders / septic synovitis
Describe Transient Synovitis
rare in adults (4-10 years old); in response to viral/auto-immune response, so recent illness is often present (40%); imaging typically appears normal; often recovers spontaneously within 2-3 weeks, though 15-20% develop Legg-Calve-Perthes Disease (regular imaging is required); presents with antalgic gait; treatment consists of 2-4 weeks of bedrest with cuff traction and gradual weight-bearing;
Describe Coxarthrosis
may be painless; synovitis from overuse or trauma; can be Primary or Secondary; symptoms/pain may be similar to synovitis, but pain and progression are due to changes that take place in the subchondral bone as opposed to the synovium
Describe the historical progression of Coxarthrosis
pain with weight-bearing activities that progresses to constant pain even at rest; then pain subsides and motion is limited progressively in a capsular pattern
How is Coxarthrosis best treated?
manual therapy in the short-term to reduce pain; therex for improving function, home exercises that emphasize movements from treatment several times per day
Why should home exercises be performed several times per day with patients that are being treated for Coxarthrosis?
to support any remodeling initiated with manual therapy procedures
What are reliable predictors of ambulation after THA?
hip abduction and knee extension strength
List 7 exercises that should be performed with patients post-THA. Why these?
- squats
- single leg heel raises in standing
- partial knee-bends
- single leg balance
- alternate marching in standing
- standing hip abduction / extension
- unilateral pelvic raises in standing
Weight-bearing programs are superior to traditional isometric / AROM exercises due to improved postural stability and muscle strength
What are some examples of conditions that present with a non-capsular pattern of limitation in the Hip?
Slipped Capital Femoral Epiphysis (SCFE), Ischemic Necrosis, Legg-Calve-Perthes Disease, CFJ Loose Body, Tumors, Infectious Processes, Fractures, Metabolic Disorders, Cancers
Describe SCFE. How does it present clincially?
Slipped Capital Femoral Epiphysis; femoral head slides off the femoral neck; limited IR and flexion; 30% chance in bilateral involvement; if acute, significant groin pain with weight-bearing (similar to fracture); if gradual, mild groin or anterior knee pain; as slipping progresses, increased muscle guarding and decreased IR, increased ER, (+) Drehmann Sign; (+) Trendelenberg
What does the typical SCFE patient look like?
more often…
- males
- young (age 11-15)
- overweight
- underdeveloped
What is Drehmann Sign?
obligatory abduction and ER during passive hip flexion
What is the typical prognosis with SCFE if left unaddressed?
more likely to develop femoral head necrosis, chondrolysis due to disrupted blood supply
What is chondrolysis?
rapidly progressive loss of articular cartilage
How is SCFE best treated?
surgical pinning, partial weight-bearing, ambulation with assistive device for 4-6 weeks (or until callus formation is seen on imaging)
What is Ischemic Necrosis of the Femoral Head and how does this relate to pediatric and adult pathological conditions?
compromised blood supply to the head of the femur; in young adults, it is typically associated with LCPD or SCFE; in adults, it can be due to a LOT of different pathologies, (ex. fracture/dislocation, chemotherapy, liver/kidney disease, opiod/cigarettes)
Describe Legg-Calve-Perthes Disease and its clinical presentation
self-limiting disorder due to imperfect vascularization of the femoral head & resultant necrosis / gradual disintegration of the bone; pts are most commonly between 3-10 years old and present with groin/anterior thigh/anterior knee pain; capsular pattern limitations, decr IR, incr ER, (+) Drehmann Sign, antalgic gait
How is Legg-Calve-Perthes Disease staged?
% of femoral head involvement or collapse / amount of articular space
Describe conservative management of Legg-Calve-Perthes Disease.
stage-specific; if pt is younger than 6: bed rest, casting, traction in abduction, orthoses; If pt is older than 6: strengthen abductors
Describe post-operative management of Legg-Calve-Perthes Disease
PROM/mobilization, avoiding active flexion/abduction for the first 40 days; prevent hip flexion by lying in prone, partial weight-bearing for 3-6 months
Describe the clinical presentation of a pt with a Loose Body in the Coxafemoral Joint
(1) non-capsular limitation, pathological end-feel with adduction or ER (2) “sharp”/”shooting” pain (3) giving way that immediately follows pain
Describe the Loose Body Manipulation technique
pt is supine with stabilization at ASISs; hip in flexion, abduction, neutral rotation; axial traction is maintained throughout the procedure; thrust into ER; rotate back to neutral and extend hip further; perform 5x total
What are Red Flags that indicate non-orthopaedic causes of hip pain?
age < 20; age > 50; PMHx of CA; trauma; sacral pain in the absence of trauma; osteoporosis; PMHx of IV drug abuse; Signs of infection/malignancy: cachexia, fever, night sweats, decr appetite, fatigue; night pain, pain at rest
What is Cyriax’s “Sign of the Buttock”?
painfully limited hip flexion with knee both flexed and extended
What are two examination findings that might indicate serious pathology at the hip?
non-capsular pattern + Cyriax’s “Sign of the Buttock”
What is the difference between primary bone tumors of the pelvis vs the proximal femur?
pelvis: more malignant; femur: more benign
Which disorders present as hip pain without motion limitation?
