MSK 2: Hip
Can you recall from Anatomy what the three primary ligaments of the hip joint are and what motions they support?
*Blue question 1. Ischiofemoral (resists hyperext, ADD) 2. Iliofemoral (resists hyperext, ABD, ADD) 3. Pubofemoral (resists hyperext, ABD)
What other impairments could lead us to false neg/pos trendelenburg?
*blue question
What specific muscles could potentially be susceptible for impingement?
*blue question -ADD longus, proximal hamstrings, ABDs, iliopsoas, hip flexors
Which patient's would you not incorporate SLR exercises with? What would you incorporate in replace of SLR?
*blue question -Hip pathology patients -Maybe a hip flexion exercise with the knee bent: marches
What are the two best examination steps and findings to confirm an entrapment of each of the nerves referenced above?
*blue question -Neuromuscular (need a stretching and contractile component) -PFT
Can a physical therapist diagnosis osteoarthritis of the hip?
*blue question No, but we can hypothesize it using CLUSTER FINDINGS
What do you think is specifically occurring with a pathology of FAI?
*blue question Soft tissue (labrum, joint capsule, surrounding muscles) is being impinged between the acetabulum and femoral head
What would be the best examination step and finding to identify the presence of a Pincer and/or Cam FAI?
*blue question my guess is you can only see this on an x-ray
What would be the best examination steps and findings to identify a femoral acetabular impingement?
*blue question -PROM-A -Special Tests (Quadrant scouring, FADIR) -IMAGING!!
What is included in the examination of a patient with suspected ilioinguinal N pathology?
-Abdominal wall tone/weakness/hernia -Hip joint mobility loss of IR ADD EXT -retroverted hip -forward flexed posture -inability to stand erect -ASIS palpation (medial to) -Kendall's leg lowering test with hand under lumbar spine
What are the 2 types of labral tears in the hip?
-Acute -Degenerative
Treatment of someone with suspected obturator N pathology:
-Address psoas muscle impairments -Educate on diaphragmatic breathing and transversus abdominis activation for stabilization -Add strengthening -Hip mobilization
Impairment cycle components for OA:
-Cartilage breakdown -Muscle weakness -Mobility impairments -Cartilage breakdown (remember this cycle can go in any order)
What are the motions that can lead to posterior FAI?
-Extension -ABduction -External rotation
Where can the ilioinguinal nerve get entrapped?
-Fascia of iliacus -ASIS -Directional changes over muscle fibers or fascial edges associate with the muscle -Loss of abdominal corset -Violent tensing of abdominal muscles -Femoral head deformity
What are the motions that can lead to anterior FAI?
-Flexion -Adduction -Internal rotation
Cluster 4 of OA:
-Hip IR greater or equal to 15 -Pain is present with IR -Duration of morning stiffness of the hip less than or equal to 60 minutes -Age is greater than 50 years old
Cluster 3 of OA:
-Hip IR less than 15 degrees -Hip flexion less than 115 degrees -Age > 50
Examination for sciatic N entrapment:
-Hip ROM provocation (attention to recruitment of motion) -Sensory exam (specifically plantar sensory changes in the neuropathy) exception of S1 level -Muscle bulk- sciatic neuropathy will spare gluteals -PFT-sciatic notch -MMT-lumbar radiculopathy -IR and flexion rules in, ER and flexion rules out -SLR from 30-60 degrees, contralateral (+) specific for disc herniation
What may lead us to a false positive Trendelenburg sign?
-Hip pain on the WB side (this causes the patient to tilt opposite hip away) -ADD tightness on WB side (would cause opposite pelvis to tilt)
What can injure the sciatic N?
-Iatrogenic (THA) -Posterior dislocation of the femur -Fall in sitting -Compensatory lordosis -Back instability, hypertonic muscles -Direct pressure -Piriformis hypertrophy, spasm, contracture, inflammation, scarring -Gait dysfunction
You are suspecting a lateral femoral cutaneous N entrapment. What are some features your patient may have?
-Large abdomen -Excessive anterior pelvic tilt -Tight clothing on ASIS area -Leg length discrepancy
Cluster 2 of OA:
-Moderate anterior or lateral hip pain during weight-bearing activities -Morning stiffness less than 1 hour in duration after wakening -Hip internal rotation 15 degrees less than nonpainful side -Hip flexion 15 degrees less than nonpainful side
Cluster 1 of OA:
-Moderate anterior or lateral hip pain during weight-bearing activities -Morning stiffness less than 1 hour in duration after wakening -Hip internal rotation less than 24 degrees
The ilioinguinal N is motor to? Sensory to?
-Motor: internal oblique, transversus abdominis -Sensory: Iliac crest and labia/scrotum
What may lead us to a false negative Trendelenburg sign?
-Non-weight bearing leg is in excessive hip flexion and knee flexion -Tightness of QL on non-WB side
What do you include in examination of a patient with suspected lateral femoral cutaneous N entrapment?
-PFT -Fascial mobility -ITB, abdominal contractions (iliacus fascia connection to transversalis) -Burning/paresthesias, numbness in later stages, differentiation of lumbar spine dysfunctions above L4 -Sartorius muscle
What is the best examination to confirm lateral femoral cutaneous N entrapment?
-Palpation for tenderness -A posterior pelvic tilt may eliminate the pain -A shoe insert for the opposite leg may functionally alter the pain. -Check abnormal muscle play of the iliacus.
Sciatic nerve sensory innervation? Motor innervation?
-Sensory: Skin from posterolateral leg and dorsal/plantar foot -Motor: hamstring, add magnus, all muscles of leg and foot
The obturator nerve is motor to the hip ADD and sensory to medial thigh. What can cause entrapment sx?
