Week 7 - hip/groin/pelvis Flashcards
Discuss gluteal tendinopathy
Pain at the greater trochanter
Insidious or gradual onset
Predominant in distance running or new runners
Can occur in physically inactive population
Pathology and principles of management – refer to week 1 lecture on tendinopathies/overuse injuries.
* Consider multiple risk factors …. previous or current injury
Pathomechanics (Grimaldi et al 2015):
* Lateral shift and lateral tilt of the pelvis leads to hip adduction and ITB tension at the greater trochanter resulting in compression
* Coxa vera (reduction in angle between femoral head and shaft of femur)/lower angle NoF also results in compression
The LEAP trial (Mellor et al 2018):
* Education plus exercise versus corticosteroid inj use versus a wait and see approach on global outcome and pain from tendinopathy
* Education – advice on condition, advice on aggravating postures and avoidance, advice on gradual tendon loading
* Exercise – static abduction, functional retraining, weightbearing abductor loading, abductor loading via frontal plane movement, pelvic control during functional loading
* After 8 weeks (rates of success) – education + exercise (77%), corticosteroid (59%), wait and see (29%)
* After 1 year (rates of success) – education + exercise (79%), corticosteroid (58%), wait and see (52%)
Common conditions of the hip
- Common conditions
o Hip dysplasia
o Capsulitis
o OA hip
o Femoral-acetabular impingement (FAI) (Cam or pincer) (Acetabular labrum tears)
Basic anatomy of the hip
Synovial joint formed by the head of the femur and the cup-shaped acetabulum
Both surfaces are covered with articular hyaline cartilage
The acetabulum forms the union of three pelvic bones – ilium, pubis and ischium
The acetabulum labrum is a ring of fibrocartilage
It is a very mobile yet stable joint
* Ligaments:
o Illiofemoral (anterior)
o Ishiofemoral (posterior)
o Pubofemoral (ant)
The above ligaments strengthen and blend with the hip joint capsule and prevent excess movement
Discuss hip capsulitis
- Hip capsule hypertrophies/ becomes inflamed in response to repetitive strain
- Often affects the older athlete
- Presents with pain deep within groin, especially on twisting.
- Capsular hip pattern of restriction (early sign for development of OA)
- Inv
- X-ray: will appear normal or show early degeneration joint
- Arthrogram: may show signs of reduced joint recesses
- Mx
- Control pain
- Restor ROM
- Hip strengthening for core and hip
- Function specific drills
- Injury prevention
Discuss femora-acetabular impingmeent
Occurs due to abnormal contact between proximal femur and acetabular rim
Can be as consequence of activities requiring high ROM in hip or 2ndary to abnormal anatomical variation
Presents with a diffuse pain groin/ anterior hip region
Onset pain can be acute, post injury, or insidious
Occurs when the ball shaped femoral head rubs abnormally or doesn’t have enough motion in the acetabulum “CAM or PINCER”
-> cam characterised by abnormal configuration of head/neck junction in proximal femur with inadequate head/neck offset
-> pincer is characterised by an abnormal acetabular rim contacting a normal femoral head-neck junction, meaning ossification of acetabular rim leading to further deepening of acetabulum and therefore more over-coverage of femoral head
Signs and symptoms:
* Often present with groin pain but also lumbar spine and pelvic dysfunction if diagnosis is late
* Restricted range of hip movements (esp IR)
* +ve FADIR/ quadrant ( The premise of this test is that flexion and adduction motions approximates the femoral head with the acetabular rim)
* Symptoms are usually exacerbated with sport
X-rays may show alteration of hip anatomy, decreased joint space, sclerosis
MRI may show bony oedema and labral pathologies
Management:
Non op - modification of activity and avoiding excessive hip movement, NSAIDs
* Hip arthroscopy - debriedgement of labral lesions/chondral damage areas, Cabral repair for specific tears, micro fracture technique for cartilage lesions, osteophytes resection
* Open repair - hip osteoclasts, periarticular osteotomy
Prevention (Packer and Safran 2015):
* No firm evidence that FAI is genetic
* Higher prevalence in athletes playing sport during adolescence at a high level
* Sports – particularly football, hockey, ice hockey, basketball, rugby
Future research: (Dijksra et al 2021)
* What is a normal ”bump” and what could be a potential hip disease bruden for athletes
Discuss acetabular labral tears
Acetabular labrum is thick rim of dense fibrous tissue. It can degenerate and tear, producing a flap.
