Week 4 Flashcards
What are the normal pregnancy challenges in the 1st trimester of pregnancy?
– Nausea/morning sickness (vs HG)
– Dizziness/lightheadedness
– Fatigue
What are the normal pregnancy challenges in the 2nd trimester of pregnancy?
– Low blood pressure (watch out for orthostatic hypotension!)
– Easily dehydrated
What are the normal pregnancy challenges in the 3rd trimester of pregnancy?
– Cramping/pain with uterine stretching – Fatigue – Dizziness/lightheadedness – Easily dehydrated – Braxton-Hicks contractions – Stress incontinence – Shortness of breath – Pain/swelling in the feet
What are the big changes a pregnant woman experiences that may lead to an MSK problem?
– 25-35 pounds gained (on average) – Force across the joints is increased up to 2-fold – Release of hormones (primarily relaxin) triggers laxity in ligaments and increased mobility in the joints – Position of uterus/weight distribution changes dramatically – Dramatic increase in breast size
What are the red flags to watch out for in the pregnant population?
• DVT/Blood Clot (increased risk during pregnancy due to changes in blood flow)
– Requires immediate referral to ED
• Blood glucose crisis
• Fracture
– Transient osteoporosis of pregnancy (rare)
• Preterm labor symptoms
– Differentiate from Braxton-Hicks
What is the biggest thing to find out about the precautions and contraindications of pregnancy?
• It is crucial to determine whether the patient has had an uncomplicated pregnancy thus far!
What do you do if a patient has a history with the complication of a pregnancy?
– If there has been a complication, make sure you
consult with the doctor or another resource to determine what level of intervention is acceptable
What are the contraindications, precautions when a patient has had episodes of early labor?
- Exercise that gets the heart rate up may be contraindicated
- Manipulations/mobilizations are
contraindicated - Massage is a precaution
What is one thing to make sure to measure if pre-eclampsia is a concern?
Blood pressure
What are the normal pregnancy precautions/ contraindications?
– No prolonged supine positioning during the 3rd trimester*
– Most cannot tolerate prone positioning
– No heavy lifting
– No Valsalva/breath holding during exercise
– Monitor for lightheadedness and educate regarding eating
prior to exercise to hold off potential hypoglycemic events
– No moist heat on the low back or abdomen (cold is fine)
• Heat recommendation: don’t increase core body temp by >1 deg F
– No electrical stimulation or therapeutic ultrasound on the
low back or abdomen
How is the physical examination process of a pregnant patient different form a normal patient?
No difference, except more attention being paid to the positioning of the pregnant patient
___ physical exam is very important in the pregnant patient and why?
Gait analysis physical exam is very important in the pregnant patient.
Very important, because it gives the most vital information about functional strength since MMT positions might not always be possible
It is never too early to educate about the correct way to ___
It is never too early to educate about the correct way to sit up!!
What position should a patient use to try to sit up and what is the purpose?
Log roll. Purpose is to prevent or decrease the severity of diastises rectus abdominis
What is the biggest change a PT makes during a joint mobility physical exam?
Changes in the spine mbility.
– Lumbar mobility-sidelying
– Thoracic/rib mobility-seated and leaning forward
– Cervical mobility-lower the table, stand behind them
What happens to the hip in hips joint mobility?
Hips: reclined or supine
What are the normal findings during pregnancy?
- Laxity in joints
- Increased lumbar lordosis
- Slight “waddle” in gait (after about week 35)
- “G11ravid” appearance (enlargement of abdomen)
What are the abnormal findings during pregnancy?
• Pain with joint mobilization • Increased thoracic kyphosis • Trendelenberg or antalgic gait pattern • High tone/”spasm” feeling in lower abdomen • Inability to single leg stance
What is the most common MSK pain in pregnant patients?
Low back and SI pain
What is the cause of low back and SI pain in pregnant patients?
Gravid uterus (posterior posture) causes weight of the uterus to be carried posterior to normal center of gravity. This creates a tremendous mechanical strain on the low back.
– Additionally, relaxin causes ligamentous laxity in
the spine and pelvic jointsWhat are the characteristics of low back/ SI pain in the pregnant population?
• Very exaggerated Trendelenberg gait (can be compensated or uncompensated)
• Inhibited ability to use pelvic floor and/or abdominal musculature
• Dramatically increased joint
mobility in the lumbar spine and SI region
• Often accompanied by muscle spasms
• Increased pain with single leg
stance or active hip flexion
• Often point tender to palpation
____ is severe leg pain that may accompany low back pain or occur in isolation and can often be severe enough to wake pregnant patient at night
Sciatica is severe leg pain that may accompany low back pain or occur in isolation and can often be severe enough to wake pregnant patient at night
Pregnant women do NOT have a higher incidence of disc herniation, and as a result their sciatica is a ___ one from ___
Pregnant women do NOT have a higher incidence of disc herniation, and as a result their sciatica is a mechanical one from *the changes in the joint position and the joint pressures, posture and are accompanied by spasms in the piriformis
The sciatica in the pregnant patient is more of a ___ syndrome than it is a disk herniation sciatica
The sciatica in the pregnant patient is more of a piriformis syndrome than it is a disk herniation sciatica
What are the characteristics of a sciatica in pregnant patients?
• Common to see antalgic gait in addition to Trendelenberg
• Typically worsens with standing or walking and is relieved in hooklying (but not sitting)
• May present as pain only or be accompanied by weakness
and/or numbness and tingling
• Can switch sides or be bilateral
What are the treatment options for LBP and sciatica in the pregnant population?
• Maternity support belt-helps lift weight closer to the center
of gravity and supports the joints
• Belly wrapping
• Manual Therapy
• Neuromotor retraining of the transverse abdominus and
other spinal stabilizers
• Stretching and strengthening as needed (determined during
initial evaluation)
• Pelvic mobilization exercises
• Modified hand/heel rocks, hula hoop
• Education: flat shoes, adequate rest, KEEP MOVING!
What are the manual therapy treatment techniques for pregnant patients?
- Soft tissue mobilization
- Lumbar mobilization/manipulation
- Muscle energy techniques
- Pelvic shotgun is particularly helpful for SIJ pain
- Hip long axis distraction
Meralgia parasthetica/ lateral femoral neuropathy can be ___ or ___
Meralgia parasthetica/ lateral femoral neuropathy can be unilateral or bilateral
Meralgia parasthetica/ lateral femoral neuropathy typically presents as a ___
Meralgia parasthetica/ lateral femoral neuropathy typically presents as a * burning pain along the skin innervated by the lateral femoral cutaneous nerves*
Meralgia parasthetica/ lateral femoral neuropathy is caused by ____
Meralgia parasthetica/ lateral femoral neuropathy is caused by * compression of the
lateral femoral cutaneous
nerves*
Meralgia parasthetica/ lateral femoral neuropathy is usually resolved with ___
Meralgia parasthetica/ lateral femoral neuropathy is usually resolved with delivery
What are the presentation characteristics of meralgia paresthetica?
– Weak hip flexors and gluts – Weak hip abductors – Tight ITB, piriformis, and hamstrings – Antalgic and/or Trendelenberg gait – Pain is not usually position dependent
What are the treatmennt options for meralgia paresthetica?
• Worst case-surgical excision after delivery • Exercise • Neuromotor re-education – Hip flexors, spinal stabilizers, gluts • Manual therapy • Ice may be used (cold pack or ice massage) as a pain relief mechanism PRN • A support belt is often helpful
What are the exercise techniques used for treatment of meralgia parasthetica?
– Aerobic exercise-Nustep or recumbent bike
– General hip strengthening
What are the manual therapy techniques used for treatment of meralgia parasthetica?
– Hip long axis distraction
– MFR to ITB and hip flexor tendons
Is there a motor component to meralgia parasthetica?
