Musculoskeletal Hip
Describe the population usually effected by systemic lupus erythematosus (SLE), the clinical signs and symptoms and lab values?
1. Autoimmune condition (unknown etiology): body produces antibodies, mainly antinuclear antibodies (ANA), that attack multiple organs/tissues causing inflammation & destruction 2. Female gender predilection typically childbearing age 3. Widespread fatigue/arthralgia/myalgia 4. Malar/Butterfly rash on face Lab Values: ANA: + *Only one seen from MS1
Which pelvic position would put the Iliopsoas muscle on overstretched? What about shortened?
Anterior pelvic tilt the Iliopsoas will be shortened and not very efficient when contracting. Posterior pelvic tilt the iliopsoas could be overstretched may have insufficient cross bridges of the muscle and less force production of the muscle
Clinical Prediction Rule for Hip OA, 4 out of 5 of clinical findings most likely they will have OA, probability of hip OA will be 91%. What are the 5?
• Squatting as a aggravating factor • Scour test -Active hip flexion reproduces lateral hip pain because reduced joint clearance of the femoral head and acetabulum prematurely come into contact that could reproduce the pain in the groin area -Active hip extension reproduces pain, the femoral head glides anteriorly and if you have the anterior superior area of the acetabulum being involved than when you extend the femoral head has to glide anteriorly than that pathological issue will contact the femoral head and give you the hip pain in the groin area (labrum is the most likely sight of labral tears anterior superior) • Passive hip IR equal or less than 25 degrees
When using a mobilization belt or gait belt to perform an inferior glide of the hip describe the procedures that should be followed? *Remember to always assess the inferior glide at the 30 deg of hip flexion and 30 deg of hip abduction FIRST
• Supine with involved knee and hip flexed • Belt placed around the patient's proximal thigh • Force is applied in a long axis traction • Hip inferior glide can be used for pain and improve abduction, and flexion
Muscle Length Test: What 4 muscle length tests are commonly used for the lower extremity?
• Thomas and Modified Thomas • Ober Test • Ely's test • 90-90 Straight-Leg Raise
What are the normative values for the following functional tasks? -Walking: Hip flexion & Hip extension -Descending stairs: Hip Flexion -Ascending stairs: Hip Flexion -Sitting: Hip Flexion -Squatting: Hip Flexion, abduction and medial rotation -Don socks: Hip Flexion
• Walking: 30-40 degrees of flexion, 10-15 degrees of hip extension • Descending stairs: 45 degrees of flexion • Ascending stairs: 60 degrees flexion • Sitting: 90-112 degrees flexion • Squatting: 115 degrees flexion, 20 degrees of hip abduction, 20 degrees of hip medial rotation • Don Socks: 120 degrees of flexion
We may not have time to do everything in a 1 hour evaluation period. What is the bare minimum that we want to do during a hip assessment besides a history?
○ Observation standing test ○ Examination (all the components) ○ Dynamic Examination
When conducting a physical exam what type of findings could be found for someone who has Femoral Acetabular Impingement (FAI)? Whats the difference if the labrum is involved compared to the Iliopsoas tendon?
- Antalgic gait - Femoral anterior glide syndrome - Posterior tightness - Lumbar pathology and hypertonicity of ER (tight not allowing femoral head go posteriorly during hip flexion, get an obligatory force of the femoral head to come forward causing premature contact between the femoral head and acetabulum) - Pelvic tilt and occurrence of bony impingement (anterior pelvic tilt, posterior pelvic tilt increases the distance) - Possible + Thomas' Test - Possible + Ober's Test: excessive IR during squatting, could also decrease the distance of the acetabulum as well Iliopsoas tendon could get impinged from decreased joint clearance (look at RIMT and MMT) Labrum involved: clicking, buckling, locking and groin pain, positive findings in log roll and impingement test Iliopsoas involved: hip flexors groin pain when contracted
What type of findings would you find when conducting a history for someone who has a Labral Tear?
- Buckling - Clicking - Instability - Pain primarily in the anterior groin oMultiple RCT studies demonstrating the evidence for anterior hip pain and labral tear (warning intra-articular pathologies such as OA) oMultiple RCT studies demonstrate the evidence for buckling, clicking and instability providing useful diagnostic information for the presence of labral tear
What are some secondary predisposing factors for labral tears?
- Disease (Global): oLegg-Calve' Perthes disease oDown's and Marfan's syndromes - Mechanical trauma (focal): oTrauma ER with hyperextension oTorsion and loading (pivoting and twisting) o Femoral Anterior Glide Syndrome: Occurs when the head of the femur is unable to go in its appropriate backward gliding into the hip joint during hip flexion. Instead the head of the femur is forced forward into the joint resulting in an improper moving pattern. Placing pressure at the front of the hip, leading to pain and discomfort
Total hip replacement (THR) is one of the most common and successful procedure performed in acute care hospitals. What are some indications for this procedure, and conditions why a patient may undergo THR?
- Indications: Pain, functional limitations, lack of mobility and radiographic indications -Conditions: OA, AVN, Infection, destructive process, fracture of the femoral neck or head that cannot be successfully treated with fixation
What are some hip stress fracture interventions that should be considered? If you are dealing with a runner describe how much they should reduce their running if the patient has pain after running, if the patient present with pain during running and after but it does not affect their performance, and if the patient has pain during running after running and it affects their performance?
- Rest - Immobilization - Assistive device - Addressing predisposing factors -Hip Spica -Address LLD - Stretching (hip flexors, IT band, hamstrings) - Strengthening (glut med, glut max) (open chain-close chain, short lever arm-long lever arm) - Stationary bike (chair is at the level of the greater trochanter) - Aquatic therapy - If the patient has pain after running, than you can have the patient reduce running by 25% - If the patient presents with pain during running and after and it does not effect performance reduce running by 50% -Pain during, pain after and effects performance discontinue the running completely
With a THR greatest recovery is between ______ weeks with plateau _______ weeks. What types of interventions should be addressed during this time?
-12-15 weeks with plateau 30-35 weeks (see these patients for 2-3 months but no more than that) o Modalities o Address impairment: Gluteus med weakness and iliopsoas and quadriceps contracture o Manual therapy o Exercise and home program: • Flexibility ex. with limitations of THR precautions • SLR flexion, quad and gluteal sets, ankle pumps, standing knee flexion, heel slides, SAQ, sitting knee extension, mini squats, heel raises, abduction supine-to standing to side-lying position o Psoas (Thomas test position), quadriceps, gastrocnemius, soleus and hamstrings (stretch these) o Close kinematic exercises (Total Gym), supported squats-ball squats (60 degrees to 90 deg) o Neuromuscular reeducation o Balance o Gait training and transfers o UBE o Stationary bike. Careful with hip precautions (7 days post op) starting with seat as high as possible
What time frame is used to classify acute, sub-acute, and chronic pain? What Interventions can be used for acute pain?
-Acute: 0-4 days (inflammatory process), or 1 week, Interventions will be used to treat that inflammatory process (modalities to decrease inflammation, rest, assistive devices as needed, etc.) - Subacute is your 5-14 days, or 2-3 weeks Chronic: After your 14 days, after 4 weeks
When gathering the history for an OA patient what key factors are you looking for?