Association with adjacent chondral damage, Cabral disruption and degenerative joint disease
Mechanism of injury-twisting/slipping falling (common in dancers/gymnasts/hockey/rugby)
Present with groin pain, feelings of catching/clicking/locking. Decreased IR
Positive impingement tests/quadrant. Impingement on IR
Diagnostic tests-
Plain radiograph may be useful for differential diagnosis, may also show lateral marginal sclerosis in long-standing cases. MRI esp with lesions of superior labrum
Arthroscopy gold standard
Management:
Conservative - limited weight bearing, analgesia, limitation of activities (4-6 weeks)
Surgery- arthroscopic/open labrum repair
Good prognosis with early diagnosis and treatment
Discuss pubic bone stress syndrome
Overuse injury caused by biomechanical overloading of pubic symphysis and adjacent parasymphyseal bone caused imbalance in forces from the abdominal and groin musculature with resultant bony stress reaction
Consider if unresolving groin pain
Occurs when
o Restricted hip ROM
o Tight/ overactive hip flexors
o Tight/ overactive adductors
o Tight/ overactive rectus abdominis
o Stiff lumbar spine
o Weak Core +++
What is it?:
An overuse, repetitive strain injury.
Gradual onset - likely to have been misdiagnosed for months/years.
Common sports are hockey/AFL/soccer/rugby.(sprinting and suffer changes in direction)
S&S (Hiti et al 2011):
Vague groin/lower abdominal pain
Significant muscle imbalances will have developed
Squeeze test, palpation will reproduce pain
Tenderness over pubic symphysis
Painful hip abduction
Wide based gait
Inv:
Radiographs neg in early stages.
MRI (gold standard) irregular reabsorption/sclerosis/bone oedema/ increased signal intensity
Management:
Self-limiting and usually improves within 1 year though is recurrent in 25% of athletes
Early detection essential
Rest-up from aggravating activity three months plus
Address imbalances muscles and flexibility
Address other joint dysfunctions Lx/ hip
Identify contributing factors
Injury Prevention
Strengthing and balance exercises of muscles acting as opposing forces across the symphysis pubis (rectus abdomens, iliopsoas, adductors)
Management (McAleer et al 2017):
Early stage – complete rest from aggravating activities
Mid stage - retrain core, return soft tissue flexibility, address all associated problems, straight line running
Late stage - Graduated return to training, change direction, sport specific
Prevention (Pizzari et al 2008):
Significant sporting problem
Identify “at risk” individuals.
Functional core strength
Monitor loads/ intensity of training
Profiling
Sport Specific Pre-hab.
Rehab:
Load management and modification
Restore ROM- stretches/lumbar spine and SIJ mobilizations/ MFR/ STM
Restore core control/hip musculature
Sports Specific drills.
Injury prevention
Discuss hip assessment
Look, feel, move
Hip Assessment (Griffin et al 2016):
Assessing ROM :
Flexion, MR in 90 degrees flexed, LR in 90 degrees flexed, extension
Quadrant – hip flexion, internal rotation, adduction
Fadirs test:
Flexion/adduction/IR
A test indicating pathology of the hip, with pain the indicator - it does not tell you what the hip pathology is.
Fabers test:
(flexion/ abduction/ ER)
A test to alert the examiner of hip or SIJ dysfunction. Pain in groin suggests hip pathology, pain in SIJ pain
Asymmetry in movement indicates tightness in the hip flexors/ adductors or joint capsule.
Assess for pain
Thomas test:
Fixed flexion deformity can be masked by increased pelvic tilt and exaggerated lumbar lordosis. Test he’s unmask a fixed flexion deformity
A test for flexibility hip muscles
Tight ITB (hip abducts)
Tight Rectus Femoris (knee extends)
Tight Iliopsoas (hip flexes)
Ankle between cough and lower limb is the fixed flexion deformity angle
Hip abd/strength ratio
Tendelenberg - assess integrity of the abductor mechanism of the hip . Pain on weight bearings weakness of abductors, shortening of femoral neck, and dislocation or sublet of hip result in positive trendelenberg