Snapping Hip, Stress-Related Avulsion, Tendinopathy
Describe Snapping Hip clinical presentation and causes
pt reports pain/snapping with walking; can be intra-articular (iliopsoas over iliopectineal eminence) or extra-articular (thickening of ITB, gluteus maximus, proximal hamstring at nearby bony landmarks)
How will a patient with an avulsion fracture describe the history of their symptoms?
If complete: initial severe pain with trauma, pain reduces and weakness increases; If incomplete: similar hx, but with persistent pain and weakness
What are the 5 most common muscles involved in avulsion fractures at the hip?
- adductors
- sartorius
- iliopsoas
- rectus femoris
- biceps femoris
What concomitant injury often occurs with rectus femoris avulsion fractures?
labral tear (similar to SLAP lesion in shoulder)
What is the basic treatment approach for avulsion fractures in the hip?
4-6 weeks of rest, measures to decrease pain, resume activity gradually as pain permits
Describe the concept of “stress shielding” and the injury to which it relates.
Stress shielding is a protective mechanism in which damaged parts of a tendon insertion are “shielded” by loading healthier sections (think donut vs hole); but it’s a double-edged sword, because if the damaged portion of a tendon isn’t exposed to loads (or only exposed to light loads), it doesn’t get disrupted enough to stimulate tissue growth and healing. Many insertional tendinopathies are related to stress-shielding mechanisms, and this is why the isometric/concentric/eccentric loading exercise often needs to hurt a little in order to be effective. That damaged/sensitive area of the tendon needs to be loaded and so the exercise needs to be at a sufficient intensity level.
What is the most frequent cause of groin pain in the pubic and medial thigh regions?
tendinopathies
List the 5 the most common muscles of the hip involved in tendinopathies & their respective attachment sites.
- hamstring / ischial tuberosity
- rectus femoris / AIIS
- sartorius / ASIS
- iliopsoas / iliopectineal eminence
- gluteal muscles / greater trochanter
What is the basic treatment approach for tendinopathies of the hip?
NSAIDs, transverse friction massage at insertion, light stretching progressing to isometric/concentric/eccentric loading
What does transverse friction massage do?
stimulates fibroblast (synthesize collagen / extracellular matrices) proliferation & promotes tissue healing via increased fibroblast recruitment; can produce temporary analgesia for hours to days via noxious stimulus (minimum 2 minutes); increases blood flow if performed on muscle tissue; (needs more/better research)
List 7 potential generators of buttock pain.
- sciatic nerve (piriformis syndrome / hamstring syndrome)
- ischial bursa
- coxafemoral joint
- labrum
- trochanteric or gluteal bursae
- lumbar spine (disc, nerve root, facet)
- S.I. / sacrococcygeal joint
Why is examination and special testing so critical when diagnosing the cause of buttock pain?
there are so many potential pain generators in the lumbosacral spine and pelvis that can cause buttock symptoms
List 3 areas of the spinal nerve that can cause buttock pain when irritated.
- lumbosacral nerve roots
2 dorsal root ganglia - dural root sleeves
Is lumbosacral imaging helpful when diagnosing the cause of buttock pain?
Not really. There are too many false positives and “the margin of error in interpreting plain film imaging of the SIJ is considerable”
What are indicators that buttock pain is referred from the lumbosacral spine?
symptoms worsen with trunk flexion, extension, and/or side-bending
What can cause buttock pain symptoms to present as
local and “sharp”? What happens to cause more diffuse pain?
disc issues are “sharp” due to compression of dorsal root ganglia; this can lead to mechanosensitivity in response to a histochemical irritation, causing pain to become more diffuse.
What is the anatomical explanation for the diffuse nature of pain in spinal structures?
because of the polysegmental innervation of the posterior longitudinal ligament, disc, and ventral dura. These structures are innervated by sinuvertebral nerves from multiple levels.
What is the difference between referred pain and radicular pain? How are they differentiated clinically?
Referred pain occurs because two separate areas are innervated by common neural pathways & the brain can’t differentiate between the two. (ex. mid-scapular pain due to stomach pathology). Radicular pain occurs as a result of irritation and/or compression of nerve tissue. Slump (DI) and SLR (DI) will more likely be positive when pain is radicular.
Describe Hamstring Syndrome
biceps femoris proximal attachment projects fibers to the ischium that create an envelope that may surrounds the sciatic nerve as it travels just laterally to the ischial tuberosity. The epineurium of the sciatic nerve can become irritated and cause buttock pain
Describe the typical history of someone with Hamstring Syndrome.
episodic “hamstring” injury or LBP/surgery; generally active people like athletes who run or jump. Symptoms are worse with sitting, start at the ischial tuberosities and generally worsen with physical activity. Hamstring stretching also worsens pain
How does someone with Hamstring Syndrome present clinically on exam?
Clinical Triad for Hamstring Syndrome (pain with sitting, pain with resisted knee flexion when hip is in 90 degrees of flexion, no pain with resisted knee flexion when hip is in extension in prone); pain with palpation of ischial tuberosities; neurodynamics may be positive
What is the Clinical Triad for Hamstring Syndrome?
