W9 Flashcards
1
Q
Causes of buttock pain - common
A
Proximal Hamstring Tendinopathy
2
Q
Proximal Hamstring Tendinopathy Aetiology
A
- Caused by compression of the hamstring tendon against ischial tuberosity
- Common in sports that involve sprinting, jumping or repeated hip flexion and extension movements
3
Q
Proximal Hamstring Tendinopathy Clinical Presentation
A
Sudden or gradual onset posterior buttock pain
* initially with sports
* as progresses pain also with ADLs – walking, stairs, sitting (especially on hard surfaces)
4
Q
Proximal Hamstring Tendinopathy
Physical Examination
A
- TOP (tender on palpation)
- Replication of aggravating factors = reproduction of Sx (symptoms)
- Sx/pain reproduced with hamstring stretch or contraction (remember biarticular origin and insertion)
5
Q
Proximal Hamstring Tendinopathy Diagnostic Imaging
A
- MRI or U/S (ultrasound)
- Thickening, oedema, increased signal intensity
- Helpful for DDx (differential diagnosis) of tendon
versus, or includes, the ischiogluteal bursa
6
Q
Causes of buttock pain – less common
A
Piriformis Syndrome
7
Q
Piriformis Syndrome
Aetiology – highly debated
A
? Enlarged, inflamed and/or tight piriformis causing mechanical compression of the
sciatic nerve.
* Anatomical variations in course of the sciatic nerve.
? Neurological condition or myalgia due to gluteal weakness
* Frequent hip flexion, IR and adduction (e.g. cycling, skiing, dance, gymnastics)
8
Q
Piriformis Syndrome
Clinical Presentation
A
- Either gradual or acute traumatic onset
- Deep and diffuse, central buttock Sx.
- Aggs = sitting > standing; stretching buttocks.
9
Q
Piriformis Syndrome
Physical Examination
A
- TOP
- Possible decreased hip flexion, adduction and/or IR ROM due to pain or reduced length, OR
- decreased strength of hip extensors, abductors and/or ER, OR
- Faulty hip extension pattern
- FADER-R may reproduce Sx
- Neurodynamic SLR to DDx
10
Q
causes of HIP PAIN
A
Labral Tear
Osteoarthritis
Hip Joint Instability
Gluteus Medius Tears & Tendinopathy
Trochanteric Bursitis- less common
Ligamentum Teres Tear
Femoroacetabular Impingement
11
Q
Labral Tear (common hip pain) aeitology
A
- Trauma - single or repetitive trauma – rotation & flexion, repetitive pivoting, hip flexion, twisting or direct trauma (fall/MVA)
- Congenital – due to acetabular or hip dysplasia
- Degenerative – may be associated with OA
- Capsular laxity – due to systemic connective tissue disorder or repetitive activities
- Idiopathic - may be associated with FAI (Cam or pincer morphology) Syndrome
- Most common intra-articular hip injury in athletes (22% of athletes with hip pain).
12
Q
Labral Tear (common hip pain) Clinical Presentation
A
Anterior groin pain
* Gradual onset of symptoms or related to trauma/injury
* Pain increases with activities
* intermittent, sharp “catching” pain, clicking, locking, catching, giving way
* referred pain to the buttock and/or anterior thigh
13
Q
Labral Tear Physical Examination
A
- Hip Quadrant, and/or
- FADIR, and/or
- Thomas Test IF reproduction of patient’s pain and/or click
- FABER IF reproduction of patient’s Sx
- Possible glut med and/or lower fibres of glut max atrophy
14
Q
Labral Tear
Diagnostic Imaging
A
- MRI and MRA most sensitive
- CT
15
Q
Labral Tear Diagnostic Surgery
A
Arthroscope
16
Q
Osteoarthritis (O.A) commom
Aetiology
A
- Age-related response to abnormal loading from an acute traumatic event or repetitive microtrauma.
- Trauma = cartilage degradation = inflammatory response = further cartilage damage.
Damage to subchondral bone
Hypertrophic (osteophytic) and/or atrophic bone response
Bone necrosis and periostitis
Synovial inflammation and thickening
17
Q
OA clinical ptresentation
A
Local Sx, usually affecting a single joint, and develops gradually
* Morning stiffness < 1 hour
* Pain and stiffness in the affected joint, leading to muscle changes and functional limitations.