-Age (greater than 50) -Previous injury (5 times more likely to have hip injury and end up with OA) -Insidious and gradual -Pain with sit to standing -Morning stiffness less than 60 min (ICD)
What is the difference between Anatomical and Functional LLD? What is considered clinically significant? *Measured in cm
-Anatomical LLD: one leg is longer than the other one because of the tibia is longer or the femur could be longer, measured from the ASIS to the medial malleolus -Functional LLD: could be because of a functional shortening or compensation that makes one lower extremity longer than the other one or shorter. Could be due to adaptive shortening of soft tissues, could be a joint contractures, ligamentous laxity, or some kind of mild alignment of the lower extremity, measured from the Umbilicus to the medial malleolus -5 mm or greater
Where is the ischial bursitis (Weaver's bottom) located? What types of findings would you find in the history and the physical exam?
-Between the hamstring insertion and ischial tuberosity • History o Trauma: overuse trauma in activities like jumping and running o Mechanical irritation o Prolong sitting o Thinner patients • Physical Exam o Tenderness to the ischial tuberosity o Pain with weightbearing o Prolonged sitting o Possible pain with hamstring or gluteal stretch o Pain with hip extension *Bursa behave like contractile lesion meaning when you contract the involved muscle that has the bursa and or you stretch the muscle that the bursa is involved than you may elicit the concordant symptoms when you do that
Patient with intraarticular pathology usually present with groin type of pain as well as C-Sign. What is this and what does the term intraarticular pathology mean?
-C-Sign: when you place your hand on the side of the hip where your thumb is at the greater trochanter and your index finger is pointing towards your groin. Typically pain that patients with hip intraarticular pathology usually present with -Intraarticular Pathology: any pathology inside the joint - Ex: Labral tears, Hip OA, Subchondral Lesions, and also Chondral defects - All of these patients usually present with C-type of pain as well as groin pain
When stretching the quadriceps you start the patient in sideling and have them pull the heel toward the buttock until stretch is felt in the front of thigh. What's another way we can do this stretch, what would be a progression from this stretch? *Make sure the hip is at zero or neutral extension
-Could use a gait belt (for those older patients) -Progress them could have them in prone (could also use a gait belt in this position as well), progress them further standing with the leg back (make sure they contract their gluts and rectus abdominis so you can do a posterior pelvic tilt)
Neuromuscular Reeducation Motor Control: What types of External and Internal cues can be given when asking a patient to perform a squat?
-External cues: -When the individuals attention is drawn on an object or a mental image outside of the body part in question Ex: While bending your knees keep your knees pointing at a cone you place directly in front of them (there attention is more directed towards the cone in front of them than their own body to avoid excessive adduction and IR or perhaps to avoid that knee going beyond the toe) Research has shown that External cues are superior to internal cues, this does not mean to not use internal cues, mixture of both with more emphasis on external cues is the more desired intervention Ex: if you want more hip hinge to occur tell your patients to visualize them sitting on a toilet when they are squatting. EX: Perhaps in front of a mirror and having tape in front of them and tell them to make sure when they are squatting that the knee does not touch or point toward the line that is more perhaps adducted and IR -Internal cues: - The individuals attention is drawn to the body part in question Ex: Bend your knees while keeping your knees over your feet avoiding bringing your knees towards the midline
For a patient that has FAI why do we want to encourage gluteus dominance over hamstring?
-Glut max origin and insertion closer to the joint makes the femoral head into a compact position on the acetabulum leads to more stability of the joint, and less pain -Want to encourage gluteus dominance, want to primarily recruit the glut max when we do extension type of exercise, squatting, prone hip extension, jumping -Hamstring dominance makes the femoral head excessively move into anteriorly during activities that require hip extension (do not want hamstring dominance) - Ex: Prone hip extension, creates more of an anterior glide of the femoral head against the acetabulum (excessive movement of the femoral head forward could lead to that impingement of the femoral head against the acetabulum)
Besides recruiting the hip abductors in a Clamshell I position what other muscles are recruited here? How can we progress this?
-Glut med, and Glut Max -Progress this exercise by placing a theraband around the distal end of the thigh -OR could progress to the Clamshell II them by having them in the same position where the bottom lower extremity is in 45 degrees of hip flexion, the knee at 90 degrees and the effected leg is in 0 degrees of extension and the knee is at 90 degrees while having the patient in this position will have them IR and ER the leg
90-90 Straight Leg Raise or Active Knee Extension is used to evaluate tight...? What is considered a positive finding?
-Hamstrings -Norm: Less than 20 degrees
What two outcome measures were not intended for the general outpatient clinics and what populations are they typically used for?
-Harris Hip Score: developed for the assessment of surgery, used by surgeons not really used in clinics too much. ○ This outcome measure is used for these populations: total hip replacements, femoral neck fractures, and hip OA -Hip Disability and Osteoarthritis Outcome Score: also not as common in the general outpatient clinics, and intended for the following populations ○ Hip OA, any other hip disability condition, or any disability that has an associated disability
When strengthening the hip Abductors we can have them starting in supine (gravity eliminated), the unaffected leg flexed at 90 degrees and 45 degrees at the hip while the effected leg is nice and straight (make sure there is no ER or IR) and it goes from midline out into abduction. How do we progress this, and is there another way to work on the abductors without having them stand?
-Have them lay on their side with the uninvolved lower extremity flexed approximately 45 degrees and the knee at 90 degrees. Gonna have the hip in neutral or zero degrees extension. Can progress by applying an ankle weight at the distal end of the thigh and could progress that by having the ankle weight at the distal end of the lower extremity instead -Could progress this exercise into the side plank (this recruits the most for the hip abductors. Get them into a blank position while the unaffected leg is on the TOP. It's the bottom leg that is getting all the loving (lower extremity that is getting the most recruitment.
What kind of reactivity level are being described below: -Can not get into the end-feel (will not do aggressive strengthening or stretching) and has a 6 out of 10 for pain -They stop you right at the tissue level and has a 3 out of 10 for pain -Able to stretch the joint into its end-feel and they have pain at the end-feel its below a 3 out of 10
-High reactivity level -Moderate reactivity level -Low reactivity level
If we wanted to introduce weight bearing with a hip abductor exercise what 2 options could we pick?
-Hip Hikes -Lateral Monster Walks
Snapping Sounds: Internal snapping that are anterior is caused by...? External snapping, especially if you hear it on the lateral side...? Snapping is posterior to the hip...?
-Internal snapping that are anterior= iliopsoas and the iliofemoral ligament making the noise - External snapping: especially if you hear it on the lateral side= iliotibial band and the glut max -Snapping is posterior to the hip: Perhaps its your hamstrings that are making the sounds
Dull & Sharp pain usually found in__________ Dull & Deep pain usually found in__________ Sharp, burning, lacerating, paresthesia usually those are _________ Graveling does not have a great diagnostic utility for ______ but is still used Clicking has a better diagnostic utility for __________
-Ligaments -Bone -Nerve involvements -OA -Labral Tears
Always look at the patients medications; What are Lyrica and Neurontin (Gabapentin) typically used for?
-Lyrica (pain) -Neurontin (radiculopathy)
The Numerical Pain Rating Scale could also be used not necessarily as a functional outcome measure but as a way to monitor improvements. What is the MCID of this outcome measure? What is the MDC and MCID of the Lower Extremity Functional Scale (LEFS)?
-MCID: 2 points -MDC & MCID: 9 points
Describe the population usually effected by Ankylosing Spondylitis (AS), the clinical signs and symptoms and the lab values?