-THA -Pelvic trauma -periarticular cysts -Obturator hernia -Fascial adhesions in anterior branch associated with ADD brevis tendinopathy
If a patient has a lateral femoral cutaneous N entrapment due to leg length discrepancy, which leg is the longer one? How can we help treat this?
-The affected leg is the the longer leg -We can put a shoe lift under the opposite leg
How do you treat a ilioinguinal N pathology?
-Treat fascial restriction -Hip hypo-mobilities -Transversus abdominis (corset) training
The lateral femoral cutaneous N is sensory only. Where can it get entrapped?
-Under inguinal ligament -Iliacus fascia
What is included in examination of someone you suspect has an obturator N entrapment?
-Valsalva -Hx of area affected by sx -Add weakness -hip mobility testing -c/o from groin to inner thigh -sx not relieved by rest -Differentiate from lumbar radiculopathy
Hip labral repair precautions:
-Variable depending on type of surgery -Protected weightbearing -ROM restrictions: FLEX, ER, EXT
What are the primary risk factors that we should consider when examining for OA?
-age -developmental disorders -previous hip injury
Normal movement at the hip is not commonly composed of one classical movement alone. ABD requires?
ABD, ext, ER
Normal movement at the hip is not commonly composed of one classical movement alone. ADD requires?
ADD, Flexion, ER
Based on the image above, what other muscle may also be a source of sciatic nerve entrapment?
Blue question Biceps femoris (it runs right over the sciatic N)
What type of impingement related to FAI: osteophytes are located along the femoral head?
Cam --> more common in young men
What type of impingement related to FAI: osteophytes are located along the rim of the acetabulum and femoral head?
Combination (pincer and cam)
What division of the sciatic N is most commonly injured?
Common peroneal because the fibers are more superficial, less supporting connective tissue and are fixed at 2 points (sciatic foramen, fibular head)
What type of labral tear (acute/degenerative) is most common in older individuals?
Degenerative MOI: repetitive rotation, or just with aging -Sx: pain, clicking, popping, catching, locking, giving way
Normal movement at the hip is not commonly composed of one classical movement alone. Extension requires?
Extension, ADD, ER
You are trying to determine if the patient has a sciatic N issue or nerve root issue. If the superior gluteal N is involved (hip ABD are weak), what do you think?
Nerve root issue
What would be the best examination to confirm an obturator N entrapment?
PFT
what are the posterior, anterior, lateral and medial musculature that could be a source of pain and pathology?
Posterior: Hamstrings, plantarflexors lateral: TFL, peroneals Anterior: hip flexors, quads, dorsiflexors
What are the special tests you have been taught that would help you confirm or refute the presence of an FAI?
Quadrant scouring FADIR (bc the labrum could be impinged)
What is an example of a hip exercise that increases the joint compressive forces at the hip >3x the body weight
SLR (supine and sidelying)
What is a Trendelenburg gait versus a Trendelenburg sign? How would you examine for each?
Sign: contralateral hip drop during single leg stance Gait: trunk shift over the affected hip during stance and away during the swing phase of gait
Forces on the hip:
Standing: .3 x the body weight Standing on one leg: 2.4-2.6x the body weight Walking: 1.3-5.8x the body weight Walking upstairs: 3x the body weight Running: 4.5+ x the body weight
Why would you need a shoe insert versus a heel lift to effect the tension on the nerve?
The heel lift would give the foot a relative plantarflexion position not a lengthening of the leg. The shoe lift will lift the entire leg so that it matches the longer one
Why would a patient with obturator N entrapment likely complain of low back pain?
The rectus abdominus maybe weak by this entrapment and hence the lumbar spine will not have the functional dynamic stabilization.
What part of the hip joint faces anterior, lateral and inferior?
acetabulum
What part of the hip joint acts as a the primary form of stability and plays a role in preventing excessive translator movements?
acetabulum -The acetabulum is concave
Follow the pathway of the lateral femoral cutaneous N:
beneath psoas --> anterior surface of iliacus --> medial to ASIS --> splits into anterior and posterior branches
What part of the hip joint faces anterior, medial and superior?
femoral head/neck
Normal movement at the hip is not commonly composed of one classical movement alone. Flexion requires?
flexion, ABD, IR
Excessive ____ of the labrum could predispose the patient to a labral tear at the hip.
impingement
What nerve is aka the meralgia paresthetica?
lateral femoral cutaneous (L1-L3)
What is a classic sx of labral tear?
pain, clicking, catching, locking, giving way
What type of impingement related to FAI: osteophytes are located along the rim of the acetabulum?
pincer --> more common in active females in middle age
The sciatic nerve is a peripheral N that can get entrapped by the ___ muscle.
piriformis --> Sciatic stems from roots L4-S2/3
What does the posterior branch of the lateral femoral cutaneous N innervate?
skin over posterolateral thigh from the trochanteric region to mid-thigh
What does the anterior branch of the lateral femoral cutaneous N innervate?
skin to anterolateral thigh as far as the knee
Since the sciatic N stems from so many N roots, we tell the difference between a N root issue and sciatic peripheral N issue by testing the ____ N.
superior gluteal (L4-S1) --> if the ABD of the hip are strong, the superior gluteal N is not involved aka its only the sciatic N
What is the average force acting on the hip throughout the day?
the weight of the person
The sciatic nerve descends into the ___ and ___ nerves
tibial common peroneal
(true/false) the femoralacetabular joint is never fully unloaded during ADLs
true -->there are only moments of increased and decreased load
what is the MOI for an acute labral tear?
weight bearing with sudden uncontrolled rotation -Demographic: younger, active individuals -Sx: pain, clicking, catching, locking, giving way