No, because the lateral femoral cutaneous nerve does not have any motor innervations
The compression of the lateral femoral cutaneous nerves that lead to meralgia parasthetics is caused by ___
The compression of the lateral femoral cutaneous nerves that lead to meralgia parasthetics is caused by a combination of tightness of the musculature and ligaments and the weight of the baby
What is a double crush syndrome?
Dual entrapment of a nerve-usually one proximal and one distal site
Most of the time during pregnancy one is a true entrapment (scar tissue from an old ankle injury, fibular head immobility from an old sprain, etc.) and the other is ____
Most of the time during pregnancy one is a true entrapment (scar tissue from an old ankle injury, fibular head immobility from an old sprain, etc.) and the other is an irritation from excess movement of the sacrum and pelvis
What are the characteristics of a double crush syndrome?
– Extreme pain with radicular component
– May or may not be positional in nature
– Patients may be very debilitated (need walker for gait)
What are treatments for a double crush syndrome?
– Relieve secondary site of compression, work on stability and position/alignment of sacrum/pelvis
In pregnancy, ____ may accompany back pain or occur in isolation and its most common cause is pelvic instability
In pregnancy, hip pain may accompany back pain or occur in isolation and its most common cause is pelvic instability
What are the 2 rare yet serious potential diagnoses of hip pain in the pregnant population?
– Transient osteoporosis of the hip
– Osteonecrosis of the femoral head
What is the exact mechanism of osteonecrosis of the femoral head in the pregnant population?
Exact mechanism unknown, but the rise in cortisone
levels may be partly to blame
What are the characteristics of transient osteoporosis of the hip?
– Occurs during the 3rd trimester
– Pain and limitation of ROM of the hip accompanied by
radiographic signs of unilateral or bilateral osteoporosis of the hip
with preservation of joint space
– Continued unprotected weight bearing can result in a fracture of the femoral neck
What are the characteristics of the osteonecrosis of the femoral head during pregnancy?
– Symptoms usually begin in 3rd trimester
– Deep pain the groin radiating to the knee, thigh, or back
– Unlike most pathologies, this will not resolve upon delivery
What are the presentations of osteonecrosis of the femoral head and transient osteoporosis of the hip?
- Extreme waddling gait
- Pain is deep in the groin
- Pain is not position dependent
- Extreme loss of AROM
What are the treatment options for normal hip pain?
– Strengthen hip musculature – Manual therapy (soft tissue and joint mobilization) as needed for pain control – Retrain core musculature as needed – Heat or ice as needed – Sleep with a pillow between the knees
Pubic symphysis pain often occurs in conjunction with __ or ___ pain
Pubic symphysis pain often occurs in conjunction with low back or hip pain
What is the cause of pubic symphysis pain?
Pelvic instability which can
lead to displacement of pubic
symphysis
What are the symptoms/presentations of pubic symphysis pain?
- Pain (often sharp/severe) directly over pubic symphysis,
- Extreme Trendelenberg
gait - Difficulty initiating/ controlling hamstrings
and quads
How can pubic symphysis pain be relieved?
May be relieved by
position changes
What are the treatment options for pubic symphysis pain?
– Pelvic shotgun muscle energy technique
– Pubic symphysis mobilizations
– Manual therapy to sacrum/sacroiliac joints
• Muscle energy techniques, sidelying sacral distraction, soft tissue mobilization
– Retrain transverse abdominus
and pelvic floor musculature
– Other strengthening as needed
What are the causes of thoracic and or rib pain in the pregnant population?
• Dramatic increase in breast size can put relatively sudden increased strain on scapular stabilizers
• Relaxin decreases the ligamentous stability in the
thoracic spine and rib cage
• As the baby grows it can place a strain the ribs and intercostals from the inside
What are the characteristics of thoracic and or rib pain in the pregnant population?
– Rib pain often focal and localized
– Decreased thoracic and rib mobility
– Pain with deep inspiration or expiration
– Pain with coughing/sneezing/laughing
– May have pain with UE movement (sometimes incorrectly diagnosed as a shoulder pathology)
– Can be accompanied by symptoms of neural impingement
What are the treatment options for thoracic and or rib pain in the pregnant population?
– Strengthening of the scapular stabilizers
– Mobilization/METs for thoracic spine and ribs
– Spine mobility exercises
– Breathing exercises
– Soft tissue work as needed for pain control
What is the cause of neck pain or cervicogenic headache?
Growth of breasts/changes in posture placing new strains
on muscles and joints plus joint hypermobility
What are the characteristics of a cervicogenic headache?
– May be bilateral or unilateral, commonly unilateral
– Worsens with sitting, may worsen with activity
– Need to differentiate from other forms of headache
(can have hormonal headaches with pregnancy)
– Usually have spasm of upper trapezius, levator
scapula, suboccipitals
What is the 2nd most common complaint of pain in the pregnant population?
Carpal tunnel syndrome
When does carpal tunnel syndrome usually occur?
Most commonly in the 2nd and 3rd trimesters, usually bilateral
What is the cause of carpal tunnel syndrome?
Swelling in the carpal tunnel due to the body’s tendency to retain fluid during pregnancy
What are the treatment options carpal tunnel syndrome?
Primarily palliative; custom molded night splints can be helpful
- Manual therapy and exercise can also be of aid if splinting alone is inadequate
Exercise/fitness in the pregnant population depends on ___
Exercise/fitness in the pregnant population depends on prior level of fitness
What exercises can be done only in the 1st trimester?
Normal abdominal exercise
What type of exercises should be done after the 1st trimester?
Stabilization type exercise
What are the specific exercises should be done in pregnancy?
- Resistance training is fine-low weight, high repetitions
- Cardiovascular is great-swimming, walking,
biking, running - Stretching is especially important
- Yoga and pilates can both be really great!
What are exercises to avoid during pregnancy?
Avoid exercise in supine after mid second trimester
__% of people with n back pain have a bulging disc
40% of people with n back pain have a bulging disc
What are the main points in the summary of psychological processes of pain?
- Attention
- Cognition
- Emotion
- Behavior
Pain demands ___
Pain demands attention
What is the cognition portion of the psychological processes of pain?
How we think about pain may influence it
What is the emotion portion of the psychological processes of pain?
Pain often generates negative emotions which can influence other aspects
What is the behavior portion of the psychological processes of pain?
What we do to cope with pain may also influence it
What is a description of the fear-avoidance model?
A painful injury may result in catastrophizing and fear, which lead to avoidance of certain movements.
What does the fear-avoidance model behavior lead to?
Leads to more avoidance, dysfunction, depression, and ultimately more pain
What is the cognitive psychological process featured in the fear-model behavior?
- Cognitive interpretation featuring catastrophizing
What is the emotion psychological process featured in the fear-avoidance model?
- Fear, worry and depression
What is the attention psychological process featured in the fear-avoidance model?
Fear keys attention on internal stimuli (hypervigilance)
What is the behavior psychological process featured in the fear-avoidance model?
Avoidance of movement
What is the mechanism of the fear-avoidance behavior?
Activity avoidance leads to physical degeneration and social isolation; vicious circle
What are some examples of treatment intervention strategies of fear-avoidance behavior?
Promote physical and social activation
What is the description of the acceptance and commitment model?
Rigid beliefs may block the pursuit of long-term life goals. Reducing futile attempts to achieve unrealistic goals (acceptance) produces flexibility and engagement in pursing important life goals (commitment)
What is the cognitive psychological process featured in the acceptance and commitment?
Flexibility in beliefs, life goals, and commitment
What is the emotion psychological process featured in the acceptance and commitment model?
Anger and frustration
What is the behavior psychological process featured in the acceptance and commitment model?
Commitment, and pursuing goals
What is the mechanism of the acceptance and commitment model?
Repeated (futile) attempts to control or alleviate pain lead to frustration
What are some examples of treatment intervention strategies of acceptance and commitment model?
Provide realistic treatment goals and encourage patient participation in decision making
What is the description of the misdirected problem-solving model?
