Week 5 Flashcards
What is an outcome measurement?
The process of data collection, analysis and
interpretation of the effectiveness and efficiency of patient treatment for the purpose of improving the
quality of clinical care and lowering health care costs
What percent of therapist surveyed use outcome measures?
48%
What are the reasons to not use outcome measures?
- Time
- Considerations in a systems movement that doesn’t provide necessary provisions for scoring
What are the common categories of outcome measurements?
- Clinical outcomes
- Process outcomes
- Patient satisfaction
- Costs
What are the concepts under the clinical outcomes of outcome measurements?
- Pathology
- Impairments
- Functional limitations
- Disability
What are the concepts under the process outcomes of outcome measurements?
Utilization of resources
What are the concepts under the patient satisfaction of outcome measurements?
- Satisfaction with caregiver
- Satisfaction with support staff
- Satisfaction with result
What are the concepts under the costs of outcome measurements?
- Direct cost of medical care
- Indirect cost
What are the different presentations from a patient that falls under the Nagi disablement model?
- Active pathology
- Impairments
- Functional limitations
- Disability
Active pathology can be shown in ____
Active pathology can be shown in Laboratory & Imaging Studies, Surgical findings
When are impairments typically found?
From Clinical examination
How do we get information regarding functional limitations and disabilities?
Observation and Patient Self
Report
What is a primary outcome measure be used for in a research report?
To help determine the sample size needed, the main power of the study, and the statistical significance of the study
Primary and secondary outcome measures should be __
Primary and secondary outcome measures should be clinically meaningful, one that patients care about and ultimately defines treatment
usefulness
What are the types of outcome measures used in patients with LE disorders?
- Health Related Quality of Life (HRQoL) Questionnaires, Health outcome measures (HOM), self report measures
- Pain Scales
- Goniometry
- Global Rating of Change (GROC, GRC, GRCS)
- Test - retest
What are the psychometric criteria/ the statistics behind the outcome measure and what makes it meaningful?
- Reliability
- Validity
- Clinical meaning
- Sensitivity to clinically important change
What are the 2 types of clinically important change?
- Minimal Detectable Change (MDC)
* Minimal Clinically Important Difference (MCID)
What is a Minimal Detectable Change (MDC)?
Change that is beyond statistical error in measurement
What is a Minimal Clinically Important Difference (MCID)?
Smallest noted clinically significant change
What is reliability?
Reliability is consistency over time in measurement
Why is reliability important?
Reliability is important because we want to make sure that the measure continues to asses the same items both within and between patients
What is a valid measure?
One that measures what we intend for it to measure
For an outcome measure to be clinically meaningful, it must be both ___ and ____ in the patients that we’ve chosen to use it in
For an outcome measure to be clinically meaningful, it must be both reliable and valid in the patients that we’ve chosen to use it in
What type of goal creators are MCID?
Short term goals
What are the common HRQoL measures for patients with hip disorders?
- Harris Hip Score
* Hip Outcome Score
____ HRQoL is used extensively with patients with hip OA?
Harris Hip Score
What is the design of the harris hip score?
- 10 items: pain, walk, ADL, ROM
* Patient and provider scored
What is the scoring of the harris hip score?
0% (max disability) – 100% (no disability)
What is the ceiling effect of the harris hip score?
It may not have an effect on patients who are a higher level of functioning
What are the MCID for the harris hip score?
- Pts w/ hip OA: ≥ 8%
- Pts 3 mo post-op FAI: 13%
- Pts 6 mo post-op FAI: 9%
The hip outcome score was developed for ___ patients and patients with ____
The hip outcome score was developed for younger patients and patients with acetabular labral tears
What is the design of the hip outcome score?
- ADL Subscale: 17 items
* Sports Subscale: 9 items
Whats is the scoring of the hip outcome measure?
(score each scale separately)
• Each item: 0-4 points
• (total# / (total # of items x4) x 100 = %
• Higher score = higher function
What are the MCIDs of the hip outcome score?
- ADL Subscale: 9%
* Sports Subscale: 6%
What are the Common HRQoL measures for patients with knee disorders?
- Knee Outcome Survey-Activities of Daily Living Scale (ADLS)
- International Knee Documentation Committee 200 Subjective Knee Evaluation Form (IKDC 2000)
In what population is the knee outcome survey studied?
Studied in 18-72 y/o w/ various knee disorders: lig, OA, meniscus, PFP
What is the design of the knee outcome survey?
- 7 items: symptoms
* 10 items: function
What is the scoring of the knee outcome survey?
- 0-5 each item
- Total score expressed as %
- Lower score = greater disability
What is the MDC for the knee outcome survey?
MDC: 8.87 @ 95% CI
In what population International Knee Documentation Committee 200 Subjective Knee Evaluation Form (IKDC)?
Studied in pts w/ ACL tear, meniscal injury, OA
What is the design of the International Knee Documentation Committee 200 Subjective Knee Evaluation Form (IKDC)?
- 18 questions
* Function, sports, symptoms
What is the scoring of the International Knee Documentation Committee 200 Subjective Knee Evaluation Form (IKDC)?
Total score expressed as a %
What is the MCID for the International Knee Documentation Committee 200 Subjective Knee Evaluation Form (IKDC)?
MCID: 20.5% (Sp: 0.84, Sn 0.64)
What are the Common HRQoL measures for patients with foot & ankle disorders?
- Foot and Ankle Ability Measure – FAAM
* Foot Function Index - FFI
What population is the Foot and Ankle Ability Measure – FAAM used on?
Various foot / ankle conditions
What is the study design for the Foot and Ankle Ability Measure – FAAM?
- ADL Subscale: 21 items
* Sports Subscale: 8 items
What is the scoring for the Foot and Ankle Ability Measure – FAAM?
- Each subsection separately
- 0-4 each item
- Score / (Total # of items x 4) x 100 = %
- Higher score = higher function
What are the MCID for the Foot and Ankle Ability Measure – FAAM?
- ADL Subscale: 8 points
* Sports Subscale: 9 points
What population is the Foot Function Index - FFI used on?
Foot and ankle conditions;
more useful in older individuals with low functional ability
What is the study design for the Foot Function Index - FFI?
3 scales, 23 questions
What is the scoring for the Foot Function Index - FFI?
- XXX/230 x 100 = %
- 0-100
- Higher score = higher disability
What is the MCID for the Foot Function Index - FFI?
7 points (pts w/ PHP)
What are the Common HRQoL measures for broad range of lower extremity conditions?
- Lower Extremity Functional Scale – LEFS
* Patient Specific Functional Scale - PSFS
What does the development of the Lower Extremity Functional Scale – LEFS cover?
Developed to cover broad range of LE conditions
What is the study design for the Lower Extremity Functional Scale – LEFS?
20 items
What is the scoring for the Lower Extremity Functional Scale – LEFS?
- Each item: 0-4 points
* Max score of 80 (full function)
What is the MCID for the Lower Extremity Functional Scale – LEFS?
- 9 points
* Useful for variety of conditions
What is the study design for the Patient Specific Functional Scale - PSFS?
- 3 patient-selected activities
- Activity is related on a scale of 0-10
What is the scoring for the Patient Specific Functional Scale - PSFS?
- 0 is cannot do activity at all and 10 is no difficulty
- Average individual item scores
What is the MCID for the Patient Specific Functional Scale - PSFS?
- 2.3 for small change
* 2.7 for medium to large change
What are the outcome measures for a Self-Reported Pain and Function?
- VAS
- NPRS
- Global Rating of Change (GROC, GRC)
The body chart is an excellent tool to track ___
The body chart is an excellent tool to track symptom location and quality
What are the reliabilities of assessing pain response during ROM using kappa?
- Flexion: .55
- Rotation: .40 - .70
- SB: highly variable (.0 -.80)
What point change is considered small but meaningful in a NPRS?
• 1.5 points considered small but meaningful
What does the Global Rating of Change (GROC, GRC) assess?
Assesses overall response to care
What is the question that needs to be specifically asked in a Global Rating of Change (GROC, GRC)?
Is the amount of change
important to the patient?