* May have gait changes (slower; shorter step length; greater step width; greater step duration)
18
Q
non modifiable factors for hip OA
A
- Age – increased risk in >55 year olds, with further increased risk in >65- 80 year old
- Gender/sex – increased risk in women
- Genetic/familial predisposition
- Ethnicity or Race – lower incidence in Asian cultures than white
Caucasian. Very low incidence in Koreans - Leg length difference
- History of lower limb or hip trauma
19
Q
modifiable factors for hip OA
A
- Occupational factors
- manual labor /physical stress work
- sporting activities
- Increased weight or obesity (BMI)
- questionable for development of OA but Yes for progression of OA)
20
Q
Osteoarthritis (O.A)
Physical Examination
A
AROM- hip internal rotation less than 15 degrees
AROM- hip flexion less than 115 degrees
FABER will reproduce symptomes
quadrant test will be positive (will be positive in labers tear as well)
21
Q
Osteoarthritis (O.A)
Diagnostic Imaging
A
- X-ray
- CT
- MRI
22
Q
Hip Joint Instability aeitology
Causes of hip pain - common
A
- Capsuloligamentous laxity
- Traumatic
- hip dislocation - fall on flexed knee & hip or from dashboard (MVA)
- repetitive rotation movements with axial loading
- Trauma -> stretching of capsule, possible labral damage /tears of ligamentum teres
- Recurrent dislocation
- Atraumatic
- In congenital-hypermobility conditions = generalized ligamentous laxity and/or acetabular dysplasia
- Certain sports, including football, golf, horse riding, dance, gymnastics
23
Q
Hip Joint Instability clinical presentation
Causes of hip pain - common
A
feeling of instability, clicking and/or clunking
* pain in hip/groin region which may increase with activity
24
Q
Hip Joint Instability- Physical Examination
Causes of hip pain - common
A
Extremes of end AROM and PROM and PAM
ROM (significantly increased compared to normal)
* May also observe:
* Poor balance
* Poor control in functional tasks
* Excessive anterior translation of femoral
head, especially during Lx and/or hip extension
* Global hypermobility syndrome
* Hip clicking and/or clunking
25
Greater Trochanteric Pain Syndrome (GTPS)- Aetiology
Causes of hip pain - common
GTPS is an umbrella term for one, or multiple-coexisting, pathomechanophysiological diagnoses:
* Gluteus Med or Min tears
* Gluteus Med or Min tendinopathy
* Trochanteric bursitis
* Subgluteal bursitis
* Proximal ITB thickening
* Lateral Snapping Hip Syndrome
26
Greater Trochanteric Pain Syndrome (GTPS)- clinical presentation
Causes of hip pain - common
* Lateral, localised hip pain, ache, intermittent, persistent or unrelenting
* Pain lying on affected side, sitting with legs crossed, prolonged standing on one leg
* Decreased physical exercise
* 10 – 25% of the population in 40 - 60 old
27
Greater Trochanteric Pain Syndrome (GTPS)
Physical Examination
* Lateral hip tender on palpation, specifically localized over the greater trochanter
* Plus - pain with at least one of the following:
1. Pain EOR hip Abd/Add or hip IR/ER
2. Positive FABER
3. Active resisted abduction in adducted position
4. Pain with sustained single leg stance (30 sec)
5. Positive resisted External De-rotation/FADER-R Test
6. Positive Ober’s test
* VISA-G (PROM Questionnaire)
28
Greater Trochanteric Pain Syndrome (GTPS)
Diagnostic Imaging
* MRI (gold standard)
* U/S
29
Gluteal tendinopathy Clinical Presentation
* Females > males
* Usually insidious pain onset
* Onset may be associated with increased training loads or sudden, unaccustomed changes to load or volume.
* May be due to an acute, traumatic episode (fall on, or blunt trauma to, lateral hip)
30
signs and symptoms of Gluteal tendinopathy
* Pain and tenderness over the greater trochanter
* Pain may radiate down lateral thigh
* Pain maybe worse at night
* Painful to sleep on affected side
* Pain with prolonged single leg stance or stairs
31
Lateral Snapping Hip Syndrome MechanoPathology
Gluteus max anterior fibres & ITB band move over the greater trochanter from
posterior to anterior as the hip moves from extension to flexion, causing a snapping
sensation
* May be associated with pain & inflammation
32
Symptoms of Lateral Snapping Hip Syndrome
* Audible +/- painful lateral hip snap during repetitive E to F +/- Abd
* Snap increases with repetitive hip E/F
33
Lateral Snapping Hip Syndrome Clinical Signs
Patient can usually reproduce their symptoms:
* in side-lye with the ITB on stretch – ask patient to actively extend and flex their hip.