-Male 15-40's -SIJ affected first -Pain/stiffness>3 months -Symptoms relieved with exercise NOT rest -Stiffness worse AM and last >30 min -Disturbed sleep 2nd half of night -Radiographic bamboo appearance, prone to osteopenia and enthesophytes -Limited spinal mobility and chest expansion Lab Values: Rheumatoid Factor: (-) ANA: (-) HLA B27: (+) CRP: increase during flare ESR: (increase) WBC: (WNL) Uric Acid: (WNL) Anti-CCP: (-)
What types of fibers are involved with an Athletic Pubalgia otherwise known as a sports hernia? *Typically due to trauma, change directions, requires by sports with a lot of agility
-Micro tears of: Transversalis fascia Conjoined tendon Internal oblique fibers
What positions should be avoided for those with hip OA?
-Not to cross their legs -Not to sleep on the effected side (due to pain) -Sleep on opposite side with pillow in between their legs (lay down on their backs with pillows under their knees comfortable for hip pain) -Need a heal lift, significant change in lower extremity in regards to length (correct for LLD) -Avoid prolonged sitting or standing (45 minutes)
Hip Assessment: During a hip assessment we start off taking a history thats used to identify a preliminary hypothesis, and or identify problems that require a referral to another provide. What position is preferred during Observation (standing or seated)? During a scanning test what other regions can be causing hip pain?
-Observation: Standing posture evaluation (prefer standing) -Scanning Test: If you don't know whether the pain is coming from the neighboring region. ○ For the hip it would be the lumbar spine (Lumbar ROM or Lumbar screening; have them flex, extend side bend and rotate to see if those movements reproduce the concordant symptoms that the patient is coming in with), perhaps the pain is coming from the knee itself ○ If Lumbar ROM reproduces the hip joint type of pain, should get a thorough evaluation of the Lumbar Spine *Can Scan for hip pathology by simply having a patient perform a squat. If the squatting reproduces the concordant pain will need to do a hip evaluation
Describe the population usually effected by Psoriatric Arthritis, the clinical signs and symptoms and the lab values?
-Occurs in both males and females, 20-40's -Inflammatory disorder/Seronegative Spondyloarthropathy -Periarticular bone erosion and over time possible destruction -Asymmetrical SIJ involvement -Common in those with psorarsis -Nail oncholysis, dactylitis, and pitting -Familial association, may develop inflammation of the eye -Absence pf osteopenia -Lab Values: Rheumatoid Factor: (-) ANA: (-) HLA B27: (+) CRP: increase during flare ESR: (increase) WBC: (WNL) Uric Acid: (Increase possible) Anti-CCP: (-)
What are some other differential diagnosis we could see with someone who has Athletic Pubalgia?
-Pubic osteitis pubis, symphysitis, adductors/hip flexors strains, rectal or testicular referred pain
Ely's Test is used to evaluate tight...? What is considered a positive finding for PROM and AROM? What is the MDC for this test?
-Rectus Femoris -PROM: test is positive if the same hip flexes as the knee is flexed -AROM: Less than 125 degrees of knee flexion -MDC: 7 deg
Describe the population usually effected by Reactive Arthritis, the clinical signs and symptoms and the lab values?
-Reiter Syndrome=most common -Acute inflammatory athropathy (more than one joint) -Immune response is just triggered from remote infection -Arises from a remote site after an infectious process -Intestinal and genitourinary -May be considered a spondyloarthopathy if spine involved, good prognosis -Clinically presentation is mild to severe/bed bound -May present with clinical triad of: Conjunctivitis/iritis/uveitis, Urethritis/Dysuria, & Arthritis Lab Values: Rheumatoid Factor: (-) ANA: (-) HLA B27: (+) CRP: increase ESR: (increase) WBC: (Increase) Uric Acid: (Increase possible) Anti-CCP: (-)
What are the 8 special tests used for the hip?
-Scour Test -FABER/Patrick's Test -Log Roll Test -The Impingement Test -Leg Length Discrepancy -Trendelenburg Sign -Sign of the Buttock -Craig's Test
What are some Interventions that can be prescribed for someone who has Hip OA?
-Stationary bike good 5-10 minutes (tissues more pliable for stretching, enzymes like to work better when tissues are hot and warm) o Modalities: hot pack o Manual therapy o Mobilization (increase IR, flex, Abduction) o Addressing predisposing factors(LLD) anatomical vs functional: 5 mm clinical significance o Posture (anterior tilt); neuromuscular reeducation o Stretching: hip flexors and IR o Strengthening (OKC-gluteus med and max) o Balance Training o Gait training: -Assistive device (axillary crutch or cane) o Cardiovascular: 20-30 mins. a day 4-5 times a week (hip OA, lower back or neck) o Weight control program: 5lb can make a big difference o Patient education o Aquatic therapy: (or walk first instead of run) oForward running oHeel to buttock run forward oKnee to chest forward run oBackward running oProne and supine flutter kick oSwimming
The lateral monster walks is a great exercise for the hip abductors, but if you have the knees flexed at 45 degrees (athletic stance) with the theraband by your forefoot what other muscles are being recruited besides the glut med?
-TFL -Glut max; the band will make the foot go inwards and the body will have to recruit the ER musculature to maintain that foot pointing forward will be your glut max which is your main ER. Always maintaining tension on the band
The Ober test is used to address the length of the...? What is considered a positive finding? Which version of the Ober test should be performed?
-TFL and Iliotibial band -Failure of the knee to drop below the horizontal (imaginary line) -The best one to do is the 30 degrees of knee flexion, Modified Modified Ober Test
What are some findings you may discover in the history and physical exam with someone who has Iliopectineal Bursitis, where is this bursa located?
-This bursa is located between the Ilipsoas muscle and the joint capsule and the iliopectineal line • History - Trauma (getting hit in front of the hip) - Mechanical irritation • Physical Exam o Tenderness to the femoral triangle o Pain with power walking and running o Pain with passive hip flexion and adduction: compresses the femoral head and neck against the bursa creating a form of impingement o Pain with PROM hip extension and lumbar extension: stretching the iliopsoas against the bursa o Pain with resistive hip flexion and adduction (cause compression) o Pain during passive hip ER in the fully flexed position: -Move the lesser trochanter more anteriorly full flexion of the hip leads to the lesser trochanter to compress the bursa (iliopectineal bursa)
What type of motions can cause an Inert Lesion (capsular and ligaments), what ligaments could be involved, and are these acute symptoms resolved quickly? (find these under the history)
-Twisting motion during weightbearing -Iliofemoral, Ischiofemoral and Pubofemoral ligaments as well as the capsule -Acute symptoms resolve quickly
Describe the population usually effected by Rheumatoid Arthritis, the clinical signs and symptoms and the lab values?
-Women 30-40's -Systemic autoimmune inflammatory disease -Affects synovial joints primarily BILATERALLY (MCP, IP, and/or wrist rarely DIP) -Morning stiffness lasts longer than 60 min -Hypermobile Arthrokinematic Lab Values: Rheumatoid Factor: (+) ANA: (+) HLA B27: (-) CRP: increase during flare ESR: (increase) WBC: (WNL) Uric Acid: (WNL) Anti-CCP: (+)
When you have an isolated labral tear this is typically found in what population...? What about when you have a labral tear in conjunction with chondral lesions? What type of labral conditions would you find at 3 o'clock (R), and your 9-10 o'clock (R)?
-Younger patients: when you have an isolated labral tear -Labral tear in conjunction with Chondral lesions: older patients -3 o'clock due to iliopsoas degeneration tendon attaches to the capsule and the underline of the labrum, activity that requires hip flexion the iliopsoas that is degenerating on top of the capsule (tear away at the labrum) -Posterior labral tears not as common more around your 9-10 o'clock very rare
Hip Assessment: What components are found in the Examination portion?