What is the scoring of the Global Rating of Change (GROC, GRC)?
-7 to +7
What are the estimates of change in a Global Rating of Change (GROC, GRC)?
- 1 to 3: small
- 4-5: moderate
- 5-7: large
What is a 0 on the GROC mean?
I am neither better nor worse
What is the 1A evidence grade for the propositions for OA?
1A – Meta-analysis of RCT
What is the 1B evidence grade for the propositions for OA?
1B –> 1 RCT
What is the 2A evidence grade for the propositions for OA?
2A -> 1 controlled trial without randomization
What is the 2B evidence grade for the propositions for OA?
At least one quasi experimental study
What is the 3 evidence grade for the propositions for OA?
Descriptive studies
What is the 4 evidence grade for the propositions for OA?
Expert reports/opinions
The 1st proposition of the MOVE consensus states that : Both ___ and ___ exercise can reduce pain and
improve function and health status in individuals with knee
and hip OA
The 1st proposition of the MOVE consensus states that : Both strengthening & aerobic exercise can reduce pain and
improve function and health status in individuals with knee
and hip OA
What is the evidence grade for the 1st proposition for OA?
1B knee; 4 hip
The 2nd proposition of the MOVE consensus states that: There are a few ___ to the . prescription of strengthening or aerobic exercise in individuals with hip/knee OA
The 2nd proposition of the MOVE consensus states that: There are a few contraindications to the . prescription of strengthening or aerobic exercise in individuals with hip/knee OA
What is the evidence grade for the 2nd proposition for OA?
4 both
The 3rd proposition of the MOVE consensus states that: Prescription of both___ an ____ exercises is an essential aspect of management of hip or knee OA
The 3rd proposition of the MOVE consensus states that: Prescription of both general (aerobic fitness training) and
local strengthening exercises is an essential aspect of management of hip or knee OA
What is the evidence grade for the 3rd proposition for OA?
4 both
The 4th proposition of the MOVE consensus states that: Exercise therapy for OA of hip or knee should be ___ and ____ taking into account age, co-morbidity, and overall mobility
The 4th proposition of the MOVE consensus states that: Exercise therapy for OA of hip or knee should be individualized & patient-centered taking into account age, co-morbidity, and overall mobility
What is the evidence grade for the 4th proposition for OA?
4 both
The 5th proposition of the MOVE consensus states that: To be effective, exercise programs should include __ and ___ to promote a positive lifestyle change with an increase in physical activity
The 5th proposition of the MOVE consensus states that: To be effective, exercise programs should include advice and education to promote a positive lifestyle change with an increase in physical activity
What is the evidence grade for the 5th proposition for OA?
- 1B advice/education;
- 4 that these are required for exercise program to be effective
The 6th proposition of the MOVE consensus states that: ___ exercise and ___ exercise are equally effective and patient preference should be considered
The 6th proposition of the MOVE consensus states that: Group exercise and home exercise are equally effective and patient preference should be considered
What is the evidence grade for the 6th proposition for OA?
- 1A to support group and home, but no head to head comparison has been made
The 7th proposition of the MOVE consensus states that: ___ is the principal predictor of long-term outcome from exercise in patients with hip or knee OA
The 7th proposition of the MOVE consensus states that: Adherence is the principal predictor of long-term outcome from exercise in patients with hip or knee OA
What is the evidence grade for the 7th proposition for OA?
1B as a predictor,
4 as principal predictor
The 8th proposition of the MOVE consensus states that: Strategies to improve and maintain ___ should be adopted (long-term monitoring/ review and inclusion of spouse/ family in exercise)
The 7th proposition of the MOVE consensus states that: Strategies to improve and maintain adherence should be adopted (long-term monitoring/ review and inclusion of spouse/ family in exercise)
What is the evidence grade for the 8th proposition for OA?
1B from general exercise literature
4 for specific hip/knee evidence
The 9th proposition of the MOVE consensus states that: The effectiveness of exercise is independent of the presence or severity of ____ findings
The 9th proposition of the MOVE consensus states that: The effectiveness of exercise is independent of the presence or severity of radiographic findings
What is the evidence grade for the 9th proposition for OA?
4
The 10th proposition of the MOVE consensus states that: Improvements in muscle strength and proprioception
gained from exercise programs may ___ the progression of knee and hip OA
The 10th proposition of the MOVE consensus states that: Improvements in muscle strength and proprioception
gained from exercise programs may reduce the progression of knee and hip OA
What is the evidence grade for the 10th proposition for OA?
4
According to the Hoesksma et al RCT, which was more beneficial, manual therapy or exercise?
Manual therapy.
Received better scores on the harris hip score and scored better in ROM
____ should be the treatment of first choice for all patients compared to exercise therapy.
Manual therapy should be the treatment of first choice for all patients compared to exercise therapy.
According to the MOA RCT, showed that manual therapy was better than ___ and was sustained to one year
According to the MOA RCT, showed that manual therapy was better than usual care and was sustained to one year
According to the MOA RCT, there was ___ added benefit
from a combination of the two
therapies (manual therapy and exercise).
According to the MOA RCT, there was NO added benefit
from a combination of the two
therapies.
According to the MOA RCT, Providing either manual therapy or exercise therapy in
addition to usual care was ___ relative to usual care alone when considering
According to the MOA RCT, Providing either manual therapy or exercise therapy in
addition to usual care was highly cost effective
relative to usual care alone when considering
According to JAMA, the RCT found that patients with hip OA ___ benefit anymore from manual therapy than they did for the sham treatment
According to JAMA, the RCT found that patients with hip OA DID NOT benefit anymore from manual therapy than they did for the sham treatment
What are the hip mobilization/manipulation techniques done for OA in supine done in a case series?
- Long axis non thrust oscillations in slight abduction
- Progression of above into abduction
- Non thrust lateral glides of femur with a belt
- Long axis thrust mobilization/manipulation in a loose packed position
- Thrust mobilization/ manipulation in less ABD (>15)
- hip flexion non thrust inferior glides
What are the hip mobilization/manipulation techniques done for OA in sidelying done in a case series?
- Anterior femoral nn thrust mobilization/ manipulation
- Hip distraction with non thrust medial femoral glide
- Hip distraction non thrust medial glide plus ABD
What are the hip mobilization/manipulation techniques done for OA in prone done in a case series?
- Anterior non thrust femoral glides
- Anterior non thrust glides in figure- four position
What are the home exercises that was associated with OA manipulation/ mobilization techniques done in a case series?
- Upright bicycle: 10 min
- Gluteus medius clamshell exercises: 3 sets of 12
- Hip ABD in sidelying: 3 sets of 12
- Core transverse abdominus: 2 sets of 20 in supine with hips flexed to 45 deg
- Bridge with straight leg raise: 3 sets of 10
- Hip flexor stretch kneeling or sidelying: 30 sec x 3
- Single leg balance: up to 60 sec
- Tandem stance eyes open or closed: up to 60 sec
What does wolfe’s law describe?
How bones respond to stress
___ is a disease modifiable technique
Exercise is a disease modifiable technique
What are the common hip pathologies in the pediatric population?
- Developmental dysplasia of the hip
- Septic Arthritis
- Acute transient synovitis
- Legg- Calve -Perthes
- Slipped capital femoral epiphysis
What are the chief complaints in the pediatric population?
Pain
What are the common pattern of pain referral in patients with a hip disorder?
- Hip
- Low back
- Pelvis
- Knee
What aspect of the body does the hip refer pain to the most?
Knee
What are the common hip disorders in patients from age 0-2 yrs?
Developmental Dysplasia of the hip (DDH) Septic arthritis
What are the common hip disorders in patients from age 2-12 yrs?
Acute Transient synovitis
Legg-Calve-Perthes
What are the common hip disorders in patients from age 8-17 yrs?
Slipped Capital Femoral Epiphysis (SCFE), Apophysitis
What are the common hip disorders in patients from age 5-30 yrs?
Osteoid osteoma (femoral neck)
What are the common hip disorders in patients from age 40-50 yrs?
Idiopathic avascular necrosis (AVN)
What are the common hip disorders in patients from age >35 yrs?