Normal worry about pain may tune the patient into certain ways of solving this problem. When this does not actually solve the problem, it results in more worry and an even narrower view of the nature of the problem, making it less likely to actually solve the problem
What is the emotion psychological process featured in the misdirected problem-solving model?
Worry as a driving force
What is the attention psychological process featured in the misdirected problem-solving model?
Pain demands attention
What is the cognitions psychological process featured in the misdirected problem-solving model?
Belief about cause of pain
What is the behavior psychological process featured in the misdirected problem-solving model?
Attempts to solve problem
What is the mechanism of the misdirected problem-solving model?
Hypervigilance to pain symptoms to contributes to rumination and failed attempts to escape pain; vicious circle
What are some examples of treatment intervention strategies of misdirected problem-solving model?
Redirect problem-solving effects toward achievement of functional goals
What is the description of self-efficacy model?
The belief that a person is capable of coping with pain is directly related to self-management; low self-efficacy, with feelings that the pain is uncontrollable cause physical and psychological dysfunction
What is the cognition interpretation psychological process featured in the self-efficacy model?
Beliefs concerning controllability of pain
What is the behavior psychological process featured in the self-efficacy model?
Coping skills
What is the mechanism of the self-efficacy model?
Fluctuating pain reduces perceptions of control and mastery over pain
What are some examples of treatment intervention strategies of the self-efficacy model?
Encourage self-care and self management strategies, reduce dependence
What is the description of stress-diathesis model?
Significant psychological stress and limited coping resources predispose a person to pain and being less prepared to deal with it. Thus, pain is more likely to result in functional difficulties and emotional distress
What is the emotion psychological process featured in the stress-diathesis model?
Stress, depression and anxiety
What is the behavior psychological process featured in the stress-diathesis model?
Coping strategies and skills
What is the mechanism of the stress-diathesis model?
Protective psychological factors buffer the emotional impact of pain, whereas distress and emotional dysregulation predispose to pain
What are some examples of treatment intervention strategies of the stress-diathesis model?
Improve stress management skills and social support
Graded exercise is based on ___
Graded exercise is based on operant conditioning principles
What is the primary intervention goal of graded exercise?
Increase in activity through quota attainment
Graded exercise intervention does not focus on ___
Graded exercise intervention does not focus on symptom reduction
What are the two types of graded approach?
- Graded activity
- Graded exposure
What does graded activity focus on?
Focuses on functional activities and progresses in a time-contingent manner regardless of pain
What does graded exposure focus on?
Working from least fearful activity to most fearful
Graded activity in the short term and intermediate term is
___ effective than MINIMAL care, but no more effective than other forms of exercise
graded activity in the short term and intermediate term is
slightly more effective than MINIMAL care, but no more effective than other forms of exercise
What are the 3 phases of intervention strategy in the graded approach?
- Pain neuroscience education (PNE)
- Cognition-targeted neuromuscular training
- Cognition-targeted dynamic and functional exercise
What does the pain neuroscience education component of the 3 phases of intervention strategy in the graded approach entail?
Changing pain beliefs through the reconceptualization of pain, so they’re not fearful about pain
What does the cognition-targeted neuromuscular training component of the 3 phases of intervention strategy in the graded approach entail?
- Time contingent training of coordinated activity of the spinal muscles besides the pain
- Progression to the next level preceded by motor imagery
What does the Cognition-targeted dynamic and functional exercise component of the 3 phases of intervention strategy in the graded approach entail?
- Increasing complexity of exercises to functional tasks
- Progression toward those movements for which the patient is fearful
- Exercises during cognitively and psychosocially stressful conditions
What are the steps in the approach towards accounting for the PT’s and patient’s belief and attitudes regarding chronic musculoskeletal pain in clinical practice?
- Therapist self reflection
- Asses patient’s attitudes and beliefs
- Clinical reasoning
- Education for the alignment of beliefs
- Treatment
What are the principles for providing cognition-targeted exercise therapy for chronic musculoskeletal pain?
- Time contingent exercises
- Goal setting
- Address perception about exercises
- Motor imagery
- Address feared movements
- Make use of stress
What is the explanation of the time contingent exercises principle for providing cognition-targeted exercise therapy for chronic musculoskeletal pain?
Do not let pain determine the number of repetitions or exercise duration
What is the explanation of the goal setting principle for providing cognition-targeted exercise therapy for chronic musculoskeletal pain?
Let the patient define the treatment goals. Use the predefined goals to design the exercise program. Use the goals for motivating patients
What is the explanation of the address perception about exercises for providing cognition-targeted exercise therapy for chronic musculoskeletal pain?
Question and if required discuss thoroughly the patient’s perceptions about exercises
What is the explanation of the motor imagery for providing cognition-targeted exercise therapy for chronic musculoskeletal pain?
When progressing to a next level(more difficult) of exercise, a preparatory phase of motor imagery may be helpful
What is the explanation of the address feared movements for providing cognition-targeted exercise therapy for chronic musculoskeletal pain?
Retrain pain memories especially for feared movements. Discuss the fears thoroughly and challenge the perceptions about negative consequences of performing the movements. Apply graded exposure in vivo principles
What is the explanation of the make use of stress for providing cognition-targeted exercise therapy for chronic musculoskeletal pain?
Progress towards exercising under cognitively and psychosocially stressful conditions
What are the things required for the completion of tasks involving the lower quarter?
Healthy hip, knee and ankle joints working in concert of the core musculature and the body’s neurological control centers
What are the variabilites that we see in the lower quarter?
- Patient variability
- Condition variability
What are the functions of the pelvis?
- Supports the abdominal contents
- Links vertebral column to the lower limbs
- Transmits forces from the lower limbs to the vertebral column (trabecular systems)
What makes up the pelvis?
Sacrum, coccyx, innominate
bones
What are the joints in the pelvis?
- Lumbo-sacral
- Sacroiliac (2)
- Sacro-coccygeal
- Symphysis pubis
- Hip joints (2)
The acetabulum is a ___ socket
The acetabulum is a concave socket
What does the acetabulum consist of?
- 2/5 ilium
- 2/5 ischium
- 1/5 pubis
The acetabulum is ___ in configuration
The acetabulum is ellipsoidal in configuration
What is the upper margin of the acetabulum?
True circular contour
The roundness of the acetabulum decreases with ___
The roundness of the acetabulum decreases with age
How is the acetabulum oriented?
Anterior-lateral-inferior
The magnitude of the anterior orientation of the acetabulum is described as ___
The magnitude of the anterior orientation of the acetabulum is described as anteversion
What is the angle of acetabular anteversion of men?
18.5 deg
What is the angle of acetabular anteversion of women?
21.5 deg
The larger the angle of acetabular anteversion, the ___ the stability
The larger the angle of acetabular anteversion, the less the stability
What does the lesser stability of the acetabulum do?
It increases the likelihood of the anterior dislocation of the head of the femur
The acetabular labrum is a ____ shaped component of the acetabulum that is made up of ___
The acetabular labrum is a Wedge shaped component of the acetabulum that is made up of fibrocartilage
The labrum has free ____ present and receives
vascularization from ___ (superficially)
The labrum has free nerve endings present and receives
vascularization from adjacent capsule (superficially)
What is the function of the labrum?
- Deepens socket (Increases joint concavity)
- Grasps femoral head to maintain contact with acetabulum
- May serve proprioceptive and pain sensitivity role
What does the center edge angle describe?
The actual roof of acetabulum that sits over the top of the femoral head
As the center edge angle decreases, there is more ____
As the center edge decreases, there is more instability of the joint
What is the center edge angle in men?
38 deg
What is the center edge angle in women?
35 deg
The center edge angle is used radiographically to describe ____
The center edge angle is used radiographically to describe potential sources of instability in the hip
What is the shape of the femoral head?
1/2-2/3 sphere
The femoral head is lined with ____
The femoral head is lined with hyaline cartilage
What is the ligament of the head of the femur?