1. Active ROM: Flexion, extension, adduction, abduction, external and internal rotation 2. PROM-->followed by end-range and end-feel 3. Joint play assessment (arthokinematics): Looking at hypo, hyper, or normal mobility and this can tell you the source and lack of ROM that the patient exhibited o Manual muscle testing/ RIMT: always ask if the resistance reproduces any symptoms. Looking for a contractile lesion o Muscle length test: Length of the hamstrings, iliotibial band, rectus femoris, and hip flexors o Special Test: Hip special tests o Palpation o Gait: Can be assessed at the end or the beginning of the patient client management (when they walk into the room). Looking for gait impairments and antalgic gait
What are different weight-bearing exercises we can have the patient perform for the hip extensor muscles?
1. Deadlifts: Focus on your hip hinging the hips are nice and aligned here (no flexion of the lumbar spine, avoid any lumbar pathologies. Bar or dumbbells 2. Could do some single leg deadlifts have the bar nice and straight (standing on the affected leg that's getting the exercise) and have the unaffected leg at 90 degrees and have them lean forward when maintaining that hip straight and kicking the leg backwards in a nice extended position (great for strengthening the glut max, the quads, the plantar flexors, hamstrings as well as your tibialis posterior and foot extrinsic muscles) 3. Can also have them perform single leg squats
There are 21 bursa's in the hip, what are the three most important ones in regard to Trochanteric Bursitis? What are the typical findings in the history and physical exams for someone who has Trochanteric Bursitis?
1. Glut minimus bursa 2. Subgluteus maximus bursa 3. Subgluteus medius bursa • History o Trauma: compression o Mechanical irritation o Poor biomechanics: excessive adduction and IR with squatting • Physical Exam o Tenderness to the lateral hip o Sleep intolerance on affected side o Pain with ITB stretching o Pain resistive abduction: especially if Subgluteus Medius Bursa is involved
What are the four outcome measures of the hip?
1. Harris Hip Score 2. Hip Disability and Osteoarthritis Outcome Score 3. Lower Extremity Functional Scale (LEFS) 4. Numerical Pain Rating Scale
The coxofemoral joint is the articulation of the actebaulum and the femoral head, what three structures consists of the actebaulum?
1. Ischium 2. Ilium 3. Pubic Bones
When stretching the Tensor Fascia Lata (TFL) we should start by having the patient in a side lying position, allow the leg to drop downward over the edge of the table with overpressure of the uninvolved leg (can also use your other leg to press or push don on the lower extremity towards the ground to get a better stretch). What are two other ways we can stretch the TFL?
1. Long sitting, cross leg over the other (knee approximately 45 deg), rotate trunk towards the leg being stretched. 2. Cross leg over the other, then lean to same side until stretch is felt on the other hip
Describe the Craig's Test and what is considered a positive finding?
1. Patient lays prone 2. Assess the IR and ER of the lower extremity and femoral anteversion 3. Knee is in 90 deg of flexion 4. Stop when the greater trochanter is in the most lateral position, normal angle is 8-15 degrees 5. Positive is if the value doesn't fall between the range in number 4
Describe the Scour Test and what is considered a positive finding?
1. Patient lays supine 2. Examiner moves patient's hip through a ROM from hip flexion, adduction, and IR to---> Hip Extension, Abduction and external rotation 3. Compressing the femoral head against the actebaulum (do 2 full arcs) 4. If the patient complains of hip pain (usually in the groin area) on the C-Shape of pain of the hip joint Lateral side of the hip going towards the hip (indicative of intraarticular pathology) Pain and joint clicking perhaps we have intraarticular pathology (Hip OA, Labral tear, OCD; osteochondral defect) and positive findings for this test
Describe the FABER or Patrick's Test and what is considered a positive finding?
1. Patient lays supine 2. Examiner passively positions the leg into hip flexion, abduction and ER (above the knee cap in figure 4) 3. Apply a mild force to extremity involved and opposite pelvis 4. -If the knee is above the opposite knee than we have positive findings; could be due to Iliopsoas Spasm -If the patient also complains of groin pain or C type of pain (perhaps we have a patient with an intraarticular pathology or positive findings) -Could also assess the sacroiliac joint (if the pain that is exhibited is inferior medial to the PSIS right by the sacroiliac joint than perhaps this test is positive for sacroiliac joint dysfunction .
Describe the Log Roll test and what is considered a positive finding?
1. Patient lays supine 2. Move the leg into max ER and IR (do 3 full arcs) 3. Clicking, popping sounds this may indicate a possible labral tear 4. If there is an excessive ROM into ER compared to IR may be due to capsular laxity
Describe the Sign of the Buttock and what is considered a positive finding?
1. Patient lays supine 2. PT performs a passive unilateral straight-leg-raise 3. If restriction, the PT flexes the knee and notes whether the hip flexion increases -If restriction by the hamstrings or the lumbar spine hip flexion increases -If the hip flexion does not increase positive finding for possible osteomyelitis, neoplasm, septic arthritis of SI joint, septic bursitis ischial rectal abscess and rheumatic fever • Patient must be immediately referred to the physician for further testing
Describe the Impingement test and what is considered a positive finding?
1. Patient lays supine 2. Examiner passively moves the patients lower extremity into a position of hip flexion, adduction, and internal rotation (brings knee basically across the body) 3. Reproduction of hip or groin pain is a positive test 4. Pinches the front of the acetabulum: Most common area of labral tears is anterior superior 5. This test positions the femoral head right up against the acetabulum and labrum (and if you have a labral tear this will be positive for femoral impingement test)
In order to strengthen the hip extensors we can have the patient perform bridges. How do we advance this without incorporating standing (weight-bearing)?
1. Single bridge: uninvolved extremity nice and straight lined with the flexed 2. Progress by placing an unstable surface like a therapeutic ball on the effected leg (have the patient squeeze their buttocks at the end of the motion) 3. Plank (back is nice and straight and make sure to tuck in your tummy muscles, no flexion occurring at the trunk, or extension of the lumbar spine, 10 second holds for 10 reps and progress to higher reps or longer holds) 4. Single leg plank recruits the most for the glut max exercises
Functional Exercises: When performing a lunge how do we progress this exercise? *Remember as we progress the lunge we put more stress the patellar femoral joint
1. Static 2. Backward 3. Front Or could also be progressed by doing the front lunges on an unstable surface like an Airex
Some risk factors of a hip stress fracture include someone who is young, military/runner, Female Athlete Triad and Anterior groin pain. What factors fall under the Female Athlete Triad? (3 factors) What is the typical findings in the history with someone who has a hip stress fracture?
1.) Low Energy Availability not eating enough (working and burning too many calories effecting their hormones specifically estrogen) 2.) Menstrual Dysfunction 3.) Altered hormones leads to Altered Bone mineral density o Insidiously o Improper training techniques o Overuse
There are two ways we can stretch the piriformis muscle what are they? Which one would you choose over the other if you had a patient with FAI?
1.) Lying on back with knees flexed and feet planted on the table, bring knee towards the chest and opposite shoulder 2.) Cross Legs o Gently pull other knee toward chest until stretch is felt in the buttock posterior hip area (hold for 15-30 sec for 3-5 times for both of these stretches) ^^You would pick this stretch over the other if the patient had an FAI to avoid that position (stretch is similar to Impingement test)
When performing a hip flexor stretch we can start with a Thomas Stretch position. How would we progress and regress this stretch? What are some precautions with this stretch?