Rheumatoid arthritis
What are the common hip disorders in patients from age >40 yrs?
Degenerative joint disease (DJD)
What are the common hip disorders in patients from age >50 yrs?
Hip fractures
What is going on in the Developmental Dysplasia of the Hip (DDH)?
A condition in which the acetabulum is not fully developed and tends to be shallow, such that the femoral head can easily be subluxed or dislocated
When is Developmental Dysplasia of the Hip (DDH) screened for?
Shortly after birth
What are the possible causes of Developmental Dysplasia of the Hip (DDH)?
Either mechanical, physiological, or environmental conditions
What is an example of a mechanical cause of Developmental Dysplasia of the Hip (DDH)?
Mal-position in the womb
What is an example of a physiologic cause of Developmental Dysplasia of the Hip (DDH)?
In utero hormones – estrogen & relaxin
What is an example of a environmental cause of Developmental Dysplasia of the Hip (DDH)?
Cultural positioning of infants (swaddling in a blanket)
What are the statistics of occurrence for Developmental Dysplasia of the Hip (DDH)?
- 1 in 100 live births (subluxatable); 1 in 1000 (dislocatable)
- 6:1 ratio girls to boys
- 30:1 ratio whites to blacks
- 1.5:1 ratio left to right
- When bilateral, left more severe (30%)
What are the clinical features of Developmental Dysplasia of the Hip (DDH)?
- Limited or asymmetrical hip abduction (limited hip abduction is often the only evident clinical sign in the infant > 1 month of age)
- Asymmetric thigh folds
- Positive Galeazzi sign
- Positive Ortolani sign
- Telescoping
What are the intervention methods in patients from birth to 9 month?
- Abduction diapers (x 1 month–re-evaluate)
* Pavlik harness
What are the intervention methods in patients 9 month and older?
- Abduction orthosis
* Surgical treatment
What is the definition of a septic arthritis?
An acute, rapidly progressive infection of the hip
What is the epidemiology of a septic arthritis?
< 2 years
What is the cause of septic arthritis?
• Pyogenic bacteria from hematogenous osteomyelitis,
subcutaneous abscess, otitis media, pneumonia, gluteal
infections, transusion, femoral venipuncture
What are the clinical features of septic arthritis?
- Initially: irritable infant
- Hip held in open packed position
- Fever, sweating, chills tachycardia, loss of appetite
What are the interventions of a septic arthritis?
- Aspiration, surgical drainage and intravenous antibiotics
* Skin traction or spica cast immobilization may be used
What is the definition of an acute transient synovitis?
Self-limiting condition in children 2-10 years
What is the epidemiology of an acute transient synovitis?
- 2-10 years of age
- Usually no other health problems
- Often preceded by upper respiratory tract infection
- Up to 5% later develop AVN or LCP
What is the cause of an acute transient synovitis?
Unknown – may be related to infection
What are the clinical features of an acute transient synovitis?
- Hip pain; walks with limp; refuses to walk
- Decreased hip ROM (esp IR)
- Fever possible
What are the radiologic features of an acute transient synovitis?
- Performed to rule out other problem
* Bone scan may be positive
What are the management options for an acute transient synovitis?
- Bed rest (relative rest)
- Partial WB with crutches
- F/U radiographs
What is the definition of a Legg-Calve-Perthes Disease?
AVN of the femoral head in a growing child
What is the epidemiology of a Legg-Calve-Perthes Disease?
- 3-12 yrs more common (4-5 years most common)
- Boys slightly more than girls
- Whites more than blacks
- Bilateral involvement: 5%
What is the cause of a Legg-Calve-Perthes Disease?
- Self-limiting
- Occasionally preceded by transient synovitis
- Initial stage is avascularity of femoral head
What is the clinical presentation of a Legg-Calve-Perthes Disease?
- Hip pain, limp and referred pain to the superior knee
* Decreased ABD, rot and a flexion contracture common
What are the radiologic features of a Legg-Calve-Perthes Disease?
- Early: capsular swelling
* Mid: ossific nucleus
What are the management options for a Legg-Calve-Perthes Disease?
- Bracing, casting, surgery. . .
* PT: ROM, gait training, education
What are the goals of treatment for a Legg-Calve-Perthes Disease?
1) to reduce hip irritability
2) restore and maintain hip mobility
3) to prevent the ball from extruding or collapsing
4) to regain a spherical femoral head
What is the definition of a slipped capital femoral epiphysis (SCFE)?
Post & inf. displacement of femoral head relative to the neck
What is the epidemiology of a slipped capital femoral epiphysis (SCFE)?
- 2:1 ratio boys to girls
- 10-16 years of age most common; X= 12yrs
- ~ 50% are bilateral
- Obese body type common
- More common in Black and Polynesian race
A slipped capital femoral epiphysis (SCFE) is majorly ___
A slipped capital femoral epiphysis (SCFE) is majorly idopathic
What are the idiopathic causes of a slipped capital femoral epiphysis (SCFE)?
Endocrine disorders, radiation therapy are other causes
What are the clinical features of a slipped capital femoral epiphysis (SCFE)?
- Patient reports gradually increasing hip pain & limp
- IR in extension and abduction ROM decreased
- Passive flexion presents with abduction & ER
- Chronic slip can be present for 3-12 months or longer
What are the radiologic features of a slipped capital femoral epiphysis (SCFE)?
AP view of each hip/pelvis and frog-leg lateral view
What is a grade 1 classification of a slipped capital femoral epiphysis (SCFE)?
Less than 33% displacement
What is a grade 2 classification of a slipped capital femoral epiphysis (SCFE)?
Between a 33% and 50% displacement
What is a grade 3 classification of a slipped capital femoral epiphysis (SCFE)?
More than a 50% displacement
What is the management of a slipped capital femoral epiphysis (SCFE)?
- Reduction of acute slip by traction or gentle manipulation
- Subacute slip treated with traction in ext and IR
- Open reduction with internal fixation (ORIF) using screw
- Severe slips treated with proximal osteotomy
___ is the 2nd leading cause hospitalization in older patients and incidence of it increases with age
Hip fracture
What is a galeazzi sign?
An observed inequality of the knee height, indicating hip dysplasia
How is the galeazzi sign tested?
The height of the child’s knees are measured with the child placed in hook lying position
What is the ortolani sign?
A palpable sensation of the femoral head gliding in and out of the acetabulum
How is the ortolani sign performed?
Examiner places finger on the outside/lateral aspect of the hip, and places the thumb on the medial aspect, close to the hip joint in attempt to grasp and move the femoral head, relative to the acetabulum. Gentle pressure is then added from a lateral to medial direction to glide the femoral head over the ridge of the acetabulum, a clicking sound indicates that the femoral head is relocating on the acetabulum
How is telescoping performed?
With the hip and knee in a flexed position, while the examiner applies a repetitive anterior to posterior glide through the femur in an attempt to assess movement of the femur on and off the acetabular rim, thus indicating a subluxing or dislocating joint
What is the goal of interventions for a Developmental Dysplasia of the Hip (DDH)?
To position of the femur appropriately relative to the acetabulum and then allow nature to take its course
What will the positioning done during the intervention for the Developmental Dysplasia of the Hip (DDH)? allow?
The positioning will allow the congruency of the femur relative to the acetabulum and then allow the surrounding capsular ligaments to tighten appropriately to help maintain the position
What leg position are parent s usually adviced to keep the leg of a baby with a Developmental Dysplasia of the Hip (DDH)?
In a frog like leg position
What happens during stage 1 of Legg-Calve-Perthes Disease?
The femoral head will begin to necrose and become dense, which may lead to a possible fracture
How long does stage 1 of Legg-Calve-Perthes Disease last?
6-12 months
What happens during stage 2 of Legg-Calve-Perthes Disease?
The bone fragments or fractures, which signals the process for new bone growth to start. The necrotic bone will be resorbed by the body
How long does stage 2 of Legg-Calve-Perthes Disease last?
A year or more
What happens during stage 3 of Legg-Calve-Perthes Disease?
