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LE Ortho > Week 1 1-B - The Hip > Flashcards

Week 1 1-B - The Hip Flashcards

1
Q

Got it

A

Got it

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2
Q

Sources of Hip Pain

Labral tear
Loose body
FAI
Capsular laxity
Hip dysplasia
Chondral damage
Joint degeneration / OA
(Intra-articular/Extraarticular)
A

Intraarticular

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3
Q

Sources of Hip Pain

Iliopsoas tendonitis
Iliotibial band syndrome
Greater trochanteric bursitis
Gluteus medius or minimus tendonitis
Stress fracture / reaction
Adductor strain
Hamstring strain / rupture
Piriformis syndrome
(Intra-articular/extra-articular)
A

Extra-articular

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4
Q

Sources of Hip Pain

Sports hernia (core injury
Osteitis pubis
Lumbar spine / SIJ
Pain referred to hip region/Intra-articular)

A

Pain referred to hip region

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5
Q

Iliotibial Band Syndrome (ITBS)

People complain of pain in the (medial/lateral) hip/knee.

A

lateral

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6
Q

Iliotibial Band Syndrome (ITBS)

Most common cause of (medial/lateral) knee pain
2nd most common cause of knee pain in runners

Occurs in cyclists frequently
(15% of overuse injury)

A

lateral

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7
Q

Lateral Hip / Knee Pain Differential Diagnosis

PFPS
DJD lateral compartment
Lateral meniscal pathology
LCL sprain
Superior tib-fib joint sprain
Popliteal or biceps femoris tendonitis
Common peroneal nerve injury

Referred pain from lumbar spine
What Level?

A

L5

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8
Q

ITBS

Clinical Presentation

Pain 2 cm (above/below) lateral joint line - (femoral epicondyle)

Usually at same point (after/of) run / bike - (irritation w/ repetition)

Stabbing / sharp pain - may not be able to continue

up/down stairs

after sitting for a period of time

Pain (increases/diminishes) with rest

A

above; of; diminishes

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9
Q

Got it

A

Got it

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10
Q

ITB Anatomy

____ crest to (inferior/superior) aspect of lateral femoral epicondyle, then again at ______ tubercle

Unattached portion where it crosses knee joint

A

iliac; superior; Gerdys

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10
Q

Got it

A

Got it

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11
Q

ITB is a thickening of the _____ lata

A

fascia

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12
Q

What attaches to the ITB?

Gluteus (maximus/minimus
TFL/Vastus intermedius)
(Medial/Lateral) retinaculum of the patella

A

maximus; TFL; lateral

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13
Q

The ITB attaches the full length of the femur

A

Got it

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14
Q

ITBS

Small portion where ITB is not attached

People have pain (above/below) the joint line

A

above

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15
Q

ITB Anatomy

“Tendon” portion - Attachment to femur

“Ligament” portion - Controls tibial (EROT/IROT)

Tendon connects muscle to bone – the muscle being the TFL – bone being the femur .

Ligament attaches bone to bone – tibia and femur

A

IROT

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16
Q

MR of distal femur

Layer of fat tissue deep to ITB:
(Highly/Lowly) innervated
(Highly/Lowly) vascular
Pacinian corpuscles
(BURSA/NO BURSA) PRESENT

At _° knee flexion, ITB compresses fat layer below against fem epicondyle

Lot of pain receptors due to being highly vascular

If you constantly compress that area it will be irritated.

A

Highly; Highly; NO BURSA; 30;

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17
Q

Iliotibial Band Syndrome

Biomechanical Etiology – Current Concept (Fairclough et al., 2006, 2007)

IT band is attached to the distal femur and cannot rub on epicondyle
IT band is compressed against epicondyle during movement
Tibial IROT occurs on femur with knee (flexion/extension)
Tibial IROT (decreases/increases) compression
Pain due to compression of fat layer under ITB vs repetitive friction

A

flexion; increases;

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18
Q

ITBS Risk Factors

Cyclists
Toe (in/out) position – pedals
Saddle too high, too far back
Bike fit?

Bike fit – can cause irritation of the IT band.

Toe in – (decreases/increases) internal rotation

A

in; increases;

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19
Q

ITBS

Clinical Tests
(+/ +/-) Noble compression test
Common: (+/ +/-)Thomas test
(+/ +/-) Ober’s test?