1.) Regression: Have the leg on the table instead of hanging off (done for S/P posterolateral approach THA) 2.) Progression: Add an ankle weight or apply manual pressure, have them in a Half-Kneeling Stretch (make sure they maintain a posterior tilt, have them lean forward, back straight), to progress this can add a bolster or step stool Precautions: S/P posterolateral approach THA on the opposite leg, protective phase of s/p anterior approach THA on the involved leg, labral repair in the acute/subacute stage, and acute fracture.
Prevalence of labral tears with patients with groin and hip pain has been reported to be _______. Labral tears are most common with _____ _____ tears. Right is ______ o'clock Left is ________ o'clock
22-55% Anterior Superior Labral Tears 1-2 o'clock most common one (R) 10-11 o'clock most common one (L)
The prevalence of labral tears in patients with hip or groin pain has been reported to be ______. Labral Tears may be a sequela for _______ of the hip joint.
22-55% Hip OA
What is the normative value for the joint space between the Acetabulum and the femoral head, moderate and severe? The typical ESR average for men_________, for women ___________, Hip OA_____________, and Lupus, RA__________ What are some other Differential Diagnosis associated with Hip OA?
3-5 mm normal 2.5 mm moderate 1.5 mm severe with osteophytes/subchondral sclerosis 15 mm/hour 20 mm/hour Less than 20 mm/hour Greater than 20 mm/hour - HNP (L2-L3) Lumbar, labrum, SI joint, bursitis, femoral neck fracture, osteonecrosis of femoral head, septic hip arthritis, Paget's disease and systemic inflammatory diseases
The prevalence of symptomatic hip OA or Hip DJD of the acetabulum or the femoral is _______ with the incidence higher in ______(men or women)? *This is symptomatic hip OA, not necessarily degeneration because degeneration of the coxofemoral joint is "ubiquitous" found everywhere
7-25% Men
Weakness and lack of muscle performance of the glut med could lead to excessive....? Glut max important muscle for ER of the lower extremity, weakness eccentrically of the glut max could lead to excessive....?
ADDUCTION AND IR of the lower extremity (same answer for both)
When the muscle goes from eccentric contraction to that concentric contraction (phase in between these two were muscles typically tear), is known as...?
Amortization Phase
During a Straight Leg Raise (SLG) you feel or see an obligatory shift into ABD/ER especially in a child this is known as...?
Drehmann Sign suggestive of LCPD or SCFE
During a squat if we have lack of hip flexion, lack of DF or eccentric control of plantar flexors (looking at soleus more than gastroc since knee is flexed), lack of eccentric control of the quads, and lack of eccentric control of glut musculature could lead to...?
Compensation by shifting your weight towards the opposite uninvolved side (last pic on the right)
Trendelenberg Sign tests for weakness in the hip abductor muscles (glut med). If the right glut med is weak than which hip will drop down when we stand on our right side? Which nerve may cause this issue?
Contralteral side will drop (so the left side) Superior Gluteal Nerve
Hip Assessment: During the hip assessment we can also conduct Dynamic Examinations, Balance Examinations, Functional Activities and Functional Tests. What activities are used for each of these four assessments?
Dynamic Examination: o Squatting (double and single) o Step downs (3,9,12 inch steps jump bilateral lower extremity or with unilateral lower extremity) o Depth jumps o Single/Double leg hops Balance Examination: o Single Leg Stance Test o Star Excursion Balance Test Functional Activities: o Descending and ascending stairs o Sit to stand o Don and doffing socks Functional Tests: o 6 Minute Walk Test o Timed Up and Go Test o Self-Paced Walk Test o Stair Measure Test
Anterior Glide is used when the following motions are limited of the hip? How would we progress this *Position the hip (or try) in neutral don't want to position the hip into extension because your gonna get into more of a closed packed position, try to have a slight external rotation when applying the force anteriorly
Extension and External Rotation -This joint mobilization could be progressed by placing the lower extremity in more external rotation by placing more ER or leg extension
Excessive genu valgus (lower extremity IR, mild alignments) is similar to femoral ________ anteversion or retroversion? (3rd pic from left to right) Anterior pelvic rotation of the innominate pelvis usually leads to the actebaulum to position itself...?
Femoral Anteversion Retroverted or essentially facing backward) what happens here just by anterior pelvic tilting the lower extremity leads to IR and adduction
Inferior Glide is used when the following motions are limited of the hip? *Progression is when we raise them to 90 degrees of knee flexion. Slight external rotation, hip flexed at 30 degrees and hip abducted at 30 degrees (resting position), Maintain your hands on the distal end of the tibia and fibula and NOT AT the ankle and foot
Flexion and Abduction
Posterior Glide is used when the following motions are limited of the hip? How would we progress this? *Mobilization hand needs to be as proximal to the hip joint as possible (NOT TO BE ABOVE THE GREATER TROCHANTER) if above the greater trochanter may be mobilizing the joint itself (acetabulum) instead of the femoral head
Flexion and Internal Rotation -This joint mobilization could be progressed by having the patient in hip flexion (at 90 degrees), apply a posterior glide. In both pictures there is a towel or ankle weight immediately bellow the greater trochanter (posterior part of the hip) to allow the space for the posterior glide to occur
Magee Tables: Is the leg being lengthened or shortened in the following positions; Foot: Supination vs Pronation Knee: Extension vs Flexion Hip: Lowering vs Lifting, Extension vs Flexion, and Lateral vs Medial rotation Sacroiliac: Anterior rotation vs Posterior Rotation
Functional Lengthening: -Foot supination -Knee Extension -Hip Extension, Hip Lowering, Hip Lateral Rotation (ER) -Sacroiliac Anterior Rotation Functional Shortening: -Functional Pronation -Knee Flexion -Hip Flexion, Hip Lifting, Hip Medial Rotation (IR) -Sacroiliac Posterior Rotation
Pes Cavus is typically associated with Genu______ Pes Planus is typically associated with Genu_______
Genu Varus Genu Valgus
A patient has loss in hip adduction would need what kind of Arthrokinematic intervention performed?
Hip Distraction: • Supine with hip in resting position • Thigh is grasped by clinician as proximal as possible and a distraction force is applied perpendicular to the joint axis • Joint distraction can be used for pain and improve hypomobility for all motions Can also be done with a mobilization belt or gait belt: • Supine with involved knee and hip flexed • Belt placed around the patient's proximal thigh • force is applied perpendicular to the joint axis • Joint distraction can be used for pain and improve hypomobility for all motions
Thomas Test is used when someone has a tight...? What is considered a positive finding?
Hip Flexor Tightness The test is positive if the extended limb raises from the examination table when the opposite hip is maximally flexed to the chest
The Scour's Test and FABER/Patrick's Test is used typically for...?
Hip Intraarticular Pathology
Femoral anteversion leads to excessive _______ of the lower extremity Femoral retroversion leads tp excessive ________ of the lower extremity
IR ER
Coxa vera or decrease angle between the femur and the neck, this decrease angle could actually result in excessive _____ during a squat?
IR and Adduction (increase likelihood during descent phase of a squat)
If your pelvis is into acetabular retroversion (or basically the socket facing posteriorly) leads to the lower extremity into... (IR or ER)?
IR, that would lead to excessive adduction and IR during squats especially in the descending phase
If we have an increased lordosis what type of pelvic tilt would we have? What about a decreased lordosis? What would happen in both situations to the lower extremity as we descend into a squat? What is the angle from the ASIS and PSIS between?