(1) pain with sitting, (2) pain with resisted knee flexion when hip is in 90 degrees of flexion in supine, (3) no pain with resisted knee flexion when hip is in extension in prone
How is Hamstring Syndrome treated?
stop hamstring stretches, sit on wedge, gentle nerve mobilization initiated at knee or ankle, iontophoresis??; consider referral from pelvic floor; surgical release if no improvement with conservative management
Describe mobilization of the sciatic nerve.
patient is supine with trunk laterally flexed TOWARD the treatment side; hip in 45 deg flexion, 30 deg abduction; knee supported by pillows; patient straightens leg with strap to hold ankle in DF; 1 rep every 2 seconds for 30-120 reps
What is Piriformis Syndrome?
compression or irritation of the sciatic nerve in the region of the piriformis
What causes Piriformis Syndrome?
trauma to the buttock region, overuse (runners), perforation of the piriformis, sciatic artery/vein aneurism, compromised blood supply to the sciatic nerve (aortic aneurism)
What are signs and symptoms consistent with Piriformis Syndrome?
incr buttock pain with walking, decr pain with sitting; posterior thigh/knee referral; glute max atrophy, (+) FAIR Test, (+) Slump and/or SLR
Why might someone with Piriformis Syndrome present with Glute Max atrophy?
compressed axons of inferior gluteal nerve
Describe the FAIR Test
pt in sidelying, test side up; passive flexion to 90deg or less, adduction, IR; Posterior hip pain is (+), not anterior hip pain; Specific, but not sensitive; (“approximates the sciatic nerve closer to the ischial spine & angulates the nerve in a more aggressive fashion”)
Describe the treatment for Piriformis Syndrome
same as Hamstring Syndrome: stop stretching and sitting on hard surfaces; gentle neural mobilization; corticosteroids and analgesics “under fluoroscopic guidance” are effective in decreasing pain and piriformis muscle activity; Botox needs more evidence; Extreme cases require surgical release
What distinguishes Hamstring Tendonopathy from Hamstring Syndrome?
Syndrome: sitting is painful, Tendonopathy: sitting is painless;
Syndrome: SLR (+), Tendonopathy SLR (-);
Syndrome: Sump (+), Tendonopathy Slump (-)
What causes Hamstring Tendonopathy?
microtraumatic loading of the ischial tuberosity attachment
Hamstring Tendonopathy presents with similar symptom location to which other condition?
Hamstring Syndrome
Knee flexion will be painful in which testing positioning for a patient with Hamstring Tendonopathy?
both with hip flexion in sitting and with hip extended in prone; less severe cases may require the patient to bend over the table and isometrically load with hip and knee in flexion (quick stretch at end-range if negative)
What is the treatment for Hamstring Tendinopathy?
transverse friction massage to ischial tuberosity attachment with patient in side lying, 90/90; gentle hamstring stretching (avoid DF to minimize neural tension); reduced and/or unloaded functional activity; gradual eccentrics; return to activity as pain subsides; dry needling shows promise (in conjunction with eccentrics)
What conditions can present as lateral buttock pain?
loosened THA prosthesis, Greater Trochanter stress fx, Trochanteric (Gluteal) Bursitis, Glute Max Tendinopathy, “Persistent” Bursitis
What might you suspect if a patient presents with lateral buttock pain, but has no significant clinical exam findings?
Loosened prosthesis (if hx of THA); Stress fx (recommend CT and/or Bone Scan)
What is the most common cause of lateral buttock pain?
Trochanteric (Gluteal) Bursitis
Describe the typical examination findings that suggest Trochanteric Bursitis.
FADDIR / FADDER (+); Slump (-), SLR (-), pain with palpation of Greater Trochanter;
How do you distinguish Trochanteric Bursitis from Piriformis Syndrome / nerve entrapment in patients that present with lateral buttock pain?
Slump/SLR will be (-) for Bursitis: One or both will be (+) for sciatic nerve pathology
How do you distinguish Trochanteric Bursitis from Gluteus Medius Tendinopathy?
Palpation & Passive FADDIR/FADDER will be more painful with bursitis; Tendinopathy will be more painful with resisted IR in full flexion, adduction, & ER;
Compare and contrast treatment for Gluteus Medius Tendinopathy vs Trochanteric Bursitis.
Similar: corticosteroid/analgesic injections, habit changes, changing sitting behavior
Different: Transverse friction massage may be good for tendinopathy, but can aggravate bursitis
Describe the treatment for Trochanteric Bursitis
rest, ice, NSAIDs, taping gluteus medius “off the trochanter”
Which patients are most likely to experience Persistent Bursitis?
female 50+ with insidious onset
What might Persistent Bursitis indicate?
Possible Calcific Tendonitis or Gluteus Medius tear (from inflammatory reaction in nearby bursal tissue)
How does Persistent Bursitis pain present? What is the most common MMT finding?
pain localized around Greater Trochanter, but can radiate into lateral thigh & groin. Abduction is weak
Describe common causes of Gluteus Medius tearing / Trochanteric Pain Syndrome
friction of the ITB over the Glute Medius attachment; Osteoarthritis of the hip; Leg length discrepancy; Hyperadduction Injury
Why is the clinical exam so important in diagnosing Trochanteric Pain Syndrome, even if imaging has been performed?
MRI may show abnormalities, but there are lots of false positives. (Although, most people who have persistent trochanteric pain show abnormalities, so you can probably trust imaging that is negative.)