New bone is laid down
What happens during stage 4 of Legg-Calve-Perthes Disease?
The time it takes for new bone to remodel
How long does stages 3 and 4 of Legg-Calve-Perthes Disease last?
Several years
What is the position of bracing in Legg-Calve-Perthes Disease intervention and why is it done?
ABD, with slight IR.
Done in an attempt to position the femoral head appropriately relative to the acetabulum
___ used to be the standard of care for hip injuries, but was found that there was no statistical benefit with pain control or surgery
Preoperative traction used to be the standard of care for hip injuries, but was found that there was no statistical benefit with pain control or surgery
What does preoperative antibiotics for ip injuries show, according to the cochrane review?
Significant decrease in deep
tissue infections and UTI
What is early surgery associated with in patients with injuries?
Early surgery (24-48 hrs after fracture) associated with decreased mortality, pressure ulcers, delirium
What percent of patients with develop a DVT if not treated?
50%
What are the factors that can increase the risk of a DVT in hip fracture patients?
- Advanced age
- Delayed surgery
- General anesthesia
What is recommended to avoid a DVT in hip fracture patients?
- Routine use of Antithrombolic agents
- Mechanical prophylaxis better than nothing
- Continue anticoagulation at least 28-35 days after surgery
What is the mechanism of injury of a hip proximal femur fracture?
Compression trauma—direct lateral impact to hip (e.g.,
collision or fall)
What are the most common injury sites of a proximal femur fracture?
- Neck
- Inter- trochanteric
- Sub- trochanteric
What are the associated risks of a hip proximal femur fracture?
Soft tissue damage and hemorrhage
What percent of hip fractures happen at the femoral neck?
45%
What percent of hip fractures happen at the Intertrochanteric?
45%
What percent of hip fractures happen at the subtrochanteric?
10%
What is the prognosis of a femoral neck fracture upon?
- location
- displacement
- reduction
- stability and
- whether it requires fixation
A femoral neck fracture may need a ___
A femoral neck fracture may need a hemi - arthroplasty
What is a hemi- arthroplasty?
Replace ball of femur with prosthesis
Why would a femoral neck fracture need a femoral neck fracture?
If the blood flow was significantly compromised or the head of the femur itself has been fractured
___ supplies most of the blood flow to the head of the femur
Medial femoral circumflex artery supplies most of the blood flow to the head of the femur
What are the indications of total hip arthroplasty (THA)?
- OA
- Inflamed synovium (RA)
- Nonunion hip fractures
- Avascular Necrosis
- Congenital hip dysplasia
- Slipped capital femoral epiphysis
What are the contraindications of total hip arthroplasty (THA)?
- Infection.
- Injured or non-functional hip muscles
- Neuromuscular disease
- Skeletally immature
- Poor quality bone
- Poor skin coverage around the hip joint
What are the precautions of THA in the posterior approach?
- Don’t cross your legs or ankles
- Don’t raise knee above hip
- Don’t bend at the waist > 90°
- No ER if anterior approach
- No IR if posterior approach
- Don’t sleep on side or without pillows between your knees
What are the complications that can be caused by a Medial femoral circumflex artery injury?
Nonunion, osteonecrosis
Which type of hip fractures heal better? Intrascapular or extrascapular and why?
Extrascapular injuries heal better, because they are not bathed in synovial fluid
What are the surgical procedures for a Femoral neck Displaced fracture (Garden III and IV) Undisplaced and impacted fractures (Garden I and II)?
Hemiarthroplasty
ORIF
Dynamic Hip Screw
(DHS)
What is the weight bearing status for a Femoral neck Displaced fracture (Garden III and IV) Undisplaced and impacted fractures (Garden I and II)?
Weight-bearing as tolerated
Depends on the stability
of surgical fixation
What is the surgical procedure for an Intertrochanteric
Undislaced, displaced two-part fractures, or unstable three-part
fractures?
Treated operatively with multiple pins or screws and side-plate devices
DHS
What is the weight bearing status of an Intertrochanteric
Undislaced, displaced two-part fractures, or unstable three-part fractures?
Depends on degree of fracture stabilization, bone stock, patient’s frailty, and risks of immobility
What is the surgical procedure for a Subtrochanteric Simple, fragmented, or comminuted?
ORIF with a blade plate and screws (DHS) or an intramedullary nail
What is the weight bearing status of a Subtrochanteric
Simple, fragmented, or comminuted?
Delayed until fracture
demonstrates evidence
of healing
What does day 1 post op of a hip surgery rehab plan look like?
- UE strengthening
- QS, HS- sets, GS, ankle pump
- AA hip abd and add; supine leg slides
- Bed mobility
What does day 2 post op of a hip surgery rehab plan look like?
- Increased independent bed mobility
- Ambulation with appropriate WB status
What does day 3-7 post op of a hip surgery rehab plan look like?
- SLR lying an standing
- If WB to tolerance, start weight shifting exercises/ mini-squats
- Modified thomas stretch(supine) to stretch ms/ ant capsule
- Sit - stand exercises
- Increase ambulation
- Evaluate need for home assistive devices
What does 1-2 weeks post op of a hip surgery rehab plan look like?
- Discharge criteria
- Institute HEP
- Progress exercises: standing hip abd, add, ext, and flex, standing balance & proprioception training
- Progress assistive device as able
- Stationary bike, pool exercises, treadmill
What are the two categories of a stress fracture?
- Fatigue fractures
* Insufficiency fractures
Where are the common locations of a stress fracture?
- Femoral neck
- Pubic rami
- Acetabulum
- Femoral head
- Sacrum
What is the tension side fracture of the femoral neck and what is its stability status?
• Tension side (superior side): unstable
What is the compression side fracture of the femoral neck and what is its stability status?
• Compression side (inferior side): stable
What is a fatigue stress fracture?
Normal bone subject to abnormal stress
What is an insufficient stress fracture?
Abnormal bone subject to normal stress
What are the presentations of a stress fracture?
- Exercise-induced deep hip, groin, or thigh pain
* Hop test + in 70%
What are the risk factors of a stress fracture?
- Female gender and amenorrhea
- Low aerobic fitness starting intense exercise
- Overuse (military, running)
- Smoking
- Steroid use
What are the imaging factors for a stress fracture?
- Plain radiographs: sensitivity 10%
* MRI and bone scan more sensitive
What are the treatments for a stress fracture?
- Tension-side pinned to prevent displacement
- Compression-side 6-8 weeks of limited WB
- PT to address bio mechanical factors
Femoroacetabular Impingement
(FAI) is typically seen in what patient population?
Young patients with hip pain
What are the presentations of a Femoroacetabular Impingement (FAI)?
- Reduced ROM in flexion & IR
* Repetitive microtrauma
Where can there be abnormalities in a Femoroacetabular Impingement (FAI)?
The acetabulum, labrum, or both
What are the causes of a Femoroacetabular Impingement (FAI)?
- Abnormal acetabulum
- Abnormal femur
- Increased stress
What are the types of a Femoroacetabular Impingement (FAI)?
- Pincer (acetabular)♀
- Cam (femoral) ♂
- Mixed – 86 %
In what population is the pincer type of FAI seen the most?
- Middle aged women
* Ballet dancers
What is the pincer type of FAI?
An over coverage of the acetabulum on the femur
What does the pincer type of FAI lead to and in what region?
Leads to a focal articular damage mostly in the posterior inferior cartilage region
What is the cam type FAI?
A primary femoral abnormality where there is a loss of the concavity of the femoral neck
The cam type FAI is called the ___ deformity
The cam type FAI is called the pistol grip deformity
What are the causes of a cam type FAI?
• Growth abnormality of the capital
femoral epiphysis
• SCFE
• LCPD
What does the femoral head do in the cam type FAI? and what does it lead to?
Femoral head jams into acetabulum leading to shear forces on labrum which will diffuse articular damage
What are the radiographic signs of a cam type FAI?
- Pistol grip deformity
* Femoral retrotorsion
What are we looking at with examination of FAI?
- Sharp groin pain with flexion and IR
- Lateral or posterior pain with ER, stair climbing and prolonged sitting
- Difficulty squatting or with lateral and cutting movements.