Increased lordosis: ASIS is much lower than the PSIS is due to anterior pelvic tilt which is associated with IR of the lower extremity during the descent phase of a squat Decreased lordosis: PSIS is equal or higher than the ASIS is due to posterior pelvic tilt which is associated with ER of the lower extremity during the descent phase of a squat 7-15 degrees
Bulging (hernia) At or above the ilioinguinal canal than we are looking at an...? If the bulging is inferior to the ilioinguinal canal than perhaps we are looking at a....?
Inguinal Hernia Femoral Hernia
If we have groin or hip joint pain stemming from some type of lumbar radiculopathy which nerve roots are the most common nerve roots that refer pain here?
L2 and L3
If a patient recently had Labral Debridement what are the precautions, weight bearing status, and goals for PT? What about a Labral Repair?
Labral Debridement • Usually 7-10 days protected WB (50%) • ROM: no limits • Trunk and pelvic strengthening to normalize gait • See content module for protocol Labral Repair • Protective WB 3-6 weeks (TTWB) • Flex: 90 deg, 10 deg extension and abd 25 deg (10-14 days) • Emphasize in trunk/pelvic and hip control • Obtain specific MD protocol • See Content module for protocol -Progression of hip Abductors -Moving from supine to standing abduction to progressing to sideling abduction, end of rehab sideling abduction plank position -Good idea to initiate circumduction below 90 degrees as a meaning of reducing fibrosis of the hip. Similar to the Scour test (don't go to 90 degrees of hip flexion though will be painful)
Log Roll and The Impingement Test is typically used for...?
Labral Tear Pathologies
Modified Thomas Test is used to evaluate tight...? What is considered a positive finding?
Looks at hip flexor contractures, but SPECIFICALLY looks at Quadricep tightness If the hip flexes or knee elevates up towards the ceiling during PROM of knee flexion may have quad tightness
The most commonly used outcome measure used in outpatient clinics for the hip is...? Describe the following outcome measure and what does it mean to score a higher score vs. a lower one.
Lower Extremity Functional Scale (LEFS): Most commonly used in outpatient clinics ○ Has 20 Basic functional activities that goes from -0=Extreme difficulty or unable to perform activity -4=No difficulty (highest level) Overall Score is 80, so the HIGHER the score the more functional you are, the lower the score the greater the disability you have
This condition refers pain to the lateral thigh as well as to the hip/groin area due to compression of the lateral femoral cutaneous nerve...known as?
Meralgia Paresthetica
If you have no deformities during squat how would you advanced the dynamic examination?
No deformities during squats would progress to single leg squat, if no faulty movements here may go into single leg squat to a forward step down or side step down to see if increasing the difficulty or taxonomy of the movement could exacerbate the faulty movements, lastly could have the patient jump with the bilateral lower extremity and see if there is an excessive adduction, IR or any other faulty movements
Constant pain (inflammatory process, acute phase) what type of care is used here? *Could also have intermittent (mechanical) pain Morning Pain stiffness that lasts less than 1 hour is typically due to...? Morning Pain stiffness that lasts longer than 1 hour is typically due to...?
Palliative care: modalities, decrease the inflammatory phase and pain, and assitive devices -OA -Systemic inflammatory disease, RA, lupus
Neuromuscular Reeducation Motor Control: What types of movements should be monitored when observing a patient squatting?
Pelvis: Look out for excessive anterior pelvic tilt Hip: hip hinging Foot and ankle: place rear foot in neutral -Perform exercise multiple times per day, and incorporate in functional activities
What is the typical dosage if giving someone a static stretch? (duration, frequency, intensity)
Static Stretching - Stress applied to musculotendinous unit* • held for 15-30 seconds • Usually repeated between 3 to 5 times per session • Held to a point just below pain threshold • Can be done with assist devices or manual assistance Frequency: Daily 1-3 times per day Intensity: 30 -85% of a maximal stretch Mild discomfort not pain
Where would the abdominal contents be located in a femoral hernia compared to an inguinal hernia?
The intestines could move to either the inguinal canal or the testes (inguinal hernia), if the abdominal content falls into the femoral triangle (femoral hernia)
When stretching the hamstring we start by supporting the thigh behind the knee, slowly straighten knee until stretch is felt in the back of the thigh to progress this further we could...?
Use belt or towel for further stretch
True or False: An Up-Slip or when the pelvis is slipped upward on the other side of the body, can make the iliac crest higher than the other one
True
What are the different types of THR, and whats the major difference between an Anterior and Posterior Lateral approach?
Uni-Polar: one piece includes the stem and ball with no acetabulum component Bi-Polar: has two pieces that include the separate stem and ball, but no acetabular component Hip resurfacing: most common has a short stem and cap and tapped over the resurfaced femoral head and tapped onto the acetabulum. Benefits we don't have unnecessary bone loss Total hip arthroplasty: stem and ball and acetabular component. Polyethylene acetabular liner which articulates with the femoral ball Cemented: full weight bearing after Post-OP could occur, with a walker or a cane Non-cemented: weight bearing precautions, toe-touch for the first 6 weeks. Achieve full stability for the porous growth of the acetabular component on the acetabulum -Posterior approach, posterior lateral (higher dislocation rate), precautions: limit hip flexion to less than 90, no adduction past midline, and IR. Wearing an adduction pillow, and has a large incision 20 cm -Anterior approach (10 cm) best short term outcomes, no precautions may limit ER and hip extension -Long term these three are similar Mini-Posterior approach is 5cm
Trauma: Pivoting and some excessive extension and ER could tear the labrum. What types of Femoral Acetabular Impingements (FAI) could we have? (4 kinds)
o Cam: Femoral head large radius, 32 year old male o Pincer: Abnormal coverage of acetabulum, middle age women 40 years o Cam/Pincer: Over 50% with FAI have a mixed type of CAM and Pincer o Clinical syndrome: Femoral acetabular anterior glide syndrome: • Insufficient posterior glide during hip flexion and excessive anterior joint capsule laxity (leads to groin pain, catching, locking, stiffness)
What are some Primary Predisposing Factors related to Osteoarthritis (OA)?
o Congenital dysplasia: • Coxa vara and valga • Femoral anteversion and retroversion • Acetabular anteversion: when the acetabulum faces anterior and retroversion: when the actebaulum faces posteriorly • Coxa plana: when the socket is flat and profundus when the socket is deep o Leg Length Discrepancy o BMI: Odds ratio rating from 1.6-15.4 meaning someone who is obese greater than 30 BMI would be 15 times more likely to have the condition of interest; OA o Ethnicity: White Americans o Gender: Men higher risk o Genetics o Occupation o Sports: hockey, basketball and football
Labrum Tears: What are some surgeries to consider when someone has a labrum tear? (Total of 5)
o Debridement: removal of torn labrum and cleaning up joint performed arthroscopically o Repair: suturing of the labrum back to the actebaulum o Chondral lesion o Osteoplasty and RIM trimming for FAI o Capsular tightening: thermal shrinkage of the capsule
What are the primary predisposing factors for labral tears?
o Degeneration (hereditary) o Coxa valga o Cam and Pincer o Acetabular retroversion makes the acetabulum face posteriorly decreasing the distance (increasing the likely hood of impingement) -Femoral anteversion: another risk factor
What are some Secondary Predisposing Factors related to OA? What's the general age relation?
o Disease: Legg-Calve' Perthes disease, Down's and Marfan's syndromes o Mechanical Trauma o Age greater than 50 years (ICD)
What are the normative values for the following (Magee Norms): -Hip Flexion -Hip Extension -Hip Abduction -Hip Adduction -Hip Lateral Rotation -Hip Medial Rotation
o Flexion: 110-120 deg o Extension: 10-15 deg o Abduction: 30-50 deg o Adduction: 30 deg o Lateral rotation: 40-60 deg o Medial rotation: 30-40 deg
What types of findings would you find when conducting a history for someone who has Femoral Acetabular Impingement (FAI)?