Fovea capitis
What is the orientation of the femoral head?
Faces medial, superior,
and anterior
The angle of inclination helps to describe ___
The angle of inclination helps to describe the orientation in of the femoral head and neck in the frontal plane
What is the average angle of inclination?
126 deg
What happens to the angle of inclination with age?
It decreases
What is coxa valga?
Pathologic increase in angle of
inclination.
What does coxa valga do functionally?
- Decreases the hip abductor moment arm (requires greater amount of muscle stabilization)
- Decreases articular contact
A decrease in the articular contact as seen in coxa valga leads to…?
Less stability
What are some of the clinical relevance of coxa valga?
• Long ipsilateral leg • Ipsilateral subtalar pronation • Contralateral subtalar supination or plantar flexion • Lateral rotation of leg • Ipsilateral genu recurvatum • Ipsilateral knee/hip flexion • Ipsilateral anterior pelvic rotation/contralateral lumbar rotation
What is coxa vara?
Pathologic decrease in angle of inclination.
At what angle of inclination does coxa valga begin?
Over 150 deg
At what angle of inclination does coxa vara begin?
Less than 120 deg
What does coxa vara do functionally?
- Increases abductor moment arm
- Increases joint stability
- Increases shear force across neck
What are some of the clinical relevance of coxa vara?
• Short ipsilateral leg • Ipsilateral subtalar supination/plantar flexion • Contralateral subtalar pronation • Contralateral genu recurvatum • Contralateral hip/knee flexion • Ipsilateral posterior pelvic tilt/ipsilateral lumbar rotation
What is the angle of torsion?
Degree of forward projection of femoral neck to such that it is anteriorly positioned from the coronal plane of the shaft in the transverse plane
What is the normal angle of torsion in children?
40 deg
What is the normal angle of torsion in adults?
10-20 deg
The angle of torsion is between the ___ and the ____
The angle of torsion is between the femoral neck axis & the femoral condyle axis
The angle of torsion reflects the ____
The angle of torsion reflects the * medial rotation of the femoral condyles*
What is anteversion?
Pathologic increase in the angle of torsion
What are the standard angles of torsion of anteversion?
• > 30°
• 60° children with CP
• 42.3° + 16° those with hip
dysplasia
Anteversion is commonly seen with ___
Anteversion is commonly seen with Coxa Valga
Anteversion affects the ___ and the ___
Anteversion affects the knee and the feet
Anteversion is considered a ____ tibial & femoral torsion
Anteversion is considered a medial tibial torsion
What are the clinical findings of anteversion?
- Excessive hip IR, limited ER
- Squinting patella (patellas looking at each other)
- Lateral patellar subluxation
- Toeing in
What is retroversion?
Pathological decrease in the angle of torsion
Retroversion is considered a ____ tibial & femoral torsion
Retroversion is considered a lateral tibial & femoral torsion
What are the clinical findings of retroversion?
Toeing out
What are the positions of vulnerability/instability of retroversion and may be anteversion?
• Flexion w/ ADD (legs crossed) • MOI - axial load with knee flexed • Car accident – dashboard injury • Anterior < 10% • Posterior > 90% • Posterior : Adducted and flexed posture • Avascular necrosis occurs in up to 40% of adults
The hip joint capsule is strong and dense, and it contributes extensively to the ___ of the joint
The hip joint capsule is strong and dense, and it contributes extensively to the stability of the joint
What are the 2 sets of fibers found in the hip joint capsule?
- Longitudinal fibers: superficial
* Circular fibers: zona orbicularis
Where is the hip joint capsule more thickened and where is it more loose?
- Thickened anterosuperior
* Thin and loose posteroinferiorly
What movements does the thickness and looseness of the hip joint capsule allow?
- Flex/Ext
- ABD/ADD
The femoral neck is ____ in relation to the hip joint capsule, while the greater and lesser trochanter are ____
The femoral neck is intra-capsular in relation to the hip joint capsule, while the greater and lesser trochanter are extra-capsular
From where to where does the iliofemoral ligament attach?
Fron the AIIS to the intertrochanteric line
The superior band fibers of the iliofemoral ligament are the ____ of all the other hip structures
The superior band fibers of the iliofemoral ligament are the strongest of all the other hip structures
In what movements is the iliofemoral ligament taut, hence doing most of its work?
Extension and external rotation
Superior fibers of the iliofemoral ligament may be taut in ___ and inferior
fibers taut in ___
Superior fibers of the iliofemoral ligament may be taut in adduction and inferior
fibers taut in abduction
The pubofemoral ligament runs from the ___ to the ____
The pubofemoral ligament runs from the pubic ramus to the intertrochanteric fossa
In what movements is the pubofemoral ligament taut?
Taut in abduction, extension & external rotation
From where to where does the ischiolfemoral ligament run?
From the posterior acetabular rim & labrum to zona
orbicularis and inner
surface of G. trochanter
In what movement does the ischiofemoral ligament tighten?
Extension, IR, ER
All ligaments of the hip joint tighten with ___ and all
relax with ___ movements
All ligaments of the hip joint tighten with extension and all
relax with flexion
Hip Joint, Capsule, and Ligaments supports how much of the body weight?
2/3rd of the body weight
What is the position of the hip joint in normal standing?
Hip joint neutral or slight extension
Where is the LoG in reference to the hip joint?
Behind hip joint (extension moment)
Capsuloligamentous structures are strong enough to support stance w/o ____ support
Capsuloligamentous structures are strong enough to support stance w/o muscular support
The ligamentum teres is intra-articular, but also ____
The ligamentum teres is intra-articular, but also extrasynovial
The ligamentum teres runs from the ___ to the ____
The ligamentum teres runs from the * acetabular notch to
the fovea*
Ligamentum teres is not for ___
Ligamentum teres is not for stability
Ligamentum teres is a conduit for ___ and ____
Ligamentum teres is a conduit for secondary blood and nerve supply
The more weight gained, the higher the ground force to the body goes. This two forces meet at the ___
The more weight gained, the higher the ground force to the body goes. This two forces meet at the hip/hip joint
The weight bearing of the hip creates a ____
The weight bearing of the hip creates a bending moment
The moment arm of the hip depends on the ___ and ___
The moment arm of the hip depends on the length and angle of femoral neck
In its adaptation to weight, the hip gets ___ forces superiorly and ____ forces inferiorly
In its adaptation to weight, the hip gets tensile forces superiorly and compressive forces inferiorly
What does the trabecular patten of the hip joint do?
It adds some inherent stability to try to adequately disperse forces and prevent potential fractures
In the areas where the major systems cross, there is the _____ strength
In the areas where the major systems cross, there is the greatest strength
What are the characteristics of the zone of weakness?
- Thin trabeculae, no crossing
- More prone to injury
- Susceptible to bending forces
What is the normal end feel for the hip joint?
Tissue stretch or approximation
What is the AROM and PROM of flexion in the hip joint?
AROM: 120-130
PROM: 120-135
What is the AROM and PROM of extension in the hip joint?
AROM: 10-20
PROM: 10-30
What is the AROM and PROM of ABD in the hip joint?
AROM: 40-45
PROM: 30-50
What is the AROM and PROM of ADD in the hip joint?
AROM: 20-30
PROM: 10-30
What is the AROM and PROM of ER in the hip joint?
AROM: 40-50
PROM: 45-60
What is the AROM and PROM of IR in the hip joint?
AROM: 35-45
PROM: 30-45
Tibial anteversion is related to a decrease in what motion at the hip?
External rotation will decrease
What are the problems that come with the decrease in ER of the hip?
• Risks subluxation
• Encounter muscular and
capsuloligamentous restrictions anteriorly
Tibial anteversion also leads to an increase of ___, even though it is less
Tibial anteversion also leads to an increase of IR, even though it is less
What are the convex and concave surfaces of the acetabulum?