Describe how to test for Hip Lag Sign
Patient is side-lying, test side up; Hip is passively extended (10°), abducted (20°), and maximally internally rotated; 45° knee flexion throughout; Leg is released & patient attempts to hold this position; (+) if patient can’t keep the leg abducted / internally rotated & foot drops more than 10cm; Sensitivity 89.47%, Specificity 95.66% for “abductor damage”
How do you treat Gluteus Medius Tearing / Trochanteric Pain Syndrome?
Injections, heel lift on asymptomatic side, ambulation with cane, avoiding crossing legs; Surgical reattachment is frequently required
Entrapment of which nerve might cause Central Buttock Pain?
Pudendal Nerve
What are the most common causes of Ischiogluteal Bursitis? How do this type of bursitis typically present?
Increased sitting, Trauma, or Gluteus Medius tear; similar presentation to other bursitis, but located at Ischial Tuberosity
Describe the neuroanatomy of the Pudendal nerve
Terminal branches of S2, S3, & S4 (from Sacral Plexus) forms the Pudendal Nerve; The nerve passes between the piriformis & coccygeal muscles and leaves the pelvis through the lower part of the greater sciatic foramen; It crosses over the lateral part of the sacrospinous ligament and reenters the pelvis through the lesser sciatic foramen; After reentering the pelvis, it accompanies the internal pudendal artery and internal pudendal vein upwards and forwards along the lateral wall of the ischiorectal fossa, being contained in a sheath of the obturator fascia termed the Pudendal Canal
What is the function of the Pudendal Nerve?
Motor and sensory functions; Sympathetic fibers only; Pelvic floor muscles and penis/clitoris sensation.
How will a patient describe Pudendal Nerve Entrapment?
“sharp”, “burning” pain in lower inner gluteal quadrant or perineal area that worsens with sitting & improves with standing
What circumstances might cause Pudendal Nerve entrapment?
childbirth, pelvic surgery, skeletal abnormalities, bicycling
Why would bicyclists experience Pudendal Nerve entrapment?
compression due to narrow seat
Describe the treatment for Pudendal Nerve Entrapment.
pelvic floor therapy: relax muscles and decrease / minimize compression of the nerve; sacral sitting pad; decrease irritation from Sacrospinous Ligament (avoid deep squatting & sit with less hip flexion)
Other interventions: local nerve blocks, steriod injections, RFTC, pulsed radiofrequency, cryoneurolysis, neuromodulation
How can we mobilize the Pudendal Nerve
you can’t
What is the first clinical test you should consider when a patient presents with groin pain?
bilateral resisted hip adduction
List potential pain generators in a patient that presents with groin pain with resisted adduction.
Adductor tendinopathy, Rectus Abdomonis; Obturator Nerve; Osteitis Pubis; Ossifying Myositis; Symphysitis; SI Joint pathology
List potential pain generators in a patient that presents with groin pain that is not provoked with resisted adduction.
Urological/Gynecological pathology; Vascular pathology; Lymphatic pathology; Hernia; Hip labral lesion; Stress fx; Psoas Tendinopathy or Bursitis; Nerve Entrapment; Incompetent Abdominal Wall; Lumbar or Thoracic Spine pathology
What is the most common cause of groin pain?
increased tendon loading / stress shielding during directional-change sports; The collagen in the tendon gradually transitions to mineralized cartilage
How do you differentiate which muscle is involved in a patient with tendinopathy? Which muscles are most frequently involved in a patient with groin pain?
Differentiated via manual muscle testing; Adductor Longus/Brevis, Gracilis, Pectineus, Rectus Abdominis
Describe the MMT for Adductor Longus/Brevis Tendinopathy
pain with adduction, hip in neutral
Describe the MMT for Gracilis Tendinopathy
pain with adduction, hip in neutral & knee extended
Describe the MMT for Pectineus Tendinopathy
pain with hip flexion and adduction, hip in 90° flexion
Describe the MMT for Rectus Abdominis Tendinopathy
pain with resisted trunk flexion; pain with hip adduction
What is the treatment for tendinopathy in patients with groin pain?
transverse friction massage, stretching, strengthening exercise
How do you distinguish between Tendinopathy of the Iliopsoas and Iliopectineal Bursitis?
similar symptoms (pain with extension), but bursitis will be painful with passive flexion & ER (since the Lesser Trochanter is pressed against the bursa)
What pathology at the Pubic Symphysis can present as groin pain? What are common underlying contributors to this condition?
ligamentous trauma from micro- or macro-trauma; hip joint limitations and SIJD are potential contributors
How is ligamentous trauma at the Pubic Symphysis evoked during the clinical exam?
resisted adduction in 45° flexion
Groin pain provocation with resisted adduction in 45° of flexion indicates what pathology?
ligamentous trauma of the pubic symphysis
If Pubic Symphysis ligamentous trauma is suspected, what should the first treatment approach be?
stabilization belt and consider Pelvic Ring Instability
How would you confirm Pelvic Ring Instability
Resisted hip adduction at 45° flexion + Active Straight Leg Raise w compression
Describe the Active Straight Leg Raise test. Why would this be performed?