- Significantly limited flexion and IR
- Positive impingement test occurs with groin pain at 90° of flexion with IR (FADIR)
- Pain or asymmetry with FABER
What are the imaging to order for a FAI?
AP and lateral radiographs of pelvis
What are you looking for in the radiographs of a FAI?
• Assess for “pistol-grip” femoral head in cam
impingement
• Acetabular retroversion and crossover in pincer impingement
What are some other imagings to order for a FAI?
MRI and MRA
What are you looking for in the MRI and MRA of a FAI?
- Measurement of the alpha-angle
- Asphericity of the femoral head
- Evaluate any concomitant labral tears or cartilage damage
The natural progression of FAI is ___
The natural progression of FAI is labral tears
What are the 2 kinds of labral tears?
Degenerative
Traumatic
What are the risk factors for labral tears?
- Perthes’ disease
- Previous trauma
- Slipped capital femoral epiphysis
- Femoroacetabular impingement (FAI)
- Repetitive pivoting or hip flexion
What are the chief complaints of patients with a labral tear?
- Groin pain with/without click
* Clicking hip: +LR of 7
____ is a consistent finding in labral tears
Clicking is a consistent finding in labral tears
What are the examinations/ presentations of a labral tear?
- Dull and/or sharp groin pain
- Worse with activity, walking, and sitting
- 50% report catching or painful clicking
- May have Trendelenburg gait or limp
- Often positive impingement sign (FADIR)
What is the general onset of a labral tear?
Generally gradual onset vs. acute trauma
What can relief a labral tear pain?
Relief with an intra-articular injection
What test is commonly used for labral tears?
Fitzgerald test
How is the Fitzgerald test done for a suspected anterior labral tear?
Suspected anterior – full FABER, moved to Ext/ADD/IR
How is the Fitzgerald test done for a suspected posterior labral tear?
Suspected posterior – full EABER, moved to Flex/ADD/IR
How is the FABEr/ patrick’s test done?
- Hip joint is Flexed, ABducted, and ER
- ROM measured w/ inclinometer or distance of knee from table
- Anterior hip/groin pain indicates hip involvement, back pain = SIJ
What is the MDC for a FABER test?
- 8 for ROM
* 1.6 points of the NPRS
What is the best test for RULING IN a labral tear?
Historical report of clicking
What is the gold standard for the diagnosis of a labral tear?
Arthroscopy
What is the reference standard for the diagnosis of a labral tear?
MRI – gadolinium enhanced
- 90% sensitivity
- 100% specificity
- Accuracy 93% to 96%
Why is there a reference standard for the diagnosis of a labral tear?
The gold standard is not ethical for every patient
____ will miss a labral tear, while ____ may show an FAI
An MRI will miss a labral tear, while a radiograph may show an FAI
What does phase 1 of the case study looking at nonsurgical treatment for a labral tear by Yazbek state?
- Pain control
- Education in trunk stabilization
- Correction of abnormal joint movement
What does phase 2 of the case study looking at nonsurgical treatment for a labral tear by Yazbek state?
- Muscular strengthening
- Recovery of normal ROM
- Sensory motor training
What does phase 3 of the case study looking at nonsurgical treatment for a labral tear by Yazbek state?
- Advanced sensory motor training
- Sport-specific functional progression
- Reassess ROM, strength, flexibility, pain, special tests, and level of function
What were the outcomes of the nonsurgical treatment for a labral tear by Yazbek state?
- All patients improved pain, function, and strength
* Patients with labral tears can benefit from nonsurgical intervention
What are the presentation of patients that will probably have to get labral surgery?
+ MRA & persistent hip pain > 4 weeks, failure conservative management?
What are the possible surgical interventions for a labral tear?
• Arthroscopy for: • FAI – 83% return to play • Microfracture – 86% good to excellent • Labrectomy – 60-95% good to excellent • OA – 20-60% good to excellent • 88% eventually have THA • Dysplasia – failure rate high as the labral loading is not alleviated • Debridement –67% good to excellent • Labral repair - 90% good to excellent
What are the phases of rehab for a post op labral repair?
- Maximum Protection
- Controlled Stability
- Strengthening
- Return to Sport
What are the initial precautions following a labral surgery?
• Flexion to 120º • ER to 0º • ABD to 45º • Extension 0º • Weight Bearing Foot Flat WB to 30% x 3-4 weeks - this varies Microfracture = NWB x 6-8 weeks • Hinged hip brace (surgeon dependent) • DVT protection
What are the goals of phase 1 (0-2/3wks) of a post op labral tear rehab?
- Protect the integrity of the repaired tissues
- Diminish pain and inflammation
- Restore ROM within the restrictions
- Prevent muscular inhibition
What are things to work on in the mobility portion of phase 1 of a post op labral tear rehab?
PROM - circumduction
Knee to chest stretch for hip flexors
Prone laying
Aquatic program
What are the muscles to focus and promote activity of during the phase 1 of a post op labral tear rehab?
- Prime Movers & Stabilizers:
- Glut med
- Glut max
- TrA
- Hamstring
- Quads
What are the muscles to demote activity of during the phase 1 of a post op labral tear rehab?
Hypertonic Compensators
•Hip Flexor
•TFL
•Adductors
What are the goals of phase 2 (3-4wks) of a post op labral tear rehab?
- Normalize gait
- Restore full ROM
- Improve neuromuscular control, balance, proprioception
- Initiate functional exercises maintaining core and pelvic stability
What are the precautions of phase 2 (3-4wks) of a post op labral tear rehab?
- Recommend no treadmill use
- Avoid hip flexor and adductor irritation
- Avoid joint irritation: too much volume, force or not enough rest
- Avoid ballistic or aggressive stretching
What are things to work on in the mobility portion of phase 2 of a post op labral tear rehab?
• Continue PROM • Add FABER stretching • Add Hip extension • Restoration of lumbo-pelvic-extremity kinematics • Core recruitment • Gluteal firing at end-range hip extension • Progress Aquatic program • Pool to on-land progressions • Forward walk (TrA emphasis) • Backward walk (Glut emphasis) • Side Step Walk (Glut Med Emphasis) • Mini lunge walk (emphasis hip flexor stretch)
What are the goals of phase 3 (unspecific timeline: progress as tolerated) of a post op labral tear rehab?
- Restore muscular strength and endurance
- Optimized neuromuscular control, balance, and proprioception
- Restore cardiovascular endurance
- Progress sport progressions
What are the precautions of phase 3 of a post op labral tear rehab?
- Recommend no treadmill use
- Avoid hip flexor and adductor irritation
- Avoid joint irritation: too much volume, force or not enough rest
- Avoid ballistic or aggressive stretching
- Avoid contact and high velocity activities
What are the characteristics of the hip sport test to return to full activity?
• 20 points possible: 17/20 passing score
• Single knee bends x 3 minutes
• One point for each 30 sec. with good form
• Goal is 3 minutes – 6 points
• Lateral Agility with x 100 sec.
• One point for each 20 sec. with good form
• Goal is 100 seconds – 5
points
• Diagonal Lateral Agility x 100 sec.
• One point for each 20 sec. with good form
• Goal is 100 seconds – 5 points
• Box Lunge x 2 min.
• One point for each 30 sec with good form
• Goal is 2 minutes – 4 points
What are the goals of phase 4 (6-9 months: progress as tolerated) of a post op labral tear rehab?
- Restore power and maximize plyometroc strength
- Return to play
- Independent in maintenance program
4, Understands proper care for the long term health of the hip
What are the precautions of phase 4 of a post op labral tear rehab?
No specific precautions unless noted by the physician
What are the intra-articular causes of pain around the hip?
- Labral tears
- Loose bodies
- Femoroacetabular impingement
- Capsular laxity
- Ligamentum teres rupture
- Fractures
- Articular cartilage
What are the extra-articular causes of pain around the hip?
- Iliopsoas tendinitis
- Iliotibial band
- Glut med or min
- Greater troch bursitis
- Stress fracture
- Adductor strain
- Piriformis syndrome
- Greater troch pain syndrome
What is the positional order for the hip examination?