Convex: Femoral head
Concave: Acetabulum
In an open kinetic chain/ non weight bearing movement, what is the movement of the hip joint like?
- Convex(femoral head) on Concave(acetabulum)
* Head glide in direction opposite of distal end of femur
In a closed kinetic chain/ weight bearing movement, what is the movement of the hip joint like?
• Concave (aceabulum) on Convex (femoral head)
• Acetabulum moves in the same direction as the
innonimate
A posterior pelvic tilt is a hip ___
A posterior pelvic tilt is a hip extension
An anterior pelvic tilt is a hip ___
An anterior pelvic tilt is a hip flexion
A right hip pelvic hiking will do what to to the left hip?
L hip ABD
A right hip pelvic drop will do what to to the left hip?
L hip ADD
Bilateral weight bearing leads to a __ in the pelvis as we are taking a step
Bilateral weight bearing leads to a drop in the pelvis as we are taking a step
What does a pelvis shift to the right result in?
- Left pelvic drop
- Left hip abduction
- Right hip adduction
Pelvic rotation is a normal part of ___
Pelvic rotation is a normal part of gait
A forward pelvic rotation equates to ___
A forward pelvic rotation equates to hip IR of supporting limb
A backward pelvic rotation equates to ___
A backward pelvic rotation equates to hip ER of supporting limb
The lumbopelvic rhythm is the ____
The lumbopelvic rhythm is the coordinated hip/pelvis/spine motion
What is the accompanying hip motion and the compensatory lumbar motion of the pelvic motion: anterior pelvic tilt?
- Accompanying hip motion: hip flexion
- Compensatory lumbar motion: lumbar extension
What is the accompanying hip motion and the compensatory lumbar motion of the pelvic motion: posterior pelvic tilt?
- Accompanying hip motion: hip extension
- Compensatory lumbar motion: lumbar flexion
What is the accompanying hip motion and the compensatory lumbar motion of the pelvic motion: lateral pelvic tilt (drop) in LE stance?
- Accompanying hip motion: hip ADD
- Compensatory lumbar motion: lumbar R sidebending
What is the accompanying hip motion and the compensatory lumbar motion of the pelvic motion: lateral pelvic tilt (hike) in LE stance?
- Accompanying hip motion: hip ABD
- Compensatory lumbar motion: lumbar L sidebending
What is the accompanying hip motion and the compensatory lumbar motion of the pelvic motion: forward rotation in LE stance?
- Accompanying hip motion: hip medial rotation
- Compensatory lumbar motion: lumbar L rotation
What is the accompanying hip motion and the compensatory lumbar motion of the pelvic motion: backward rotation in LE stance?
- Accompanying hip motion: hip lateral rotation
- Compensatory lumbar motion: lumbar R rotation
What are the primary hip flexor muscles?
- Iliopsoas
- Rectus Femoris
- Tensor Fascia Lata
- Sartorius
What are the secondary hip flexor muscles?
- Pectineus
- Adductor Brevis
- Adductor Longus
- Adductor Magnus (oblique fibers)
- Gracilis
Which muscle is the most important hip flexor muscle and why?
Iliopsoas and because it is the only muscle that flexes the hip past 90 deg
What are the proximal actions of the iliopsoas muscle?
- Anterior pelvic tilt
- Lumbar flexion
- In standing: creates extension / lumbar lordosis as head is kept over CoG
Iliopsoas is a weak ____
Iliopsoas is a weak external rotator
What innervates the Iliopsoas and what is its nerve root?
Femoral n. (L2-L3)
___ is a two joint muscle
Rectus femoris is a two joint muscle
Rectus femoris is the only part of the quadriceps to cross ___ and ____ joints
Rectus femoris is the only part of the quadriceps to cross the hip and knee joints
The simultaneous action of the rectus femoris at both joints increases the likelihood of ___
The simultaneous action of the rectus femoris at both joints increases the likelihood of active insufficiency
The rectus femoris strongest action as a hip flexor is when ___
The rectus femoris strongest action as a hip flexor is when the knee is flexed
What innervates rectus femoris and what is its nerve root?
Femoral n. (L2-L4)
___ is a two joint muscle, but is affected a little by the knee position
Sartorius is a two joint muscle, but is affected a little by the knee position
What are the hip actions of the sartorius muscle?
Flexion, ABD, ER
What are the knee actions of the sartorius muscle?
Flex, IR (when knee is flexed)
What innervates the sartorius and what is its nerve root?
Femoral n. (L2-L3)
What is the function of the sartorius?
Most important when knee &
hip need to be flexed simultaneously (i.e., stairs)
What are the hip actions of the TFL?
Flex, ABD, IR
There is a decrease in tensile stress of the femur by producing a ____ in the ITB
There is a decrease in tensile stress of the femur by producing an increase tension in the ITB
What innervates the TFL and what is its nerve root?
Sup. Gluteal (L5-S1)
The TFL and ITB together helps minimize the excessive ____ with the ___ extended
The TFL and ITB together helps minimize the excessive hip ADD with the hip extended
The tightness and movement of the ITB over the greater trochanter/bursa is implicated in ___
- Snapping Hip Syndrome
- Inflammation of Trochanteric Bursa proximally
- Potential cause of knee pain distally
What are the hip adductor muscles?
- Pectineus
- Adductor Brevis
- Adductor Longus
- Adductor Magnus
- Gracilis (two joint muscle)
What is the action of the hip adductors?
All adduct the hip; assist with
hip flexion, extension, and rotation
What limits the secondary roles of the hip adductors?
Moment arms minimize secondary roles depending on the position of the hip
Hip adductor muscles may be ___ with hip abductors during gait
Hip adductor muscles may be synergists/stabilizers with hip
abductors during gait
Which muscles has the greatest muscle mass in the LE?
ADD: 22.5%
What are the primary hip extensor muscles?
- Gluteus Maximus
- Biceps Femoris
- Semimembranosus
- Semitendinosus
What are the secondary hip extensor muscles?
• Gluteus Medius
(posterior fibers)
• Posterior Adductor
• Magnus Piriformis
___ has the largest muscle mass of the LE and is the greatest contributor to hip extension
Gluteus maximus has the largest muscle mass of the LE and is the greatest contributor to hip extension
When is the moment arm of the glut max maximal?
In neutral hip
When is the length-tension of the glut ma at its peak?
Peak force 70° hip flexion
What is glut max an external rotator?
When the hip is extended
What are the two motions that glut max assits with?
Assists with ADD & ABD
What innervates glut max and what is its nerve root?
Inferior gluteal (L5-S2)
What are the hip actions of the hamstring?
- Extension
- Maximal MA at 35° flexion
- Influence by knee position
What actions does the hamstrings contribute to at an IR and ER perspectvie of the knee?
- Flexion
- Bicep Femoris: External rotation tibia
- Semimembranosus/ Semitendinosus: Internal rotation tibia
What are the hip abductor muscles?
• Gluteus Medius (similar to Deltoid mm in Shoulder) • Gluteus Minimus • Gluteus Maximus • Sartorius • Tensor Fascia Lata
What are the functions of the hip abductor muscles in an open chain position (foot is not on the ground)?
- Hip abduction
- Anterior fibers: hip internal rotation and flexion
- Posterior fibers: hip external rotation (medius)
- In flexion – all fibers internally rotate the hip
What are the functions of the hip abductor muscles in a closed chain position (foot is on the ground)?
Stabilizes the pelvis in unilateral stance
What are the hip external rotator muscles?