A

+; +; +/-

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20
Q

Clinical Findings in ITBS

significantly (higher/lower) Ober measurement (1.2°)

weaker hip (internal/external) rotator strength (1.2 Nm/kg)

Greater hip (internal/external) rotation motion (3.7°) 
Peak motion while running
A

lower; external; internal;

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21
Q

ITBS Biomechanics

Increased (ABD and EROT/ADD and IROT) at mid stance

(IROT/EROT) of leg increases with fatigue during running

A

ADD and IROT; IROT

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22
Q

Biomechanics to Consider

Associated with ITBS

(Narrow/Wide) Step Width - (cross over pattern)

A

Narrow

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23
Q

Step Width

A

Got it

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24
Q

Narrow Step Width

Narrow: >25% of heel is medial to vertical line from L5 spinous process.

This leads to (decreased/increased) ITB peak strain and strain rate

A

increased;

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25
Q

Step Width

Increased Step Width:

Reduced
Peak hip (adduction/abduction)
Peak rear foot (inversion/eversion)
ITB strain

A

adduction; eversion

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26
Q

ITBS

Biomechanical targets for rehabilitation:

With ITBS there is a Large hip (adduction/abduction) angle / (medial/lateral) collapse of hip:
Target weak hip (adductors/abductors), poor activation / neuromuscular control of the hip

-Narrow step width:
Modify running technique

A

adduction; medial; abductors;

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27
Q

ITBS Treatment Concepts

Start with basic movements like lunges, squats, etc

A

Got it

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28
Q

No US, doesn’t work

Local pain and acute – (local as in pointing to the spot) – iontophoresis is (bad/good)

A

good

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29
Q

Injection - (Acute/Chronic) and painful

A

Acute

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30
Q

ITBS Treatment

Stretch?
1 and 2 joint hip flexors
WHY? - Restricted hip flexor length (Thomas test) demonstrated (increased/decreased) gluteal activation

Self stretch
Contract- relax
Active stretch

Thomas test is positive – restricted hip (flexor/extensor) length

People with tight hip flexors don’t use their glutes well

Maintain core stability – if go into lumbar extension when doing these stretches then it will (increase/decrease) the stretch.

A

decreased; flexor; decrease;

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31
Q

This relates to IT band syndrome = if you don’t have motion north south, you’ll go east west. That will lead to _____ valgus.

A

dynamic

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32
Q

Can prob stretch the TFL, but not really the IT band.

A

Got it

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33
Q

What is the best ITB stretch out of the three pics?

A

The middle one

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34
Q

Probably not able to stretch the ITB

A

Got it

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35
Q

Look at the fascia all around that area.

Try to (stabilize/mobilize) the tissue

A

mobilize

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36
Q

Coo

A

Coo

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37
Q

Video

A

Video

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38
Q

Not the focus of treatment, but helps pts feel better.

ITB strap – redirects the force through the area that is compressed. Similar to thing used for LET. Indications - Pain that is limiting their function or trying to get through a race

A

Got it

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39
Q

ITBS Treatment Concepts

Prevent (sagittal/frontal and transverse) plane instability

Promote a “neutral” hip, knee position:
Avoid excessive (ADD/IROT/ ABD/EROT)
A

frontal and transverse; ADD/IROT

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40
Q

Blueprint to LE pathologies

Core stability – need a nice stable core to develop force through limbs

41
Q

Progression

(NWB > Bilateral WB > Unilateral WB / Bilateral WB > NWB > Unilateral WB)

CKC activities are (less/more) functional

B – bilateral

A

NWB > Bilateral WB > Unilateral WB; more;

42
Q

Activating the core (improves/declines) ability to recruit glute muscles and to generate force, for a good stable base

43
Q

Strength without stability - think of the same concept in the UE for the LE

44
Q

LE – proximal stability comes from the ____ to stabilize the pelvis and the muscles that attach to it to generate force

45
Q

Got it

46
Q

When someone does hip extension and they extend their lumbar spine it can come from tight hip (flexors/extensors)., spine will go into extension.
Another reason might be not having hip extension strength so they extend with their back. Watch pts closely so they don’t cheat even if its’ not on purpose

47
Q

Got it

48
Q

As you have resistance from UE the core (is/isn’t) activated. As you do side steps have them hold a weighted ball and that will engage their TA.

