WEEK 6 - hip OA, joint assessment and palpation Flashcards
what is hip OA
- OA A clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life
- OA the most common type of arthritis
- Is a repair process from trauma to the joint (repeated microtraumas or a large insult)
Pathologically, OA is a localised loss of cartilage, remodelling of associated bone and inflammation
presentation of hip OA in subjective assessment
- Groin pain with mechanical and inflammatory behaviours -> pain on loading, pain and morning stiffness
- Problems putting shoes and socks on
- Loss of mobility of hip joint (bony changes, capsular irritation and thickening, muscle tightness, esp IR +/- F ROM)
- Problems putting shoes and socks on
NICE guidelines
- Can diagnose a person with OA with imaging/ investigation if:
> age more then 45 years
> has activity-related joint pain and
> has either not morning joint stiffness or morning stiffness that lasts no longer than 30 mins
ALTMAN guidelines
Altman diagnostic criteria
- Can diagnose a person with OA if:
> hip pain and hip internal rotation less then 15 degrees and hip flexion less then 115 degrees
OR
> hip internal rotation more 15 degrees and pain on hip internal rotation and morning stiffness that lasts less then 60 mins and age more then 50 years.
Kellgren-Lawrence classification:
- Grading system for OA:
> 0 - no joint space narrowing or reactive changes
> 1- possible osteophytic lipping, doubtful joint space narrowing
> 2 - definite osteophytes, possible joint space narrowing
> 3 - moderate osteophytes, definite joint space narrowing, some sclerosis, possible bone end deformity
> 4 - large osteophytes, marked joint space narrowing, sever sclerosis, definite bone end deformity
objective assessment of hip OA
- functional movements: sit to stand, gait, stairs
- active and passive ROM: restricted and painful, particularly IR and flexion
- muscle tightness - decrease muscle length
- muscle atrophy/ weakness in quads and glutes
lateral hip pain - greater trochanteric pain syndrome
- Gluteal tendinopathy previously referred to as trochanteric bursitis
- Overloading of gluteal tendons: failed adaption model
- Degenerative changes in tendon
Made worse by FADIR / compression stretching
risk factors for lateral hip pain
Female:
- Morphology (shape) of the pelvis
- Greater compressive load of tendons
Over 40 years:
- Peri or post menopausal
- 1 in 4 women over 50
Low back pain:
- Association with gluteus Medius functions?
Weight/ BMI:
Greater birth around the greater trochanter
subjective exam presentation of lateral hip pain?
- Pain on outside of hip (greater trochanter) -> may have been told they have ‘bursitis’
- Aggravating factors:
> lying on side at night
> walking
> climbing up/ down stairs
> walking up stairs and hill
> sitting
- Aggravating factors:
24-hr pattern -> disturbs sleep
History -> insidious onset or a change in training load or physical activity -> travel or increased walking/ gym
Imaging -> thickening/ thinning/ tears of gluteus Medius/ gluteus minimum tendons
+/- changes in bursal structure
Observation -> gait may have positive Trendelenburg sign
Palpation -> pain on palpation greater trochanter and common gluteal region
Functional tests -> single leg stance/ single leg squats/ step up/ hop
Special tests -> resisted hip abduction (pain provocation)/ resisted hip ER de-rotation (pain provocation)/ FABER (pain provocation)/ Obers test (pain provocation)/ single leg stance (pain provocation)
treatment of lateral hip pain:
Education:
- Reduce compression at greater trochanter
- Avoid:
> standing with weight on one leg
> sitting with legs crossed
> sleeping on side with top leg/ hip in a flexed and adducted position
- Standing with weight evenly distributed on each leg with feet wider than normal
- Sleep on back with pillow under knees
- Sleep on side with tow pillow between knees
- Relative rest from aggravating activities (Load management)
Physiotherapy specific:
- Strengthen gluteus medius/ minimus
- Isometric exercises
> sustained isometric contractions (25%MVC)
> abduction in supine with belt/ band
> Side lying lifting uppermost leg against gravity - isometric hold
> standing - pushing the floor away (bilateral contraction)
> standing - single leg isometrics in a hitched position (reduce compression of tendon at greater trochanter (ganderton)
- Progress exercises:
> sit to stand
> 1/2 squat
> full squat
> bridging
> stepping
> gait and balance re-education
- Mechanical: single point stick in same hand as painful hip - Contributing factors: weight loss - reduce adipose tissue - Interdisciplinary referral: GP - pain relief (NSAIDs help due to prostaglandin regulation) - DON’T: > stretch gluteus medius - cause compression at greater trochanter > refer for local corticosteroid injection as ineffective long term
conservative management of hip OA
- Treatment / management is guided by goals and findings on assessment
- Address the problem list
- Education:
> verbal and written info about the condition and management
> encourage behavioural change (Motivational interviewing)
> benefits of exercise
> benefits of weight loss if needed
> pacing
Physiotherapy specific: - Core physiotherapy interventions
> local muscle strengthening -> increase muscle strength all around hip, glutes, quads and back
> improving general aerobic fitness -> land based and/ or hydrotherapy - Adjunct physiotherapy interventions
> heat and cold therapy for pain relief
> manual therapy and stretching -> increase or maintain joint ROM
> TENS for pain relief - Mechanical
> footwear - shock absorbing
> bracing/ joint supports
> orthotics/ innersoles
> gait aids - Contributing factors -> weight loss
- Interdisciplinary referral
> nutritionist / dietician for weight loss
> GP for pain relief
> GP -> orthopaedic surgeon for surgical opinion for patients who have a poor quality of life and have not improved with physiotherapy -> hip resurfacing/ partial hip replacement / partial hip replacement (hemiarthroplasty)/ total hip replacement (THR)
what is the end feel and what are the types
ensation that is transmitted to the examiners hands at the extreme end of PROM and that indicate the structure that is limiting joint movement
- End feel can be ‘normal’ (physiological) or ‘abnormal’ (pathological)
- Normal end feel = when there is full PROM and normal anatomy limits/ stops the movement
- Abnormal end feel = occurs when there is an increased or decreased PROM (outside the normal range) or, when there is normal PROM, but the structures other than the normal anatomy limit the movement
types:
- soft: when 2 surfaces come otgether and there is a soft spongy feel
- firm: firm or spongy sensation that have a little give when muscle is stretched or, firm stop to movements when capsule or ligaments are stretches
- hard: abrupt hard stop to movement when bone contacts bone
what is palpation:
method of feeling with the fingers or hands during a physical examination to evaluate the structures beneath
- Application of the fingers with light pressure to the surface of the body
- May aid in physical diagnosis
Often palpation goes hand in hand with ‘inspection’ which is visual examination for detection of features or qualities perceptible to the eye