- Piriformis
- Obturator Internus
- Gemellus Superior
- Gemullus Inferior
- Obturator Externus
- Quadratus Femoris
- Gluteus Maximus
- Sartorius
- Biceps Femoris
The line of action of the hip ER muscles are ___ making them ___
The line of action of the hip ER muscles are perpendicular to femoral shaft making them excellent ERs
The line of action of the hip ER muscles are parallel to the ___ and ___ makes them ___
The line of action of the hip ER muscles are parallel to the head and neck of the femur makes them excellent compressors
The function of the hip ER muscles are similar to ____ in the shoulder
The function of the hip ER muscles are similar to *rotator
cuff muscles* in the shoulder
Active women with PFPS have weaker ___ and ___ than
healthy controls
Active women with PFPS have weaker hip ABD and ER than
healthy controls
Runners with LE injuries were associated with ___ and ___ weakness
Runners with LE injuries were associated with *hip ABD and
flexor* weakness
Runners with ITB syndrome were associated with ___
weakness
Runners with ITB syndrome were associated with hip ABD weakness
Collegiate female athletes with unilateral PFPS demonstrated ____
• Unilateral weakness of hip ABD and ER compared to
uninjured limb
• Weakness in all planes relative to healthy control subjects
What are the hip IR muscles?
No muscles functioning for
internal rotation primarily
When is hip IR torque greater?
3 times more internal rotation torque when hip is flexed vs. extended
What are the considerations to keep in mind for a two-joint muscle?
• Active insufficiency
• Greatest force when NOT shortening over two joints
simultaneously
• Allow power transfer from the hip to the knee
Muscles that cross two joint have a ___muscle action
Muscles that cross two joint have an inverted muscle action
What are the characteristics of the inversion of muscle action of two joint muscles?
- May have alternate or even opposite (inverted) actions
- Action of muscle depends on joint position
- Implications: stretching and resistive exercises
What is the muscle function in the bilateral stance in the sagittal plane?
- LOG lies posterior to hip axis
- External hip extension moment countered by passive tension in the capsule and ligaments
- No muscles required!
- If LOG moves anterior to hip axis, hip extensor muscles must activate
What is the muscle function in the bilateral stance in the frontal plane?
- Symmetrical weight bearing
- Weight of HAT(head, arms, trunk) (2/3 body weight) transmitted to femoral heads
- Hypothetically, 1/3 BW for each hip joint (~60 lbs if 180 lb individual)
- Studies show joint compression forces of 80-100% BW across each hip
What is the muscle function in the unilateral stance?
• Tremendous change in forces:
Weight supported has gone from ~60 pounds to 150 pounds (5/6 body weight 180 pound person)
- Gravity creates a strong
adduction torque about the hip
ADD torque by BW countered by ABD torque by muscles
What are the force reduction factors of the hip?
- Weight reduction: little effect
* Reduce abductor muscle force requirements is the key
How is the abductor muscle force reduced?
- Accomplished by:
- Trunk lean
- Use of a cane
- Adjustment of a carried load
How does the trunk lean method of abductor muscle force reduction work?
Lean towards the side of pain
or weakness during single leg
stance
What would the trunk lean achieve?
- ↓ MA of BW ADD torque
- ↓ required ABD counter torque
- ↓ compressive loads
What does the tredelenburg gait look like?
Lateral lean over support leg 2° gluteus medius weakness
• Pelvic drop on opposite leg
If the lean during gait is solely caused by pain it is a ____ gait
If the lean during gait is solely caused by pain it is an antalgic gait
What are the implications of using a cane on the affected side?
- Push ~ 15% BW
* Results in 376 lbs (more than lateral lean)
What are the implications of using a cane on the opposite side of the affected limb?
- Reduces BW force by 15%
- Large MA
- Provides counter torque to the gravitational torque
- Assists ABD
What does carrying a load on the contralateral side of injury do?
- Moves the LOG away from the supporting hip joint
- Increases the gravitational torque’s MA
- More abductor muscle force required
- More pain
What does carrying a load on the ipsilateral side of injury do?
- Reduces gravitational torque’s MA
- Less abductor muscle force required Less pain
- Only to a point (no more than 25% BW)
What are the specific hip/pelvic screening questions that will indicate that pain is not of MSK origin?
- Hx of hip/pelvis/LE trauma? Childhood history of hip problems?
- Osteoporosis?
- Cancer? Recent weight loss / gain?
- Steroid Use (high dosage or long duration)? Alcohol use?
- Blood disorders: sickle cell, clotting disorders?
- Catching, clicking, giving way
- Agg w/ activity? Ease w/ rest?
- Bowel changes? Bladder changes?
What are the specific hip/pelvic screening questions for females that will indicate that pain is not of MSK origin?
- menstruating age – menstrual cycle, relationship to pain
* all females – recent GYN examination/results
What are some of the aggravating factors associated with hip dysfunction?
- Gait changes
- Sit • Crossing legs
- In/ out of car
- Put on socks
- Lying on involved side
- Up / down stairs
- Gardening
- On / off bicycle
What are the non MSK problems that can present in the anterior region of the body?
- Stress fractures
- Hip arthritis
- Transient synovitis/ septic arthritis
- Osteonecrosis
- Femoroacetabular impingement
- Labral tear
- Iliopsoas bursitis
- Groin injury
What are the non MSK problems that can present in the posterior region of the body?
- Piriformis syndrome
- Ischiofemoral impingement
- SI joint
- Lumbar source referred/radicular (MSK or non- MSK)
What are the non MSK problems that can present in the lateral region of the body?
- Bursitis
- Gluteal muscle tendonitis/tears
What are the characteristics of the onset of systemic pain?
Recent, sudden; if prolonged usually a gradual progression
What are the characteristics of the description of systemic pain?
Knifelike; gnawing, throbbing, deep ache, and bone pain
What are the characteristics of the location of systemic pain?
Unilateral or bilateral
What are the characteristics of the duration of systemic pain?
Doesn’t change with position. Constant
What are the characteristics of the agg factors of systemic pain?
Can’t make worse. Organ dependent
What are the characteristics of the easing factors of systemic pain?
Can’t make better, can be organ dependent
What are the characteristics of the onset of MSK pain?
- Sudden: injury/trauma
- Gradual: chronic load over time
What are the characteristics of the description of MSK pain?
- Stiff, ache, cramp, tender to palpation
What are the characteristics of the location of MSK pain?
Usually unilateral
What are the characteristics of the duration of MSK pain?
Changes with position, rest, constant but variable
What are the characteristics of the night pain of systemic pain?
Most intense pain; difficulty returning to sleep
What are the characteristics of the night pain of MSK pain?
Easy to return to sleep after a change in position
What are the characteristics of the agg factors of MSK pain?
Altered with movements, ADLs
What are the characteristics of the easing factors of MSK pain?
Rest or change position, Meds, Ice
What is osteonecrosis of the femoral head?
Bone & bone marrow cell death due to poor arterial supply
What are the other names for osteonecrosis of the femoral head?
- Aseptic Necrosis
* Avascular Necrosis
What are the risk factors of osteonecrosis of the femoral head?
- High dose steroids (long or short duration) or alcohol use
- Smoking
- Blood clotting disorders
- Hyperlipidemia
- Caisson’s Disease (recent scuba diving)
- Sickle cell disease
- Radiation
What are the clinical presentations of osteonecrosis of the femoral head?
- Age: 20-50 years
- Gender: slight male predominance
- Hip pain, usually of unknown origin
- Night pain: early feature
- ROM: usually normal but painful • Radiographs: often normal in early stages
- MRI: gold standard for diagnosis
What is the treatment for osteonecrosis of the femoral head?
- Recognize non-MSK signs early & refer! • Unload joint, treat impairments
- Accounts for 10% of THRs(total hip replacements) in US
What are the possible presentation of a hip joint infection?
- Joint pain of unknown origin; recent surgery
* Current or recent skin rash
What are the risk factors of the of the hip joint infection?
- History of hepatitis
- Mono
- Recent upper respiratory or urinary tract infections
- Sexually transmitted disease
- Drug abuse
- Corticosteroids
- Diabetes
What are the clinical sign of a hip joint infection?