o Insidious o Progressive stiffness and pain o Buckling o Locking o Painful clicking o Limitation of joint mobility o Pain in the anterior groin o Decreased joint clearance
What are some Labral and FAI interventions to consider?
o Joint Mobilization (posterior tightness, A/P and inferior joint mob: increase flexion and IR) o Increase IR ROM o Strengthening exercises: Gluteus med (Abd) and gluteus max (ER) o Double, single and step downs (avoid adduction and IR of hip) o Stretching o Posture (pelvic tilt): Pelvis anteriorly rotated stretch the hip flexors at rest, stand with a better posture o Functional strengthening (lunges) o Proprioceptive training: i.e. balance board, and cues to properly squat o Stationary bike if tolerated (make sure seat is high enough so no femoral impingement) o Assistive device (antalgic gait) o Aquatic therapy (good for intraarticular pathology) o Stationary bike-Elliptical and treadmill (if they have high reactivity level use heating pack) -Education: Do not cross the legs, don't sleep on leg, avoid extension and ER drives femoral head into acetabulum and labrum superiorly, don't sit for long periods of time or standing (same as hip OA)
Prognosis of OA is typically slow progression with Total Hip Replacement (THR) being the primary clinical endpoint. The most important predictive factor of having a THA is having at least...? (4 factors)
o Moderate osteophytes o Moderate narrowing of joint space o High global assessment of pain (4.7 out of 10) o Previous trial of NSAIDs
During the physical exam for a patient with OA in the hip we notice the capsular pattern of medial rotation (IR), flexion and abduction is limited, we have decreased weightbearing, and antalgic gait. Where else may they have pain or we expect them to have pain? How much Hip IR and flexion needs to be lost to be significant?
o Pain in the anterior hip, groin area, and sometimes on posterior buttocks and lateral hip (ICD) - Pain with squatting "sclerotomes" (areas of the bone that refers pain distally, the distal area or referral area of the acetabulum or femoral head is all the way towards the medial side of the knee) - Possible referral symptoms in medial knee - Possible weakness of hip abductors - Painful active hip flexion (SLG raise) - Painful active hip extension - Limited Hip IR and flexion by more than 15 deg compared to uninvolved LE (ICD)
What are some examples of what we may find when conducting a physical exam for someone who had a Total Hip Replacement?
o ROM, strength, tenderness, gait and transfer o Scar o Hip functional problems: oHip abductor weakness 47% oMuscle contracture 28% oLimb difference 13% oMalalignment 12%
When looking at Medical Tests for hip stress fractures what is considered the gold standard? What are some other differential diagnosis to consider with this condition?
o Radiographs and bone scan (gold standard), although MRI is starting to become the gold standard now • Differential Diagnosis o HNP Lumbar, SI joint, bursitis, labral tear, OA and systemic inflammatory diseases
What are some interventions to consider when thinking of a Contractile Lesion?
o Rest, ice, compression, NSAID's and elevation o Modalities o Massage o Flexibility ex. within pain-free range o Dynamic stretching (always want to do static stretching when you have an injured muscle when pain free initiate dynamic stretching) o PREs pain-free o Cross Friction massage o Upper body and trunk strengthening o Closed kinetic chain exercises o Eccentric training o Agility training o Balance exercises o Cardiovascular conditioning: Bike, treadmill, and elliptical machine
During the physical exam of someone with an Inert Lesion what kinds of things may we find here?
o Restrictive ROM acute stages -Ex: If the measurement of injury was excessive hip abduction (pubofemoral ligament could be overstretched so when doing AROM the hip abduction could cause concordant pain o Pain with weightbearing o Sit to stand transfer increase symptoms o Non-capsular pattern (may have a capsular pattern at one point but during the acute phase will not have a capsular pattern) o Pain and apprehension to end range IR, extension, and inferior glide
What type of findings would you find when conducting a physical exam for someone who has a Labral Tear?
oPain with combined: flexion, adduction and IR (bringing the knee to the opposite shoulder) oSLR flexion painful: Hip flexor (rectus femoris) has the origin into the anterior inferior iliac spine, acetabulum and the labrum (has connections directly and indirectly to the labrum), this area of the labrum is irritated when you flex the hip or recruiting the rectus femoris could irritate the acetabulum oMinimal loss to WNL ROM o Antalgic gait oPain in the anterior hip oPossible referral symptoms in medial knee, trochanteric region, and buttocks
Describe what the AROM, PROM, RIMT would be if someone had a Contractile Lesion? What would be the predictable outcomes for a 1st degree, 2nd degree, and 3rd degree strain?
• AROM: Pain when tendon/muscle strain • PROM: No pain unless tissue is stretched • RIMT: Reproduces pain with contraction • Strong and pain free: - Normal contractile tissue 1 degree: (strong and painful): 1 week better, patient could exercise and be able to continue practicing 2 degree: (weak and painful, severe but not complete tear): 1-3 weeks gets better, pain medially limping, and cannot practice 3 degree: (weak and painful, severe but not complete tear): 3 weeks to 3 months gets better, intense pain, unable to walk and have a palpable defect *Weak and pain free: indicates rupture of muscle/tendon or possible peripheral lesion
What kind of position would you get the patient in in order to stretch the posterior capsule? (there are two different stretches that can be performed)
• Begin kneeling with hips pushed back and toes pointing straight out. Lower chest towards legs and extend arms forward and overhead so they rest on table • Progress to standing (have them lean forward on a step stool) *great stretch for those patients that have a lack of posterior glide and lack of internal rotation
What are some interventions to consider when thinking of a Athletic Pubalgia?
• Factors leading to pubic bone overload: - Lumbar/SI dysfunction - Limited hip ROM - Decreased lumbopelvic stability - Hip flexor tightness - Weakness or tightness of the adductor muscles • Rest, ice, massage and NSAIDS • Warm up/ Modalities • Removing the causative factors • Stretching of hamstrings, hip internal rotators, hip flexors and adductors • Education regarding sitting, standing and supine posture and neutral spine • Hip strengthening • Hip and lumbar spine mobilization • Local and global lumbar musculature strengthening • Periodization of training
What are some Red Flags for tumors, neoplasms as well as fractures?
• Fever • Malaise • Night sweats • Weight lost • Night pain • Infection and septic arthritis • Osteomyelitis • Unable to weightbear secondary to pain • Pain with any hip movement and/or in the presence of a shorten and external rotated lower extremity
What kind of characteristics would you find in the history and physical exam when looking at someone who has an Adductor Strain?
• History - Adductor longus (more frequently injured) - Amortization phase • Physical Exam o Pain with resistive adduction o Pain during passive hip ABD o Possible muscle imbalance between abductors and adductors o Lacks mechanical advantage due to origin and insertion making it more susceptible to strain
What kind of characteristics would you find in the history and physical exam when looking at someone who has a hamstring strain? -Common injuries occur from football, basketball, and soccer
• History - Most common of the hip - Runners and joggers - Amortization - Previous hamstring injury - Lumbar DJD and DDD (lumbar radiculopathy: coming from back or hamstring strain MOI) - Biomechanics: LLD and APT • Physical Exam o Pain with PROM hip flexion with knee extended o Pain with resistive hip extension and knee flexion o Muscle imbalance: quad is a lot stronger than the hamstrings 0.5-0.8 higher risk for hamstring strain o Palpation: Tenderness to the muscle belly (bicep femoris more common) and/or ischial tuberosity o Having a previous hamstring injury #1 risk factor o Positive straight leg raise: hamstring pain may come from nerve root pathology
What kind of characteristics would you find in the history and physical exam when looking at someone who has a Iliopsoas strain?