Pt actively raises straight leg 20 cm (~8 in);
(+) test is pain is decreased with ASIS compression or stabilization belt;
Rule in Pelvic Instability
How do you use a stabilization belt?
worn just superior to greater trochanters; can be worn only with painful activities or up to 23 hours/day if pain occurs with functional activities as well
When might steroid/analgesic injections be indicated for Pubic Symphysis pain?
persistent symptoms or if symptoms are caused by infection
What is Osteitis Pubis?
bone stress injury / inflammation of the symphysis often associated with athletic trauma
Describe the clinical presentation of Osteitis Pubis.
persistent pain, symphysis tenderness, decreased passive hip internal and/or external rotation
Dx: athelete, traumatic onset, persistent groin pain, tenderness of pubic symphysis, decr passive hip IR and/or ER
Osteitis Pubis (bone stress injury / inflammation of the symphysis often associated with athletic trauma)
What is the prognosis of Osteitis Pubis?
conservative treatment typically fails; prolotherapy looks promising; surgical stabilization has good outcomes
What are other names for Athletic Pubalgia?
“Sports Hernia” or “Hockey Hernia”
What structures are suspected to be weakened in someone with Athletic Pubalgia?
transversalis fascia, conjoined tendon, and/or internal oblique tendon
What movements are most commonly associated with the onset of Athletic Pubalgia? Describe the biomechanical explanation.
twisting, turning, or directional changes in speed; these movements cause the hip to move into abduction, adduction, or extension; ballistic movements (soccer, hockey, etc.) causes shearing force at pubic symphysis
How does Athletic Pubalgia present historically and clinically?
“debilitating” pain in lower abdomen , inguinal region, and/or groin; unilateral or bilateral; pain is worse with exertion / Valsalva; resisted double knee adduction is unchanged with stability belt; hip weakness; resisted oblique abdominal tests will be painful/weak, especially with the hip in extension;
Dx: severe groin / inguinal / lower abdominal pain; unilateral or bilateral; pain worse with exertion / Valsalva; resisted bilateral adduction painful, even with stability belt; hip weakness; pain/weakness with resisted oblique abdominal tests (worse with hip in extension)
Athletic Pubalgia
What is the best way to diagnose a sports hernia?
ultrasound
How effective is surgical treatment for Athletic Pubalgia?
laproscopic repair is 97.1% successful in return to sport, but mesh may offer earlier return to activity (1-2 mo post-op); not enough evidence to say one is better
Why might the Obturator Nerve become entrapped?
trauma (near pelvic ring or acetabulum) or overuse (vascular changes under deep fascia posterior to Adductor Longus / Pectineus)
Describe the clinical presentation of Obturator Nerve entrapment
deep, vague groin pain; pain/weak resisted hip adduction; medial thigh paresthesia; pt may complain of post-exercise soreness
What test would confirm Obturator Nerve entrapment?
EMG / nerve block
What is the most common surgical intervention for Obturator Nerve entrapment.
Surgical neurolysis
Dx: deep, vague groin pain; painful/weak hip adduction; medial thigh paresthesia; pt complains of post-exercise soreness
Obturator Nerve entrapment
What are patient history items that might make you suspect Obturator Nerve entrapment?
hx of pelvic fracture, surgery, competitive athletics
Why is Sacroilitis a diagnosis that you should consider when assessing groin pain?
may cause groin pain that cannot be reproduced clinically
What are the different causes of hip labral lesions? What are the most common?
Traumatic (46%): micro- or macro-trauma; Degenerative (49%): dysplasia or CFJ instability; Congenital (5%): developmental abnormalities
Describe Femoroacetabular Impingement
abnormal morphology of femoral head and/or acetabulum causes increased hip joint contact forces in flexion; two types: Cam, Pincer, or Mixed
What is a Cam Impingement?
loss of roundness / abnormal contact of the femoral head causes increased hip joint contact forces in flexion
What is a Pincer Impingement?
too much coverage of the acetabulum causes increase hip joint contact forces in flexion
What are the 3 types of Femoroacetabular Pincer Impingement?
1.) 2/2 to acetabular retroversion (turning back of the socket); 2.) “Profunda”: socket is too deep; 3.) “Protrusio”: femoral head extends too far into pelvis
How will a patient with FAI / a labral tear present historically and clinically?
groin / buttock / trochanteric / thigh pain with sitting, climbing, and/or stairs; possible clicking, locking, or giving way during weight-bearing activities; painful / limited passive IR when hip is flexed, but not with hip extended, (+) Modified Circumduction test (Scour)
In what areas will pain commonly occur with a FAI / labral tear?
groin, buttock, trochanter, thigh, or some combination
Describe conservative treatment for FAI / labral tears.
nature of condition, comforting with reality of condition, change seating surfaces to decrease hip flexion, decrease extensive sitting & stair use; Ambulation with AD, cycling exercise (low load), rotation mobilization/manipulation
What would you want to make sure of before performing hip joint mobilization/manipulation on a patient that has FAI / labral lesion?
imaging is (-) for necrotic changes of the CFJ
Describe the procedure of a Labral Manipulation of the hip.
patient is supine with hip flexed to 90°, lower leg resting on PT’s knee, slight IR;
PT has one foot on the table, knee closest to patient is holding up the patient’s lower leg;
an assistant or belt applies downward pressure to ASISs;
PT raises heel, applying traction to hip joint; high-velocity, low-amplitude thrust into ER; repeat 3-4 times, slowly returning to IR (less traction on joint) between each manipulation
What medical procedures might be used to treat FAI / labral tears?
steroid injections, excision, labrectomy, acetabular derotation osteotomy
Why would steroid injections help a labral tear?
decrease inflammation, decrease cytokine proliferation
What is cytokine? Describe the effect of cytokines on patient symptoms.