- Temp > 100 F (caution with elderly – 98.6 F may be fever) • BP > 160/95 mm Hg
- Resting: pulse 100 bpm; respirations > 25 bpm
- Fatigue & signs of inflammation
- Elevated lab values (ESR, CRP, WBC)
- Disorientation and confusion
What is the age range of a typical of a hip joint infection?
Happens to all age ranges
What does cyriax’s sign of the buttock do?
A collection of signs that may indicate a potential serious pathology in the hip region
What are the signs in cyriax’s sign of the buttock?
- SLR: limited and painful
- Hip flexion limited to same extent as with SLR
- Hip flexion: empty end feel
- Trunk flexion limited to same extent as SLR and hip flexion
- Hip extensors: painful / weak
- Noncapsular pattern of restriction at the hip
- Swollen buttock and tender
What is a non capsular pattern of restriction at the hip?
Limited hip ext, ADD, and lateral rotation
What are the possible serious pathology that a positive cyriax’s sign of the buttock?
- Osteomyelitis of proximal femur
- Neoplasm of proximal femur or ileum
- Septic arthritis of SIJ
- Septic bursitis
- Ischial rectal abscess
- Rheumatic bursitis
- Fractured sacrum
What is a psoas abscess?
Any inflammatory/infectious process in abdomen /pelvis can
lead to psoas irritation/abscess
Psoas muscle not separate from the ___ or ___ cavities
Psoas muscle not separate from the abdominal or pelvic cavities
A psoas abscess may present as ____with hip held in flexion
A psoas abscess may present as muscular strain with hip held in flexion
What is a positive psoas sign?
Pain reproduced with passive hip extension
What is the specific test for abscess?
No specific test for abscess, so look for other red flags as well
How does appendicitis present?
- Acute onset severe pain, right lower quadrant
* Pain usually before vomiting
What are the aggravating factors of appendicitis?
- Hip extension
- Resisted hip flexion
- “jarring” effect from any motion like driving over a railroad track
- Rebound tenderness in the abdominal region
What are the potential sources for cancer?
- Colon, Prostate, Bladder, Cervical Cancer, spine
* Malignant and benign bone tumors, nerve tumors
What are the signs and symptoms for cancer?
- Age > 50
- Bone pain in adolescents (< 20 yrs)
- Prior hx cancer
- Unexplained weight loss (> 10# in 1 mo)
- Constant pain / no relief with bed rest
- > 1 mo duration pain
- Failure to improve with conservative management
Where is the McBurney’s point?
– 1/3 the way from R ASIS to umbilicus
In what population does primary bone tumors usually occur?
In adolescents 20 or years, complaining a pain deep in their bone
The inguinal lymph system, collects lymph from what parts of the body?
– legs, perineum, prostate, gonads
What are the characteristics of a normal lymph node?
- ≤ 1 cm
- Soft to firm
- Move freely
- Non-tender
What are the characteristics of an abnormal lymph node?
• > 1 cm
• Firm or rubbery
• Hard, immovable, nontender
or tender
Hip and groin pain can relate to a ___ problem
Hip and groin pain can relate to a lymph node problem
What are the deformities usually present with a hip fracture?
- Shortened leg
* ER position
What are the signs of a hip fracture?
- Antalgic gait
- Acute buttock, groin hip or thigh pain
- ROM limitations
- Pain with palpation
What are the two types of a hip and pelvic region stress fracture?
- Fatigue
- Insufficiency
What is a fatigue hip and pelvic region stress fracture?
Normal bone with abnormal stress
What is an insufficieny hip and pelvic region stress fracture?
Abnormal bone with normal stress
What may insufficiency fractures occur?
When there is metabolic bone disorder, such as osteoporosis or there is nutrient deficiency
Where are the locations of a hip and pelvic region stress fracture?
- Femoral Neck
- Pubic Rami
- Acetabulum
- Femoral head, shaft
- Sacrum
What are the signs and symptoms of a hip and pelvic region stress fracture?
• Localized bone pain • Worse with weight bearing • Reproduced with heel strike or hopping (if client capable) • Possible night pan • Fulcrum test (femoral shaft)
What are the risk factors of a hip and pelvic region stress fracture?
- Female Athlete Triad
- Overuse / increase in normal training program
- Pathologic fracture from underlying condition, i.e. CA or other condition causing loss of bone mass
- Steroid use
- Smokers
What is included in the female athlete triad?
• Amenorrhea, eating disorder, osteoporotic
The female athlete triad results in…?
Poor nutrition and the metabolic bone disorder that results to restore the lost nutrients
The patella pubic percussion test is a test for indication of ___
The patella pubic percussion test is a test for indication of nondisplaced femoral fracture
What are the procedures in the patella pubic percussion test?
• Bell of stethoscope on pubic symphysis • Percuss patella • Affected side duller/ diminished • If abnormal, suspect bony pathology
What are some adolescent hip disorders?
- Legg-Calve-Perthes disease
* Slipped Capital Femoral Epiphysis
Legg-Calve-Perthes disease occurs more in what gender and around what age range?
- Boys > Girls
* Age 5-8 years
Slipped Capital Femoral Epiphysis occurs more in what gender?
Adolescent boys typically
What is regional interdependence?
The concept that a patent’s
primary musculoskeletal symptoms(s) may be directly or indirectly related or influenced by impairments from various body regions and systems regardless of proximity to the primary symptoms(s).
What are the body systems included in the regional interdependence model?
- MSK
- Somatovisceral
- Neurophysiological
- Biopsychosocial
The symptoms of a MSK problem may be present in the lumbar spine and refer to what other regions?
- Hip
- Knee
- Foot
- Ankle
The symptoms of a MSK problem may be present in the hip and refer to what other regions?
- Lumbar spine
- Knee
- Ankle
What is the 2 joint rule?
Examine the joint above/ below & the associated spinal region
Where does the kidneys refer pain to?
LBP/ costovertebral angle pain
Where does the ureter refer pain to?
Groin pain
An abdominal aortic aneurysm can cause ___
An abdominal aortic aneurysm can cause vascular claudication
What are the presenting symptoms in vascular claudication?
LE pain and limited walking endurance
What are the factors included in the biopsychosocial system?
- Fear avoidance
- Pain catastrophizing
- Anticipation
The neurophysiological system is the interaction between the ___ and ___
The neurophysiological system is the interaction between the central and peripheral nervous systems
___ is the most relevant and obvious way of showing the interaction between PNS and CNS
Central sensitization is the most relevant and obvious way of showing the interaction between PNS and CNS
What are the neurophysiological way that patients may present their pain?
- Nociceptive
- Peripheral neuropathic
- Central sensitization
What are the things that may happen in the neurophysiological system?
Temporal summaIon which leads to widespread hyperalgesia
What is widespread hyperalgesia?
Areas that are seemingly unrelated to patient’s main area of symptoms are more hypersensitive to touch or pressure based on the hyper sensitivity and response to pain
What are the changes to the neurophysiological system as a result of manual therapy?
- Hypoalgesia
* Sympathetic activity
What are the things included in a patient profile?
- Age
- Gender
- Occupation
- Social history
- Exercise habits
What hip condition can be seen in new borns?
Congenital hip dislocation
What hip condition can be seen in 5-8 year olds?
Legg-CalvePerthes
What hip condition can be seen in adolescent boys?
SCFE (slipped capital femoral epiphysis)
What hip condition can be seen in adolescent to young adults?
Stress fracture
What hip condition can be seen in young adults?
Rheumatiod arthritis, Avascular necrosis
What hip condition can be seen in 45-60 year olds?
Osteoarthritis
What hip condition can be seen in 65+ year olds?
Osteoarthritis, fracture
____ can happen generally at any age
Stress fractures can happen generally at any age
What hip condition are females more prone to?
- Stress Fx
* Osteoporosis
What are the items that can be retrieved from the body chart?
- Location
- Quality
- Depth
- Frequency
- Relationship between symptom regions
- Clear other areas
What are the body chart questions to ask?