• History - Overuse - Mechanical irritation • Physical Exam o Tenderness to the femoral triangle o Pain with power walking and running o Pain with resistive hip flexion when the hip is position in ER o Pain with PROM hip extension and lumbar extension
What kind of characteristics would you find in the history and physical exam when looking at someone who has a Quadriceps strain?
• History - Sprinting, jumping and kicking - Rectus femoris • Physical Exam o Pain with resistive knee extension o Pain during passive knee flexion o Tenderness in the anterior thigh o Complete tear will have a palpable defect o Look out for hip flexor weakness
What kind of findings would see in the history and physical exam with someone who had a sports hernia?
• History o Trauma injury that involves twisting and turning or directional changes - Pain in the lower abdominal, inguinal, and groin regions - Either unilateral or bilateral - Exacerbated with exertion or valsalva • Physical Exam - Pain with RIMT: Hip adduction (0,45,90 deg), hip flexion, adduction, rectus/oblique abdominis (abdominal curl up) musculature - Palpation: Pubic ramus at the insertion of rectus abdominis and conjoin tendon
What are some medical interventions used for Hip OA?
• NSAIDS: - Effective for the temporary relief of symptoms and improvement of function • Viscosupplementation: Intra-articular injections (hyaluronic acid derivatives): Synvisc, Supartz and Orthovisc - Some evidence to support the short-term use of injectable viscosupplementation (mild to moderate OA) - 3-5 injections - Avoid aggressive WB exercises for 48 hours • Cortisone injection: Evidence supports the use corticosteroid injections in patients with hip OA with benefits lasting 3 months
Describe the Micro Fracture Procedure for Chondral Lesion and what is the typical recovery rate, weight bearing status and PT goals?
• OCD: Drilling to allow exposure of the mesenchymal stem cells from blood, marrow and endothelium (They puncture the subchondral bone in hopes to stimulate the stem cells to activate the stem cells, so the stem cells can eventually differeinate into chondral blasts, these should than secrete the ingredients for cartilage growth) • Recovery: One year plus • Protective WB for an average of 8 weeks (no weight bearing AT ALL) • Transition to full WB at 8 weeks • Early emphasis on AAROM and pelvic control for 0-3 weeks • Use pool for progression • WB exercise once FWB is established (after 8 weeks) *Osteochondral autologous transplantation system (OATS): takes hyaline cartilage from the lower extremity into the area that is effected (old system)
What physical examinations could be found with someone who has a Hip Stress Fracture? What are some special tests related to this condition?
• Physical examination: o Decreased mobility, ROM, and strength o Non-capsular Pattern o Pain with WB o LLD o Antalgic gait (painful gait) o Pain with sit to stand • Special Test o Leg Hop/ Heel Thump o Patellar-Pubic Percussion Test o Stress Fracture Fulcrum Test
List the intensity, sets, reps, and rest for the following resistance training parameters: -Power -Strength -Hypertrophy -Endurance
• Power: - Intensity:75-90% 1RM - Sets: 3-5 - Repetitions: 1-5 - Rest: 2-5 min • Strength: - Intensity:> 85%1RM - Sets: 2-6 - Repetition: less than or equal to 6 - Rest: 2-5 min • Hypertrophy: - Intensity:67-85%1RM - Sets: 3-6 - Repetition: 6-12 - Rest: 30-90 seconds • Endurance: - Intensity:< 67%1RM - Sets: 2-3 - Repetition: greater than or equal to 12 - Rest: less than or equal to 30 sec
What types of interventions are performed for someone who has an Inert Lesion?
• Rest, ice, massage and NSAIDS • Early movement • Controlled weight-bearing • Hip spica wrap • Modalities • Strengthening • Proprioceptive training: Any ligamentous injury and sprains you ALWAYS want to do proprioceptive training for this individual. Capsular weight bearing exercises as well as balance training
What are some interventions used for a patient who has Ischial Bursitis (Weaver's bottom)?
• Rest, ice, massage and NSAIDS • Modalities • Pressure relief by padded seat cushion • Stretching: gluteal and hamstrings • Hip stabilization exercises • Activity modification
What are some interventions to consider for a patient who has Trochanteric Bursitis?
• Rest, ice, massage and NSAIDS • Modalities • Removing the causative factors • Soft tissue mobilization/MFR • Stretching: TFL, ITB and adductors • Strengthening of hip abductors, external rotators and extensors • Activity modification
What are the interventions related to someone who has Iliopectineal Bursitis?
• Rest, ice, massage and NSAIDS • Modalities • Stretching: hip flexors and adductors • Hip stabilization and weightbearing exercises • Activity modification
What is the resting position, close pack position and the capsular pattern of the hip joint?
• Resting position: 30 degrees abduction and flexion with slight lateral rotation • Close pack position: Extension, medial rotation and abduction • Capsular pattern: IR, flexion, abduction (Cyriax)
What are the two positions you could stretch someone if your trying to target the Adductor musculature?
• Seated: Sitting with knees flexed and feet together • Standing: Involved lower extremity externally rotated. Lean away from the involved lower extremity • Push gently on the knees with elbows and hands
What type of special tests would be considered for a Labral Tear, Medical Tests and what are some Differential Diagnosis to keep in mind?
• Special Test - Quadrant (Scour) Test - Faber or Patrick's Test - Log Roll Test - Impingement test: flexion, adduction and internal rotation (FADIR) overpressure • Medical Tests - Arthroscopy (See if it can hold 10 cc) - MRI : Radial flap(most common typically in younger), radial fibrillated (degeneration older ), anterior superior (most common) - CT scan • Differential Diagnosis HNP Lumbar, SI joint, bursitis, and inflammatory diseases
What type of special tests, medical tests and differential diagnosis should be considered if a patient has FAI?
• Special Tests - Quadrant (Scour) Test - Faber or Patrick's Test - Impingement Test - Log roll (labral tear ruling out the labrum besides the iliopsoas) • Medical Tests - Radiographs and MRI for labral tears • Differential Diagnosis - HNP Lumbar, SI joint, bursitis, and systemic inflammatory diseases
What are some special tests, medical tests and differential diagnosis to consider for someone who has Ischial Bursitis (Weaver's bottom)?
• Special tests - N/A • Medical Tests - Injection and MRI • Differential Diagnosis - Lumbar disorders, hamstrings disorders and piriformis syndrome
What are the special tests, medical tests and differential diagnosis related to Iliopectineal Bursitis?
• Special tests - N/A • Medical Tests - Injection and MRI • Differential Diagnosis - Lumbar disorders, hip pathology and meralgia paresthetica
What types of special tests, medical interventions and differential diagnosis are considered for someone who has an Inert lesion?
• Special tests o Quadrant (Scour) Test o Faber or Patrick's Test o Long axis inferior glide • Medical Tests o Radiographs and MRI • Differential Diagnosis o Lumbar OA, fracture, labral tear, FAI, or lumbar pathology
What are the special tests, medical tests and differential diagnosis to consider for someone who has Trochanteric Bursitis?
• Special tests (no true special test for subtrochanteric bursitis) - Passive hip flexion, adduction and IR/or ER - Negative SLT or Slump Test • Medical Tests - Injection and MRI • Differential Diagnosis - Lumbar disorders, SI joint and OA