Palloff press is the pic all the way to the left

49
Q

Got it

50
Q

Hip strength/stability

51
Q

Want hips flexed more than _ degrees to increase glute max/med muscle activation

Neutral position – hips stacked, don’t want to go forward or backwards

52
Q

Also works on controlling (ER/IR) to work on NM control

53
Q

Got it

54
Q

Gluteal Muscle Recruitment

Lower crossed syndrome:
Specific patterns of muscle weakness and tightness

Weak (anterior/posterior) abdominals   (APT)
Short lumbar (flexors/extensors)
Short hip (flexors/extensors)
(Tight/Weak) gluteals – In this position gluteals can not activate effectively

Restricted hip flexor length (Thomas test) demonstrated (increased/decreased) gluteal activation

“Gluteal amnesia”

If you are in lumbar extension the hip flexors are shortened and they get tight and the glutes don’t work as well.

People with lower crossed syndrome don’t activate their glutes as well.

Have pt do clamshells on both sides. Involved side – they don’t get muscle fatigue because they are using hamstrings or something else to compensate

A

anterior; extensors; flexors; Weak; decreased;

55
Q

Got it

56
Q

Gluteal Activation

Activate gluteal muscles (prior/after) to dynamic activity
Reinforces motor program

57
Q

Got it

58
Q

Side steps – someone who has weak hip (adductors/abductors) will cheat by rocking back and forth and not keeping their pelvis level, will see hip hiking (QL)

59
Q

Pt should feel exercise on the side (on/off) the ground

60
Q

Coo

61
Q

Can make exercises harder – unstable surfaces, change BOS – make more narrow, close your eyes, tandem stance, have them reach for something like a ball that you are throwing to them, etc.

62
Q

Got it

63
Q

Added rotation

64
Q

Got it

65
Q

Got it

66
Q

Training hip extension and starting with a flexed hip to generate more force (muscle-length tension relationship – more of a mid range position so muscle works better)

67
Q

Got it

68
Q

Got it

69
Q

Pt had a hard time controlling IR in video

70
Q

Making sure it doesn’t go into a (varus/valgus) position

71
Q 
Stability
thru
(External/Internal)
Rotation
of the
Femur
72
Q

Running with it for a couple of weeks and helped her not run with so much (valgus/varus)

73
Q

Pronation distally affects what is happening up the kinetic chain

74
Q

What is Plyometrics?

Technique to develop ____ (speed-strength)

To train the muscles to become (less/more) explosive

(Concentric/Eccentric) muscle contraction immediately followed by a (concentric/eccentric) muscle contraction causes (decreased/increased) force production of same muscle

A

power; more; eccentric; concentric; increased

75
Q

Plyometrics

Benefits:

Improved neuromuscular control
(Increased/Decreased) rate and magnitude (peak impact) of loading

Decreased peak hip (abduction/adduction)

A

Decreased; adduction

76
Q

Plyometrics are done at the (beginning/end) of rehab.

77
Q

Land on box - Start pts with landing (before/after) jumping

Leg press – do much (more/less) than body weight and try to land softly.

Alternate legs - Working on quickly absorbing impact and exploding

A

before; less;

78
Q

Got it

79
Q

Coo

80
Q

Got it

81
Q

Return to Run

Run (at/under) threshold of pain
Asymptomatic (during/during and after)
Increase run volume (mileage / time) as (mobility/stability) improves

Return to run
Start with intervals - run/walk
At volume that is (not too symptomatic/asymptomatic)
Increase volume (mileage / time) as (mobility/stability) improves
Monitor for symptoms

If pain comes on at 4 miles , run underneath that

A

under; during and after; stability; asymptomatic; stability

82
Q

If you don’t correct their mechanics it comes back. Treat it like someone who has ITBS.

83
Q

Trochanteric Bursitis

Between what two gluteal muscles?

Between greater trochanter and (TFL/Rectus femoris)

A

medius and minimus; TFL

84
Q

Got it

85
Q

Trochanteric Bursitis

Clinical presentation:

Pain: (medial/lateral) aspect of thigh
Tenderness over/around (lesser/greater) trochanter
Onset: typically (trauma/insidious), may be (trauma/insidious)

Pain with 
Contraction of (adductors/abductors)
Passive stretch of (adductors/abductors)
Full passive (flexion/extension), (adduction/abduction), and (internal/external) rotation
Pressure on (lateral/medial) hip

MMT will be painful with abduction, stretching into adduction will be painful.

A

lateral; greater; insidious; trauma; abductors; abductors; flexion; adduction; internal; lateral

86
Q

Trochanteric Bursitis

Clinical presentation:
Snap in the (anterolateral/posterolateral) hip region may be reported.
May report pain with ascending or descending stairs
Weak hip (adductors/abductors)
(+/ +/-) Trendelenburg
Gait deviations - Compensated trendelenburg

A

posterolateral; abductors; +;

87
Q

Trochanteric Bursitis

Pain in (medial/lateral) hip with possible radiation of pain down to (ankle/knee) region.  
Often resembles Lumbar Spine pain referral pattern.