Essential to immune system function; small proteins (peptides) that can’t cross the lipid bilayer of cells, but they can attach to cell receptors and cause several biochemical cascades (pro-inflammatory and anti-inflammatory), including the production of more cytokines; they are produced by many different tissues and tend to have a more local effect than a generalized one (such as hormones); there is evidence that pro-inflammatory cytokines directly activate nociceptive sensory neurons
In what 3 areas do most stress fractures of the hip occur?
proximal 1/3rd of the femur, the femoral neck, and the pubic ramus
How does a patient with a hip stress fracture present?
pain immediately with weight-bearing, exam is largely negative, (+) single-leg hop test, (+) Fulcrum test
Dx: hip pain with weight-bearing, exam is largely negative, (+) Single-leg Hop test, (+) Fulcrum test
Stress fracture, most likely proximal femur, femoral neck, or pubic ramus
After it is confirmed with imaging, what is the first step in conservative treatment for a stress fracture of the hip?
reduce activity until the bone can heal
Dx: groin pain, painful resisted knee extension with hip in neutral, mild-moderate pain with resisted hip flexion
Rectus Femoris Tendonopathy
Describe the clinical presentation of Rectus Femoris Tendonopathy.
groin pain, painful resisted knee extension with hip in neutral, mild-moderate pain with resisted hip flexion
Describe the clinical presentation of Iliopsoas Tendonopathy
pain with resisted hip flexion and/or ER, no pain during resisted adduction
Describe the prevalence of Iliopsoas Tendonopathy
relatively rare, but can occur post-THA; more common in younger females
Dx: hip pain with resisted hip flexion and/or ER, no pain during resisted adduction
Iliopsoas Tendonopathy
Dx: hip pain with passive external rotation in 90° hip flexion, no pain with resisted adduction, less painful / pain-free resisted hip flexion
Iliopectineal Bursitis
What most frequently evokes pain with Iliopectineal Bursitis and why?
passive ER in 90° hip flexion; the femoral neck presses on the bursa
Describe the clinical presentation of Ilipectineal Bursitis
hip pain with passive external rotation in 90° hip flexion, no pain with resisted adduction, less painful / pain-free resisted hip flexion
How is tendinopathy best initially treated?
transverse friction massage, stretching, unloaded exercise
If you are treating a tendonopathy, what other condition should be on your mind and what might cause it?
Myositis Ossificans due to bleeding from trauma/disease
What should be considered if tendonopathy is not responding favorably to conservative treatment?
injections / surgery
What are the most common nerve entrapments that cause hip pain?
Femoral nerve, Lateral Femoral Cutaneous nerve, Ilioinguinal nerve, Iliohypogastric nerve
Dx: quad weakness, (+) neural tension test
Femoral nerve entrapment
Describe the clinical presentation of Femoral nerve entrapment
quad weakness, (+) neural tension test
What is the likelihood that injection or surgical treatment will be successful in treating Femoral vs Lateral Femoral Cutaneous nerve entrapment?
Lateral Femoral Cutaneous nerve entrapment (Meralgia Paresthetica) seems to respond more favorably to injection/surgical intervention
What is the most likely location of symptoms for someone with Ilioinguinal Nerve entrapment?
medial proximal thigh
You would suspect entrapment of what nerve if the patient presented with medial proximal thigh symptoms?
Ilioinguinal nerve
What is the most likely location of symptoms for someone with Iliohypogastric Nerve entrapment?
anterior and/or lateral proximal thigh
You would suspect entrapment of what nerve if the patient presented with anterior and/or lateral proximal thigh symptoms?
Iliohypogastric nerve
Describe the challenges that Iliohypogastric or Ilioinguinal nerve entrapments can present clinically
both are difficult to reproduce and are best treated with neurolytic surgical release or excision
Contrast Femoral nerve vs Lateral Femoral Cutaneous nerve tension tests
Femoral: knee flexed, hip extended;
Lateral Femoral Cutaneous: hip extended, adducted, internally rotated; knee extended; ankle everted/plantarflexed
What is the most common cause of hip pain in older adults (50+)?
Osteoarthritis
What are some findings and patient attributes that are associated with hip osteoarthritis?
Low range of hip IR and flexion, hip osteophytes, morning stiffness, male sex, higher BMI, and previous hip join pain/injury
What is the relationship between socioeconomic status and hip osteoarthritis?
Living in a community a higher poverty level is associated with radiographic OA in at least one hip; low education level is associated with symptomatic OA in at least one hip;
What are some conditions that might lead to more rapid femoral head osteoarthritic changes?
Developmental dysplasia, Cam deformities, SCFE
What are we looking for when we take radiographs for hip OA?
Joint space narrowing, osteophytes, subchondral sclerosis/cysts
List 9 physical performance measures that are recommended for patients with osteoarthritis?
- 6-Minute Walk Test
- 30-Second Chair-Stand
- Stair Measure
- T.U.G.