* Manual compression of the band proximal to greater trochanter or external rotation
of hip may relieve snap
* Trochanteric bursitis could also be present
34
Ligamentum Teres Tear Aetiology
* Trauma - single or repetitive trauma – forced flexion, adduction and IR and/or ER.
* Twisting motions and hyperabduction
* Can usually be in conjunction with labral tear
* Can coexist with FAI, hip dysplasia, hip synovitis
35
Ligamentum Teres Tear Clinical Presentation
* Similar to labral tear
* Anterior groin pain
* Gradual onset of symptoms or related to trauma/injury
* Pain increases with activities
* intermittent, sharp “catching” pain, clicking, locking, catching, giving way
* May observe decreased balance or proprioception
36
Ligamentum Teres Tear Physical Examination and Diagnostic Imaging
* As per Labral tear
* + Hip Quadrant, and/or
* + FADIR, and/or
* + Thomas Test IF reproduction of patient’s pain and/or click
* + FABER IF reproduction of patient’s Sx
* Possible glut med and/or lower fibres of glut max atrophy
37
Femoroacetabular Impingement (FAI) Aetiology
* Mainly when proximal femoral growth plate still open/active
* Rare after closure of proximal femoral growth plate (van Klij et al., 2019)
* Common in young athletes (hip loading in adolescence may
be a risk factor for Cam morphology) e.g. football, soccer, ballet, hockey, martial arts
38
Femoroacetabular Impingement (FAI) Clinical Presentation
* Motion or position related hip/groin pain and/or pain in the back, buttock or thigh - Pain with walking, running; squatting, performing lateral/cutting movements.
* May also have clicking, catching locking, stiffness, restricted ROM or giving way
39
Femoroacetabular Impingement (FAI) Physical Examination
* Hip impingement tests (FADIR, Quadrant)
reproduce their pain
* Limited hip ROM, especially IR in F
40
Femoroacetabular Impingement (FAI)
Diagnostic Imaging
* X-ray – AP view of pelvis and Dunn view for
the lateral femoral neck
* MRI – 3D hip morphology, cartilage, ligamentum teres and labral lesions
* may be associated with previous Slipped
Femoral Epiphysis or congenital hip
dysplasia
* can be present radiographically but be
asymptomatic (10-25% people)
41
Harris Hip Score (HHS) PROM
* Assesses pain, gait/limp, gait distance, function, ADLs. Max score =100=best function.
MDC = 4
42
Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) PROM
* Assess self reported pain, stiffness and dysfunction. Max score =96=worst function. ICC =
0.9, MDC = 9.1
43
Lower Extremity Functional Scale (LEFS) PROM
Assesses 20 functional tasks, Max score =80=best function. MDC = 9.9 ICC= 0.92
44
Hip Disability and Osteoarthritis Outcome Score (HOOS) PROM
* A hip OA specific Q with 40 items in 5 subscales (pain, symptoms, ADLs, sports & recreation and hip related QoL). Max score =100 = best function
45
iHOT 33 or iHOT 12 – International Hip Outcome Tool-33 PROM
* 33 items – symptoms, function, sport, occupational function, QOL
* Max score =100=best function ICC = 0.93, MDC = 16 (Kemp, Collins, Roos, & Crossley,
2013)
46
Adductor-related groin pain Aetiology
* Adductor muscle strain – longus, magnus, pectineus, gracilis (acute)
* Adductor tendinopathy (chronic)
* Common in sports involving sudden change of direction
47
Adductor-related groin pain Clinical Presentation
* Groin tenderness/ pain on muscle palpation, stretch or contraction (e.g. getting in/out of car)
* Can become recurrent/acute on chronic, or chronic if not correctly managed.
* Tendinopathy
= initially pain with activity which improves once warmed up.
= possible loss of running speed and kicking distance
= if untreated, pain can persist during activity
48
Adductor-related groin pain Physical Examination
* Muscle Strain
- TOP muscle belly or musculotendinous junction
- RROM outer range adduction* = pain and weakness
- PROM/adductor stretch* = decreased ROM limited by pain
- + Adductor Squeeze Test in long lever position*
* Tendinopathy
- TOP proximal-groin, over tendon and/or adductor origin
- PROM/adductor stretch = decreased ROM limited by pain
- + Adductor Squeeze Test in long lever position AND short lever position
49
Adductor-related groin pain Diagnostic Imaging
* U/S or MRI
50
Illiopsoas-related casues of groin pain Aetiology
* Strain/acute onset
* Tendinopathy
* Anterior Snapping Hip Syndrome
* Bursitis
51
Illiopsoas-related groin pain Clinical Presentation
* Strain/acute onset = primarily change of direction MOI
= must DDx +/- rectus femoris involvement:
- Illiopsoas = change of direction
- Rec Fem = kicking and sprinting
- Body Chart and Palpation important
* Tendinopathy = repetitive hip flexion, accumulated overload
= proximal groin pain, medial ASIS/illium, deep ache
52
Clinical Presentation
* Anterior Snapping Hip Syndrome
= iliopsoas tendon over anterior femoral head causing audible asymptomatic clunk.