How do you differentiate?

Reproduction with L spine movement?
Dermatomes? Sensation changes?
Myotomes?
DTR’s?
Dural Tension signs? (SLR)
Palpation Gr trochanter
Hip motion (compression)

You know its not from the lumbar spine – based on the repeated motions

LQ screen – do that to rule out the spine as the source of pain

If palpating the greater trochanter and there is pain it (is/is not) lumbar spine

A

lateral; knee; is not;

88
Q

Trochanteric Bursitis

Treatment

Remove stress:
Change lying position/padding (pillow between knees)
Modify activity level
Stretch tight tissues
(Distal/Proximal) strengthening

Anti-inflammatories:
NSAIDS
Modalities

89
Q

Trochanteric Bursitis

Early: resisted (isokinetics/isotonics) may be painful

90
Q

Got it

91
Q

Hamstring Strain

Occurrence:

2nd most common cause of injury in NFL
(knee sprain first)

1st for Elite level soccer

Re injury rate:
High -  (1/3 / 2/3) !!!!
Greatest risk during first _ weeks of return to sport:
Inadequate rehab
Return too early
both
92
Q

Mechanism of Hamstring Injuries

(Low/High) speed running
(Initial/Terminal) swing phase of gait
Hamstrings are active (accelerating/decelerating) shank in prep for foot contact
Large (concentric/eccentric) demand
(Acceleration/Deceleration) injury
(Semitendinosus/Biceps femoris) more often injured

Simultaneous hip (flexion/extension) and knee (flexion/extension)
Kicking
Dancing
Stretch injury
Semimembranosis

Hamstrings have to decelerate the tibia and it is a large eccentric demand

Most peoples quads are a lot stronger than their hamstrings

A

High; Terminal; decelerating; eccentric; Deceleration; Biceps femoris; flexion; extension

93
Q

Got it

94
Q

Hamstring Strains

Grades

Grade 1 - (mild/moderate)
Grade II - (mild/moderate)
Grade III - (moderate/severe)

Based on amount of:
Pain
Damage
Loss of motion
Reflects underlying amount of tissue damage

Can be used to estimate recovery period

More damage - the longer it takes to heal

A

mild; moderate; severe;

95
Q

Hamstring Exam

History
Sudden onset of (anterior/posterior) thigh pain during activity (running)
Audible pop - (distal/proximal) tendon
Usually unable to continue activity

Purpose of exam:
Location and severity of injury
Mechanism and location have prognostic impact on time to return to pre injury level

Biceps femoris - (high speed running/kicking)
(Shorter/Longer) recovery period

Semi membranosis - (high speed running/kicking)
(Shorter/Longer) recovery period

A

posterior; proximal; high speed running; Shorter; kicking; longer

96
Q

Hamstring Exam

Palpation:
Palpable defect - grade (1/3)
Measure length of palpable pain region - Healing reassessment

Location of pain - distance from point of maximal pain to IT
More proximal the site of the point of maximal pain, the (shorter/greater) the time needed to recover

IT - Ischial tuberosity

Palpate where pain is

Complete rupture – can feel where it is torn

The larger the area is the longer the healing

Distal hamstring tears equate to a quicker recovery

A

3; greater;

97
Q

Longer Recovery

Injury involving (biceps femoris/semimembranosis)
Proximity of injury to IT
Size of tissue damage - Length and cross sectional area

A

semimembranosis;

98
Q

Differential diagnosis:
Lumbar radiculopathy - Lumbar spine screen

Adductor strain – gracilis, adductor magnus
How do you know?
Pain with: 
Resisted (ADD/ABD)  
Passive (ADD/ABD)
Palpation (ADD/ABD) tendons

Combined injury: semi M and Add Magnus
Lateral Split / lunge (tennis)

A

ADD; ABD; ADD

99
Q

Got it

100
Q

T2 weighed MRI – White - fluid – black – swelling and scar

101
Q

Scar Formation

Changes tensile properties / length of hamstring muscle
Increases (active/passive) stiffness
May change force generating capabilities
Less capable of withstanding (concentric/eccentric) loads

(Decreased/Increased) susceptibility to re-injure.

A

passive; eccentric; Increased

LE Ortho (19 decks)

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