- Standing
- Sitting
- Supine
- Side lying
- Prone
What are the hip exams that should be done while standing?
- Observation/Posture
- Gait analysis
- Functional squat and other functional tests
- Clear the lumbar spine
What are the hip exams that should be done while sitting?
Reflexes and sensory/peripheral nerve scan
What are the hip exams that should be done in supine?
• Hip A/PROM: abduction, adduction, internal/external rotation (rotation also prone)
• Resistive testing: flexion, extension, AB/ADDuction, IR/ER, knee flexion and extension
• Special tests: Patrick/FABER test, Thomas test, Leg length tests, Rectus femoris test, SLR,
Sign of the buttock, scour test, labral tests
• Accessory motion testing: Caudal glide, Posterior glide, Lateral distraction, Quadrant test
• Palpation (done throughout)
What are the hip exams that should be done in side lying?
- Ober’s test
* Gluteus medius strength
What are the hip exams that should be done in prone?
- Hip A/PROM: Active and passive hip extension (also rotation)
- Resistive testing: Hip extension and rotation
- Accessory motion testing: hip anterior glide
- Lumbar springing
What aggravates the ischial bursa, causing a bursitis?
• Direct trauma or movement in sitting position (rowing, biking)
What aggravates the iliopectineal bursa, causing a bursitis?
• Anterior hip pain, difficult to
differentiate from hip flexor strain. Aggravated with repeated hip flexion
Why is the term trochanteric bursa being changed to Greater troch pain syndrome?
Because people with this condition does not present with all 4 cardinal signs of inflammation (warmth, redness, swelling and pain) they only present with pain
What is the typical presentation for a greater troch pain syndrome?
- General lateral hip pain that is exacerbated with lying on the affected side
- Most WB activities
What does a patient with an inflammed bursa present with?
- Sharp lateral hip pain
What is the general cause of an inflammed bursa?
Direct trauma to the lateral hip or repetitive friction from the ITB to the troch during hip flex and ext movements
What are the bursas in the lateral hip region?
- Sub gluteus min
- Sub gluteus med
- Sub gluteus max
Which bursa is most often thought of as the trochanteric bursa?
Sub gluteus max
What are the conservative treatments that are usually successful for buristis?
- Rest
- Ice
- Compression
- Elevation
- Cortico-steroid injections when the tissues are acutely inflammed
What is the snapping hip syndrome?
A snapping sensation in or around the hip during motion
What are the external causes of the snapping hip syndrome?
- Posterior IT band
- Ant glut max
- Trochanteric bursitis
What are the internal causes of the snapping hip syndrome?
- Iliopsoas tendon snapping
- Iliofemoral ligament snapping
- Hamstring syndrome
- Iliopsoas brusal/capsular thickening
What are the intra-articular causes of the snapping hip syndrome?
- Labral or ligamentum tears
- Loose bodies
- Synovial chondromatosis
- Displaced fractures
- Capsular instability
What type of snapping hip syndrome is the most common?
External
Snapping hip may or may not include ___ and is very common in 45% ballet dancers
Snapping hip may or may not include pain and is very common in ballet dancers
___ is the most common cause of groin pain in runners
internal snapping hip is the most common cause of grain pain in runners
What are the key findings when assessing someone for an internal snapping hip?
- Anterior groin pain with resisted hip flexion
- Snapping while extending the hip from flexed position
- Iliopsoas tendon tender to palpation
What will eliminate the snapping of an internal snapping syndrome during testing?
The relaxation of the iliopsaos muscle
What often elicits a palpable snap?
Movement from FABER position into extension, adduction, and IR often elicits a palpable snap
Where will the stretching exercises for internal hip syndrome?
There will be more intensive stretching at the illiopsoas, rather than the TFL
Patients with an internal snapping syndrome will gain more benefits from what interventions than a person with an external hip syndrome?
- Hip mobilization and manipulation
When conservative interventions don’t work for internal or external snapping hip syndrome, what are the surgical methods to be used?
- Tendon lengthening
- Debridement
What are common glut med and min dysfunctions?
• Tendinitis to tendinosis, and even tears
Gluteal tendons analogous to ___ of shoulder
Gluteal tendons analogous to rotator cuff of shoulder
What are the ways to examine glut med and min conditions?
- Dull lateral hip pain
- Focal tenderness at gluteal insertion
- Weak hip abduction
- Provocative tests
Glut med and min dysfunctions are more prevalent in what population?
More common in women. Most likely due to the difference in the pelvic structures
What has the best diagnostic utility of a glut med or min condition when provocation of the lateral hip pain is the criteria of the test?
30 sec single leg stance test
100% Sn
97% Sp
What test also has very good specificity and sensitivity for the glut med or min condition?
Resisted lateral denotation
How is the resisted lateral denotation test done?
PT will passively flex patient’s hip up to 90 deg, followed by passively externally rotating the hip with the it at the 90 deg flexion. The patient will then resist IR and pain in the lateral region will be assessed
What is the important thing with the FABER or ober test?
Making sure you identify the location of the patient’s pain to help differentiate between tendon pathologies and joint conditions such as OA
What are the imaging options for a glut med or min dysfunction?
• Plain radiographs – unable to identify tendon
pathologies
• MRI: most specific (gold standard)
• US: most sensitive (better to see liquids and such)
What are the treatment options for a glut med or min condition?
- Decrease compressive and tensile loads
- Therapeutic exercise and motor control training
- Corticosteroid injections
- Endoscopic debridement or repair
What are the main symptoms for nerve entrapments?
Pain
Paresthesia (decreased sensation)
Hyperesthesia
Weakness
What is the course of an obturator nerve(L2-4), how could it be injured and what does it present as?
- Course through psoas into obturator foramen
- Can be injured in pregnancy, trauma, traction used during hip surgery
- Medial thigh pain and adductor weakness
What is the course of the femoral nerve(L2-4), how could it be injured and what does it present as?
• Exits lateral psoas and courses inferior between psoas and iliacus
• Usually due to trauma, tumors, or surgical complications
• Difficulty walking, going up/down stairs, getting up from chair
Quad weakness/+Ely test
What is the course of the lateral femoral cutaneous nerve (L2-4), how could it be injured and what does it present as?
• Emerges from lateral border of the middle aspect of the psoas major, passes under inguinal ligament and then courses over the
sartorius muscle
• Common in obesity, tight belts, repetitive hip flexion
• Anterolateral thigh burning, tingling, numbness, no motor\
• Meralgia Paresthetica
How can damage to nerves occur?
- Traction mechanisms
- Prolonged compression
- Trauma
What do patients complain of with an obturator nerve entrapment?
Difficulty walking, running, and jumping, feeling like they have an unstable leg
What are the symptoms of a femoral nerve entrapment?
Pain in the inguinal region that may be reduced with hip flexion and ER, sensation loss to anterior thigh and anterior medial leg
What do patients complain of with a femoral nerve entrapment?
Knee buckles with walking, getting up from a chair or ambulating on the stairs
What is a meralgia parasthetica?
The entrapment of the lateral femoral cutaneous nerve (L2-4)
What increases the symptoms of lateral femoral cutaneous nerve (L2-4) entrapment?
- Standing
- Hip extension
What decreases the symptoms of lateral femoral cutaneous nerve (L2-4) entrapment?
Sitting
What is a common cause of a lateral femoral cutaneous nerve (L2-4) entrapment?
Compression that occurs resulting from belts or garments that may be worse when the patient is sitting in a position that compresses the anterior hip region
What is the first thing required for the treatment of a nerve entrapment?
Determination of the cause of the neuropathy and addressing it
What may be required if a nerve entrapment was traumatic and injury was severe enough to the nerve r the tissues around it?
Surgery
What are the important things to do if surgical intervention is not needed for a nerve entrapment?
- Protections of the tissues as they heal
- Gentle initiation of movement to decrease the risk of unnecessary scar tissue formation
What are the ways to provide space for a healing nerve?
- Manual therapy
- Education regarding clothing
- Posture activity modification
- Blood flow movement
What are the ways to improve blood flow movement?