- Self-Paced Walk
- 4-Square Step Test
- Step Test
- Timed Single-Leg Stance
- Berg Balance Scale
Describe the 6-Minute Walk Test.
Patient walks 30m (98.5 feet) back and forth for 6 minutes; rests are allowed; remind patient every minute; if O2 drops below 88%, take note of distance;
Describe the Self-Paced Walk Test
Typical speed is 1.2-1.4 m/s (2.5-3.0 mph); less than 0.7-1.0 m/s (1.5-2.2 mph) is associated with higher risk of poor health-related outcomes
Describe the Step/Stair Test.
Time to ascend/descend 8-14 stairs is rounded to the nearest 100th of a second; MCID for hip and knee OA 5.5sec (MCID post-TKA 2.6 sec)
Describe the Timed Up-and-Go Test.
3 meters (10 feet); normal is 12 seconds or less
Describe the 30-Second Chair Stand Test.
Arms crossed; full rep is rise back to seated; MDC 3.5; averages are between 9 and 17 reps, depending on age
Describe the 4-Square Step Test
clockwise stepping from bottom left square, facing forward throughout the test, then counter-clockwise; > 10-15s = risk for multiple falls; MDC 1.8-2.0
Describe the Timed Single-Leg Stance as it applies to hip OA examination
knee is flexed so foot is behind the body, hands on hips; 2 trials; < 20 sec is cut-off for 70 years old or younger; < 15sec for 80+
Describe the current evidence concerning the relationship between oral/injectable supplements for hip OA
oral (glucosamine, chondroitin) have not been demonstrated to be different than placebo (several RTCs show no significant effect); hyaluronic acid injections aren’t yet approved by the FDA and have little evidence currently (no high-quality RTCs)
List 4 education topics that you might want to discuss with a patient with hip OA
- activity modification
- exercise
- supporting weight reduction (if overweight)
- methods of unloading the hip joint
Describe the current evidence of the relationship between non-arthritic hip joint pain & imaging / surgical intervention.
Dx of nonarthritic hip joint conditions are made with a combo of clinical findings & imaging even though there’s no consensus on diagnostic (rule in/out) criteria for any specific condition.
Surgeries for nonarthritic hip joint conditions are growing, even though there’s not much evidence to show that it’s superior to conservative management for any nonarthritic condition.
How does the CPG define Nonarthritic Hip Joint Pain?
refers to a collection of hip pain conditions proposed to involve intra-articular structures of the hip
What are some examples of Nonarthritic Hip Joint Pain given in the CPG?
femoroacetabular impingement, structural instability, labral tears, osteochondral lesions, loose bodies, ligamentum teres tears, and septic conditions
In normal individuals, where is the cartilage of the femoral head the thickest? Why?
the central portion around the Ligamentum Teres attachment (Fovea Capitis). This is the area of maximum weight-bearing forces.
Describe the anatomy of the articular cartilage of the acetabulum
- horseshoe shaped
- thickest superiorly
- continuous with the cartilage of the labrum
- avascular
- aneural
What are the three ligaments that reinforce the hip joint capsule and where?
iliofemoral (anteriorly), pubofemoral (anteriorly), and ischiofemoral (posteriorly)
How many muscles cross the hip joint?
27 muscles
What muscle is primary source of hip joint stabilization in the frontal plane?
Gluteus Medius
What are the primary functions of the iliopsoas complex?
flex the hip and stabilize the hip joint anteriorly
What muscle is the most powerful hip extensor?
Gluteus Maximus
Which muscle group(s) should be especially considered in a patient with an acetabular labrum tear? Why?
hip internal and external rotators (TFL, gluteus medius, adductors, pectineus / piriformis, gemmelli, obturators, quadratus femoris). Labrum tearing can cause loss of passive rotational stability of the hip joint.
What are two anatomical variants that may lead to acetabular labral tears?
structural instability & femoroacetabular impingement
Describe femoroacetabular impingement and it’s sub-classifications
Increased contact of the femoral neck on the acetabular rim, causing increased shear and compression forces on the labrum. 3 categories: CAM impingement, Pincer impingement, combination
Describe a Cam impingement
SCFE, epiphyseal injury, or other asphericity of the femoral head causes protrusion of femoral head/neck junction; increased contact between femoral neck and acetabular rim
Describe a Pincer impingement
general protrusion of the acetabular rim (protrusia) or local protrusion of the anterior/superior acetabular rim causes increased contact with femoral neck as it is brought into flexion / IR; Can also be caused by acetabular retroversion
What is the prevalence of FAI in males vs females?
It depends on the type. Males are 2x as likely to have cam impingements; Pincer impingements are more common in middle-aged active women
Define hip instability.
extraphysiologic hip motion that causes pain with or without the symptom of hip joint unsteadiness
What are 3 common anatomical variations that may contribute to hip joint instability? Labral tears?
- shallow acetabulum
- excessive femoral anterversion/retroversion
- inferior acetabulum insufficiency
A neck shaft angle greater than 140° (coxa valga) combined with repetitive forceful activities -> increased risk of labral tears
Describe acetabular dysplasia and its relationship to hip labral injury
shallow acetabulum results in insufficient coverage of the femoral head. Acetabular anteversion - not enough anterior coverage, retroversion - not enough posterior coverage; In either case, the labrum undergoes excessive shear forces, since it needs to do the job of acetabulum in keeping the head stable during movement;
What effect does continued repetitive stress have on a dysplastic hip?
further instability of the hip joint and potential labral injury
What two types of pathology are most closely related to femoral anteversion/retroversion?
labral injury and increased risk for developing OA
What are the types of MOI most closely related to hip labral injury?
twisting, pivoting, falling; common mechanism in athletes is forceful rotation in hyperextension; (tears can be insidious or the result of any repetitive movement + anatomical variation)
What percentage of athletes who present with groin pain have a symptomatic hip labral tear?