- What are the joints under the area(s) of symptoms?
- What joints refer to area of symptoms?
- Contractile structures under area of symptoms?
- What other structures must I rule examine?
What are the clinical reasoning concepts questions to ask oneself?
- What is my initial hypothesis?
* What are my competing MSK and non-MSK hypotheses?
What are the present history questions to ask esp. for a recurrent/intermittent problem?
- When did current episode begin?
- How?
* Trauma?
* Repetitive?
* Unknown? - Immediate or delayed onset of symptoms?
- Is it getting worse, better, or remaining unchanged?
- Diagnostic studies?
- Treatment received?
What are the questions to ask regarding aggravating factors?
- What makes it worse?
- How long to onset?
- How long and what must you do to ease?
- Can you sustain activity or do you need to stop?
- Does it progress to another pain region on body chart?
What are the questions to ask regarding easing factors?
- How long to ease?
* What makes it better?
What are the things to be worried about if nothing eases the patient’s pain?
Inflammation or non-MSK
condition!
What are the questions to ask about the night component of the 24-hr symptom behavior?
• Trouble going to sleep? • Waking? How easy to return to sleep? • Pacing? Meds / other to ease?
What are the things that relate to to the symptom behavior at night that might be indicative of a mechanical problem?
- Unable to lie on affected side
* Change position and return to sleep
What are the things that relate to to the symptom behavior at night that might be indicative of an active inflammation or serious pathology?
• Prolonged awake, up to walk,
etc
What is the likely condition when a patient experiences morning stiffness for less than 30 mins that is eased with movement?
Osteoarthritis. Hip degenerative arthritic
What is the likely condition when a patient experiences morning stiffness for more than 30 mins up to hours?
Rheumatoid arthritis
What is the likely condition when a patient experiences pain during the day that improves throughout the day?
Possible osteoarthritis
What is the likely condition when a patient experiences pain during the day that worsens throughout the day?
Consider stress fracture or mechanical from days activity
What is the likely condition when a patient experiences pain during the day that is variable throughout the day?
Depends on activity. If no relation to activity consider other relationships…menstrual, food intake, etc
What are the past history questions a patient?
- Prior trauma, injury?
- When did it first occur? How often does it recur?
- Developmental or congenital hip region problems?
- Prior treatments and effects?
What are the things to be looking for during the medical screening?
- Constitutional signs
- Past medical history
- Family history
- Medications
- Surgeries
- Allergies
Functional scales are on what types of forms?
Regional specific forms
What are the key points to remember when examining the hip area?
- Informed consent
- Communicate clearly in patient-centered language
- Chaperone
- Document
- Drape
- Patient hand barrier when palpating near sensitive area
What is the 1st thing to look at in hip assessment?
Gait assessment and balance
What are the component of the gait assessment?
- Step length
- Trendelenburg
- Toe out gait/ “frog eye patella”
- Hip / Trunk dissociation
- Assistive device
- Willingness to move / bear weight through hip / leg
What is a trendelenburg gait indicative of?
Hip abductor weakness
What is a toe out gait/ “frog eye patella” gait indicative of?
Possible tight or overly strong
external rotators
What is a hip/trunk dissociation gait indicative of?
Hip or L-spine stiffness
How is balanced assessed?
Single limb stance, eyes open then closed
What are the things to observe in general in the hip region?
• Symmetry, edema, scars, muscle atrophy, ecchymosis, deformity
What are the things to observe in the anterior portion of the hip region?
Iliac crest, ASIS, greater trochanter, lateral shift, femur /
patella, foot posture
What are the things to observe in the lateral portion of the hip region?
PSIS / ASIS (~ 30 pelvic angle)
lumbar lordosis, knee flexion /
recurvatum
What are the things to observe in the posterior portion of the hip region?
Scoliosis, lateral shift, Iliac
crest, gluteal fold / ischial tuberosity, rearfoot position.
What are the functional test to do for the hip region?
- Squat
- Stairs
- Cross legs
- Assess: quality, quantity, pain (their pain?), ROM
What are the muscles that are usually tight in a pelvic crossed syndrome?
Hip flexors, erector spinae
What are the muscles that are usually weak in a pelvic crossed syndrome?
Abdominals, multifidus, and gluteals
What does any 2 positive SIJ clearing test indicate?
Rule in SIJ
What does any 1 positive SIJ clearing test indicate?
SIJ pain unlikely
What does all negative SIJ clearing test indicate?
Rule out SIJ
The general rule of clearing the SIJ starts with…?
Thigh thrust
What is the Sn value for a thigh thrust?
0.88
What do we do after a thigh thrust?
Distraction
What is the Sp value for a distraction?
0.81
After a distraction, what comes after?
Compression, which is
If compression is positive then SIJ is ___
If compression is positive then SIJ is confirmed
What do you do if a compression is negative?
Sacral thrust
What are the knee clearing exams?
- Squat
- Flexion with overpressure
- Extension with overpressure
- Palpation
What are the normal capsular patterns for the hip?
Flexion, Adduction, Internal Rotation
What is the normal range of hip flexion?
110-120
What is the normal range of hip extension?
10-15
What is the normal range of hip abduction?
30-50
What is the normal range of hip abduction?
30
What is the normal range of hip lateral rotation?
40-60
What is the normal range of hip medial rotation?
30-40
Functional flexion for stairs going up and coming down the stairs?
Ascending 66
Descending 45
What are the motions and their ROM for putting on socks?
- 120 flexion
- 20 abduction
- 20 lateral rotation
What is the capsular pattern order of the hip?
There is no order
what are the options for testing for joint mobility?
- Caudal glide
- Lateral glide
- Posterio-anterior glide
What are the positions that the posterior- anterior glide test can be done?
- Hip neutral to slight extension
- Prone
Doing a posterior- anterior glide test in prone helps to __
Doing a posterior- anterior glide test in prone helps to put more stress on the anterior capsule
What are the rules for hip palpation?
- Inform patient
- Drape / barriers
- Chaperone
What are the structures for hip palpation?
- Bony landmarks – i.e. ASIS, PSIS, greater troch…
- Soft tissue – muscles, ligaments
- Areas of symptoms
How is the hip special test for general pathology: hip scour or quadrant test done?
- Compresses femoral neck on acetabulum / compressed soft tissue
- Flex / add hip, then move in abduction
- Note pain, limits to motion, apprehension
How is the hip special test for general pathology: Patrick (FABER) test done?
- Positive if test leg remains above opposite leg.
- Post pain may mean SIJ affected
- Ant pain may be hip, iliopsoas, etc
What is the special test for a fracture of the femoral neck?
Patellar Pubic Percussion Test
What is the special test for a fracture of the femoral shaft stress fracture?
Fulcrum test
What is the special test for a labral tear, or impingement?
FADDIR
How is the FADDIR done?
• Start in full flexion, ER and ABD. • Move towards extension, internal rotation and ADD • Positive: pain / symptom reproduction, click, and / or apprehension.
What are the neural hip test?
- SLR
- Slump
What are the muscle length test for the hip?
- Thomas
- Piriformis
- Ely (prone knee bent test)
The ober test is for the ___ structures of the knee
The ober test is for the lateral structures of the knee
What are the positions that an ober test can be done in?
Performed either knee flex or
extended
What is the key thing in the ober test?
Stabilize iliac crest
What motions does the test leg go through in an ober test?
• Flex – circumduction – slightly
extend hip to get ITB posterior to greater troch.
When is the ober test positive?
Positive if unable to get to neutral or below (tight TFL) or
pain (likely troch bursitis).
What is a possible involvement if there are neural signs with the knee flexed?
Possible femoral nerve involvement
The intensity of the objective exam is based on the ___ which was built in the ___
The intensity of the objective exam is based on the SINSS which was built in the subjective exam
What happens to our hypothesis in the objective exam?
It gets refined, based on the responses of the objective exam