= must ascertain if clunk feels deep/internal hip joint or superficial/external to hip joint/can feel the clunk.
= usually, no MOI or Hx of trauma
= common in young females, can be bilateral
= may also be associated with iliopsoas bursitis
53
Physical Examination for strain of Illiopsoas
* Strain/acute onset = hip flexion Active/Passive/Resisted ROM limited by pain & weakness (knee ROM not affected)
= muscle belly TOP
54
Illiopsoas Physical Examination Tendinopathy
= hip flexion Active/Passive/Resisted AROM may be limited
= distal tendon TOP along its course of insertion into lesser trochanter
55
Illiopsoas-related
Physical Examination
* Anterior Snapping Hip Syndrome & Illiopsoas Bursitis
= start in hip flex-abd
= guide into eccentric hip ext
= or ask pt to reproduce snap
= reproduction of ‘snap’ = rule in
= apply pressure over tendon, if snap
reduced = further rule in
56
Illiopsoas-related Diagnostic Imaging
U/S
57
Inguinal-related Aetiology
* Rectus abdominus (RA) tendinopathy
* May also be an acute rectus abdominus strain while lifting
* May be chronic/overuse caused by excessive contraction/s (e.g. cricket fast bowler)
* No palpable inguinal hernia
58
Inguinal-related Clinical Presentation & Physical Examination
* Pain in and TOP of the inguinal canal region and insertion of RA at pubic rami
* No palpable inguinal hernia
* Pain may be aggravated by cough/sneeze (Valsalva) and/or AROM-RROM RA
59
Inguinal-related Diagnostic Imaging
* U/S
60
Pubic-related groin pain Aetiology
* Osteitis pubis/pubic bone &/or pubis symphysis stress
* Oedema, bone stress reaction, periostitis, enthesopathy, or adductor
insertional tendinopathy
* In children & adolescents, may be traction apophysitis
* Maybe secondary to microtrauma, overload, insidious gradual onset
61
Pubic-related groin pain Clinical Presentation
* Aggravated by exercise, especially twisting, turning, change of direction, kicking, single leg jumping or landing.
* Sx may be present during and after activity
* Usually long-standing pain (>6/52) before seeking help
62
Pubic-related groin pain
Physical Examination
* Local/specific TOP of pubic symphysis and/or on immediately adjacent bone
* + Adductor Squeeze (regardless of long or short lever testing position)
63
Pubic-related Diagnostic Imaging
* X-ray, MRI or CT
Bony changes
Bone oedema
Degeneration (chronic stage)
64
The Physiotherapy Scope of Practice:
P hysical devices
E PA
M anual Therapy
A dvice & Education
T herapeutic Exercise
65
GTPS specific
Posture and Biomechanics to reduce
tendon +/- bursa compression:
* Don’t ‘hang’ on one hip
* Avoid low seats/chairs
* Don’t sit cross-legged
* Avoid hip adduction
66
Hip O.A specific
Posture and Biomechanics to reduce joint load:
* Maintain mid-range joint positions
* Avoid end-range joint positions
* Gait aids
* Weight loss
* Footwear +/- orthotics
67
GTPS specific Rx
Shock Wave Therapy
Therapeutic Exercise – follow tendinopathy protocols - isometric exercise for analgesia
* low intensity pain free isometric hip abduction
exercises
* Avoid adduction (increases tendon compression)
* Closed-chain exercises in WB facilitate better
Gluteus medius activation
68
Hydrotherapy
* Good for pain relief & relieving load (e.g., osteoarthritic joints)
* Easier to exercise
69
Soft Tissue Therapy
* Trigger point release
* Massage - deep tissue massage
* Stretching, contract relax or PNF
* Acupuncture/dry needling
* Foam roller
* Massage gun
70
Physiotherapist-led rehabilitation after hip surgery should be undertaken, to address impairments in:
* hip and trunk muscle strength,
* dynamic balance
* single leg squat alignment
* gait
* ability to jump, decelerate and perform cutting movements
71
BALANCE AND PROPRIOCEPTION exercises
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