20%
What is the relationship between hip labral tears and age?
Becomes more likely after 30, and very common in older people
What are the types hip labral tear?
radial flap (most common), radial fibrillated, longitudinal peripheral, & abnormally mobile (partially detached)
Describe a radial flap hip labrum tear
free margin of the labrum is disrupted (most common)
Describe a radial fibrillated hip labrum tear
fraying of the free margin of the labrum
Describe a longitudinal peripheral hip labrum tear
tear along the acetabular-labral junction (least common)
Describe a abnormally mobile hip labrum tear
labrum is partially detached from the acetabular surface
In what hip positions might the ligamentum teres act as an important joint stabilizer?
ER in flexion, IR in extension
What other conditions are commonly correlated with ligamentum teres tears?
labral tears and cartilage injury (micro-instability?)
Describe the current evidence base on the clinical presentation of ligamentum teres tears
generally considered rare; correlation between ligamentum teres injury and clinical presentation is not well-understood
Describe a chondral lesion of the hip
focal loss of cartilage on the articular surfaces
What is the relationship between labral tears and chondral damage?
73% of patients with fraying or tearing of labrum had chondral damage
List 3 hip conditions that are commonly associated with anterior-superior cartilage lesions.
- acetabular dysplasia
- ANTERIOR joint laxity
- FAI
Describe a common mechanism of injury for acute chondral lesions
young active individual sustains trauma to greater trochanter -> acute overload to the joint articular surfaces
What are loose bodies of the hip joint?
small fragments of bone or cartilage within the hip joint (ossified or non-ossified)
What are conditions associated with hip single loose body fragments vs multiple fragments, respectively?
generally, single: dislocation, osteochondritis dissecans; multiple: synovial chondromatosis
What are potential risk factors for FAI?
genetics, sex (men -> cam, women -> pincer)
What are potential risk factors for hip structural instability?
genetics (particularly congenital hip dislocation), ligamentous laxity (Elhers-Danlos, Down, and Marfan syndromes)
Describe the most common MOI of hip ligament focal laxity and its relationship to labral injury.
most commonly occurs as anterior capsule laxity secondary to repetitive movements involving ER and/or extension (results in iliofemoral ligament insufficiency); less stress absorbed by the ligaments mean more stress on the labrum and increased risk of labral injury
Aside from Osteoarthritis, list four conditions that are categorized as hip intra-articular injury
acetabular labral tear, ruptured ligamentum teres, loose bodies, and chondral defects
What is the relationship between osseous abnormalities and intra-articular hip lesions?
not much evidence as to correlation vs causation, but 87% of patient presenting with labral tears also had either dysplasia or FAI on the symptomatic side
What are general risk factors that you should consider with a patient with hip joint pathology?
osseous abnormalities, local or global ligamentous laxity, connective tissue disorders, and the nature of activity and participation (repetitive rotation, hyperextension, hyperflexion)
Which imaging study is most useful in detecting hip intraarticular pathology (i.e. labrum tears)?
MRA (Magnetic Resonance Angiography) with contrast
What procedure may be useful in indicating hip joint chondral damage?
Image-guided anesthetic/corticosteroid injections (ultrasound or fluoroscopic); Indicated when pain is not improving or impacting participation in physical therapy
What is the general initial approach in the clinical management of nonarthritic hip pain?
8-12 weeks of conservative management (PT, medication, maybe injections); surgical intervention if no improvement with conservative care
Describe the current state of the evidence concerning surgical management for nonarthritic hip pain.
favorable evidence is growing, but most of the literature is observational studies with small sample sizes and short-term outcomes
Give 6 examples of surgical interventions that may be used to address nonarthritic hip pain conditions.
- labral tear resection/repair (best evidence currently)
- capsular modification
- osteoplasty (to address FAI)
- ligamentum teres tear debridement
- loose body removal
- periacetabular osteotomy (to address dysplasia)
Describe the Trendelenberg sign. What is the purpose of the test?
Single-leg standing with contra-lateral hip raised to 30°, hold for 30 seconds, (+) if pt is unable or if hip drops; Used to assess ability of hip abductors to stabilize the pelvis during single-limb stance
Describe the Log-Roll Test.
assess ER of hip in neutral compared to opposite side; (+) test indicates ligamentous laxity
What patient education would you give to a patient with Femoroacetabular Impingement?
avoid activities and positions that impinge the labrum or lead to further cartilage damage (end-range flexion, IR, and/or abduction)
What patient education would you give to a patient with hip joint structural instability?
avoid activities that place repetitive strain on the tissues that provide passive stability of the joint (forceful/repetitive extension or rotation)
In patients with hip joint structural instability, what movements should be emphasized during strengthening exercise and why?
abduction & rotation; loss of rotational stability may be linked to acetabular labral tears