- Neurodynamic exercises
- General activity
What is a piriformis syndrome?
The entrapment of the sciatic nerve by the piriformis muscle
___ is one of the more common LE nerve entrapments
Piriformis syndrome is one of the more common LE nerve entrapments
What population has a greater likelihood of having a piriformis syndrome?
The 12% of people that their sciatic nerve goes through the piriformis
What are the causes of a piriformis syndrome?
• Piriformis hypertrophy in relation to exercise
• Spasm or muscular fibrosis
following trauma
• Prolonged compression
What are the examination findings of a piriformis syndrome?
• May have leg pain in sciatic nerve distribution
• Numbness or weakness is rare, SLR sometimes negative
• Sitting worsens the pain, walking relieves pain
• Tenderness at sciatic notch, greater trochanter and piriformis
• Pain with FAIR test (flexion to 600
, adduction and IR in sidelying)
with or without resisted abduction
What are the treatments of a piriformis syndrome?
- Muscle relaxants
* Physical therapy addressing muscle imbalances
How is the FAIR performed?
In sidelying by flexing, adducting, and internaly rotating the hip
Imaging–guided local injection can be diagnostic and
therapeutic: good results predict success with ____
Imaging–guided local injection can be diagnostic and
therapeutic: good results predict success with surgery
___ is the most common injury in the LE region and it typically involves the musculotendinous region
Hamstring strains is the most common injury in the LE region and it typically involves the musculotendinous region
What are the things that are common with a hamstring strain?
Swelling and bruising
What are the mechanisms of injury for a hamstring strain?
- Quick explosive contraction, usually involving the knee flexion, but can also be via the hip extension, esp when the hamstring is already loaded into a stretch position
- Non-traumatic proximal hamstring tendinopathies are also common
What movement causes the quick explosive contraction that results in a hamstring strain?
During the transition of eccenric to concentric forces
What are the other factors making hamstring strains more likely?
Muscle imbalances Fatigue Running posture Gait Leg length discrepancy Decreased ROM Muscle innervation
What is the result of neurodynamic changes in a hamstring strain?
They can limit knee flexion and extension ROM, and the ability to perform resisted knee flexion
What are the potential causes for recurrent hamstring injuries?
- Neurodynamic impairments
* Improper rehabilitation
What is the rehab progression of a hamstring strain?
- Pain and swelling control, avoid NSAIDs
- Normalize gait
- Gentle AROM -> light stretching
- Neurodynamic exercises
- Isometrics -> PRE’s -> eccentrics -> ballistic/ unpredicted movements
Why do we avoid NSAIDs in the beginning or healing for hamstring rehab?
It can increase bleeding to the area, therefore prolonging recovery, and increasng the risk for complications
What are the things to include in the rehab progression of a hamstring strain?
Include hip and lumbopelvic motor control activities
What should happen to a patient following the completion of a rehab progression of a hamstring strain?
Patients should be able to perform functional activities pain-free and have completed full eccentric, plyometric, and function specific training regimen
How long does it take for a . grade 1 hamstring strain to heal?
Grade I injury may result in no lost time
How long does it take for a . grade 2 hamstring strain to heal?
Grade II injury average 5-12 days
How long does it take for a . grade 3 hamstring strain to heal?
Grade III injury 3-12 weeks
What causes a strain?
Strains occur via indirect trauma (pulled muscle)
What causes a contusion?
Contusions occur as a result of a direct blow
Contusions can lead to
___ or ___
Contusions can lead to
compartment syndromes or
myositis ossificans
What is a myositis ossificans?
Myositis ossificans means inflammation of muscle leading to bone formation
What are the factors associated with the development of Myositis ossificans?
- Too-Vigorous of a treatment that continue to cause bleeding in the area of the original injury, including: Massage directly on the
area, ultrasound, and superficial heat - Return to play before healing has occurred
- Repeated contusions
How does a myositis ossificans create bone formation?
Quads bleeding close to bone, a cascade of cellular responses can occur, causing heterotopic bone formation
What are the treatments for myositis ossificans/ quads contusion?
- Immobilize knee 120 deg of flexion with Ace wrap 24 hours
- Apply ice for 20 minutes every 2-3 hours
- Discontinue 120 deg of flexion at 24 hours
- Begin passive stretching, followed by icing
- Begin active pain-free quadriceps stretching and strengthening
- Gradual return to weight-bearing, as tolerated
- Avoid applying heat to the area or taking NSAIDs because they may increase bleeding
When may surgical removal of a quad contusion/ myositis ossificans be required?
If it continues to be painful and limit ROM for over a year
Why should a year pass before the consideration of a surgical removal for a quad contusion/ myositis ossificans?
- Waiting a year will lessen its likelihood of returning
* If removed surgically there are soft tissue ramifications!
___ is a significant cause of groin pain in athletes and can be very challenging to successfully treat and overcome
Adductor strains is a significant cause of groin pain in athletes and can be very challenging to successfully treat and overcome
In what individuals is the higher incidence of an adductor strain common?
- Hockey, soccer, and rugby
* Repetitive kicking, quick starts, or changes in direction
What are the risk factors that increases the likelihood of an adductor strain?
Adductor weakness, abductor–adductor
imbalance, or decreased preseason hip ROM
___ and ___ muscles stabilize pelvis during LE activities
Adductors and lumbopelvic muscles stabilize pelvis
during LE activities
What adductor muscle is the most at risk for an adductor strain and why?
- Adductor longus.
Origin of adductor longus at pubic symphysis has smaller tendon predisposing area to strain
What are the things you’ll find upon examination of the adductor strain?
- Present with aching groin or medial thigh pain
- May relate a specific incident
- Tenderness to palpation
- Adductor weakness
What is the imaging to be uses with an adductor strain?
MRI with gadolinium: differentiate between adductor
strain, osteitis pubis, and sports hernia
What are the treatments for an adductor strain?
• Relative Rest and anti-inflammatory medications
• PT focus on hip flexibility and hip and lumbopelvic
motor control
• Injection helpful for patients that fail conservative
treatment
• Surgical repair for diagnosed tears
• Preseason adductor strengthen & hip ROM
What is an Athletic Pubalgia / Sports Hernia?
A strain in the inguinal or lower abdominal area and is not considered a groin injury due to being more proximal that the groin region
What is the most common method of injury for Athletic Pubalgia / Sports Hernia?
Trunk extension & thigh abduction injury to insertion of abdominals onto the pubic bone
What are the risk factors for Athletic Pubalgia / Sports Hernia?
• Sports requiring repetitive twisting and turning of the thigh and trunk (hockey,
soccer, skiing, rugby, and tennis)
• Muscle imbalance between strong thigh muscles and weaker abdominal muscles
What is Gilmore’s groin?
Tears in the external oblique aponeurosis and conjoint tendon
What are the presentations of Athletic Pubalgia / Sports Hernia?
- Pain with activity, resolves with rest
- Tenderness around the conjoint tendon, pubic tubercle, inguinal canal
- Pain with sit-ups, hip adduction, or Valsalva
What are the aggravating factors of Athletic Pubalgia / Sports Hernia?
Ballistic movements:
• Coughing, sneezing, sit-ups, sprints, or kicking
What is the imaging for Athletic Pubalgia / Sports Hernia?
MRI sensitive and specific
What are the treatment options for Athletic Pubalgia / Sports Hernia?
• Relative rest
• Physical therapy
• Lumbopelvic and hip strengthening and motor
control activities
• Surgical repair of weak posterior inguinal wall or after
failed conservative management
What is the return to full activity for an Athletic Pubalgia / Sports Hernia after surgery?
2-6 months
What is osteitis pubis? and what population is it the most common in?
• Inflammation around the pubic symphysis
• Common among athletes, pregnant women, pelvic
trauma, or pelvic surgery.
What are the mechanisms of injury for osteitis pubis?
Overuse injury secondary to repetitive shear at the pubic symphysis
How is the examination of an osteitis pubis?
• Diagnosis often determined by history and physical
examination
• Tenderness pubic symphysis
• Pain with resisted adductor testing
• Correlation between decreased preseason hip
rotation ROM
What are the imaging used for an osteitis pubis?
• Radiographs: widening of symphysis; sclerosis; cyst
formation
• Bone scans may have “hot spots” over symphysis
What is the management methods of an osteitis pubis?
• Relative rest, anti-inflammatory meds
• Physical therapy for 6-8 weeks
• Address muscle
imbalances hip and core
• Adductor stretching
• Proprioceptive retraining
• Cortisone injections
• Surgery has up to 80% success rate in chronic casesHow was THA (total hip arthroplasty) done in the 70s?
• Admitted 1-2 days before surgery • Bedrest 2-3 days postop • Partial weight bearing • LOS 17 day
How is THA (total hip arthroplasty) done now?
• Admitted morning of surgery • Mobilize day of surgery or POD 1 • Usually WBAT • LOS < 5days
Where is the incision for a THA made in the posterolateral approach?
Along the femur and then curved posteriorly along the glut max to expose the posterior part of the hip
What are the characteristics for THA in the posterolateral approach?
- Return to normal abductor strength and ambulation is faster
- Higher rates of dislocation
What are the characteristics for THA in the anterior lateral approach?
- Allows immediate normal ROM
- Lower risk dislocation
- Higher revision rates
- Higher risk complication
What are the characteristics for THA in the lateral & transtrochanteric approach?
• Higher rates of post op limp due to gluteal nerve injury or avulsion of gluteal flap
What are the 2 types of techniques of a THA?
Cemented and Cementless
What is the preferred technique of THA?
Cementless
What component makes the cementless technique of THA better than the cemented technique?
It is better with the acetabular component
What are the WB limitations after a THA? and Why?
WBAT/FWB as soon as possible post op
FWB does not adversely affect bone ingrowth or prosthetic stability
What are the complications associated with THA?
- DVT (8% to 70%)
- Prophylactic anticoagulants
- Device failure
- Leg length discrepancy
- Component malalignment
- Infection
- Improper implant fixation to surrounding bone
- Nerve palsy
- Prosthetic hip dislocation
What patients are at an higher risk of complications/dislocations following a THA?
- Females
- Those with dx of osteonecrosis of femoral head
- Acute fx or nonunion of proximal part of femur
What is the evidence related to THA and rehab?
• No randomized controlled trials have been done
to determine the most effective rehab protocol
• No prospective studies have determined the advantage of inpatient rehab post THA
• No specific data on the type and duration of ROM restrictions
What happens if a patient does not receive rehab following THA?
Ongoing impairments and functional deficits for as long
as 2 years post THA
What were the HEP used in the study to determine the benefit of HEP following THA?
- Hip flexion ROM
- Low resistance strengthening hip flex/ext/abd
- 30 min walking every day
What were the results of the study to determine the benefit of HEP following THA?
- Greater improvement in Exercise high compliance group :
- Strength on operated side
- Fast walking speed
- Functional score on Harris Hip Score
- Recommend HEP 3x/week for training effect
What was the result of the study done by Trudelle-Jackson & Smith, 2004 in regards to Weight Bearing and Postural Stability Exercises post THA?
- Significantly improved muscle strength
- Postural stability
- Self-perceived function
What are the phase I rehab exercises (0-3wks) post THA?
- Gait Training
- Quad Sets and/or Terminal Knee Extension
- Gluteal Squeezes
- Heel Slides
- Supine Abduction/Adduction AROM
- Prone Lying
- Prone Hamstring Curls
- Reclined Sitting Knee Extension
- SLR????
Why is doing an SLR questionable in phase I exercises (0-3wks) post THA?
More stressful to hip than walking
What are the phase I education (0-3wks) post THA?
- Use of Abduction Pillow
- Bed Transfer Methodologies
- WB Instructions
- Breathing Exercises (to avoid pneumonia)
- Awareness of DVT (ankle pumps)
- Commode/Chair Transfers
- ADLs
What are the phase II rehab exercises (4-6wks) post THA?
• Supine Hip Lift (SLR)
Make it functional!
• Standing Hip Lift
• Standing Hip Abduction
• Standing Hip Extension
• Partial Squats
• Hip Extensor Stretch
• Reverse ThomasWhat are the phase III rehab exercises (6-12wks) post THA?
- Sidelying Hip Adduction
- Prone Hip Extension
- Step Ups
- Calf Raises
- Proprioceptive and Balance activities
- Supine Hip Flexor Stretch
- Bike
What are the sports activity recommendation post THA?
- Avoid sporting activities that create high compressive or rotatory forces or increase risk of injury to the new joint
- Recommended/allowed – e.g., swimming, walking
- Allowed with experience – e.g., canoeing, hiking, XC skiing
- Not recommended – e.g., high impact aerobics, jogging
- No conclusion – e.g., speed walking, downhill skiing, weight machines, ice skating
What is a minimall invasive THA?
Incisions that do not involve
cutting muscles or tendons
What are the indications for a birmingham hip resurfacing?
• Physically active • Under 60 years of age • Hip OA, dysplasia or AVN • Bone quality strong enough to support the implant.
How was TKA (total knee arthroplasty) done in the 70s?
• Admitted 1-2 days before surgery • Bedrest 2-3 days post-op • Ambulation with knee splint begun POD 3 • Knee ROM begun POD 7 • No discharge until knee flex = 90
How was TKA (total knee arthroplasty) done now?
• Admitted morning of surgery • Mobilize day of surgery or POD 1 • Usually WBAT • LOS < 5days • CPMs placed in post-op
What technique is thebest for a TKA, cemented or cementless?
Cemented is the gold standard
What is the evidence related to TKA and rehab?
- 20-30% slower walking speed
- 50% slower stair climbing speed
- 52% have functional limitations
- 22% without knee problems
- 75% have difficulty with stairs
- Peak recovery 2-3 yrs after TKA
- Rapid decline in function after that
According to the study by Labraca, what are the benefits of starting PT early post a TKA?
- Shorter hospital stay by 2 days
- Lower pains cores (2.36 pts)
- Greater knee flexion (16.29 deg)
- Greater extension (2.12 deg)
- Significantly greater strength in quads & HS
- Improved gait and balance
According to study by Jones, what are the benefits of continuous passive motion(CPM) and PT compared to PT alone?
- Increased active knee flexion
- Decreased length of stay
- Decreased the need for post-op manipulation
What kind of advantages does CPM provide?
- CPM may improve short-term rehabilitation
* But CPM does not appear to offer long-term advantage
What are the outcomes of TKA in the 1st 4 weeks?
- Quadriceps strength decreases by 60%
- Quadriceps activation decreases by 20%
- 2x as much strength loss as atrophy
- Walking distance decreases by 40%
- Stair climbing speed decreases by 90%
What are the long term outcomes of TKA?
40% deficits in quadriceps strength
• 30% deficits in walking distance
• 105% deficit in stair climbing speed
What are the effects of NMES in quadriceps function post TKA according to the N=1 study by Mintken?
• Results suggest that early NMES improves
quadriceps activation and strength deficits
• Randomized clinical trial needed to test hypothesis
What are the suitable sport and activity recommendations post TKA?
- Suitable: cycling
- Swimming
- Low-resistance rowing
- Walking
- Hiking
- Low-resistance weightlifting
- Ballroom dancing
- Square dancing
What are the suitable but risky sport and activity recommendations post TKA?
- Downhill skiing
- Iceskating
- Speed walking
- Hunting
- Low-impact aerobics
- Volleyball
What are sport and activity recommendations to avoid post TKA?
- Baseball
- Basketball
- Football
- Hockey
- Soccer
- High-impact aerobics
- Jogging,
- Parachuting
- Power-lifting
What are the early results of a minimal invasive TKA?
- Better ROM
- Less blood loss
- Shorter LOS
What is a unicompartmental arthroplasty?
“Partial” knee replacement, usually done with minimally
invasive technique
What are the characteristics of a unicompartmental arthroplasty?
- More rapid recovery
- Minimal bone loss
- Less pain
- Shorter LOS
- 10-15 year survival rates range from 95-98%
