Lower Extremity Hip

S&S of quad and hamstring strains (1st-3rd degree)

1st degree- muscle soreness, stretching of fibers or few fibers torn, point tenderness, mild swelling possible not always present, knee flexion >90 degrees, hip flexion >90 degrees but may create pain 2nd degree- partial tear, major pain, feeling of snap or tear, swelling, point tenderness, may feel divot, loss of ROM and strength; knee < 90 degrees, hip flexion < 90 degrees. 3rd degree- complete tear, severe pain, very point tender, severe edema, little to no ROM and strength, ecchymosis; palpable defect.

Normal ROM for hip extension

30 degrees

NROM for hip external rotation

45 degrees

NROM for hip internal rotation

45 degrees

The hip is made up of what 3 joints?

Acetabular Femoral Joint (Hip joint), Pubic Symphysis, and the Sacroiliac joint

NROM and facts about Hip abduction

Active/passive motion: athlete should be supine Resistive motion: athlete should be side lying Normal ROM is 45 degrees Make sure there is not compensatory ER Goniometer will start with a 90 degree reading

Things to observe for in the Hip and pelvis

Angle of inclination Gait patterns Trendelenburg's gait: weakness of Gluteus Medius causes opposite hip to drop Q-Angle Hip Height Posture/scoliosis/lordosis/kyphosis

ST for FAIs

Anterior Impingement Test Passively place hip in internal rotation, flexion and adduction with patient supine. Pain is positive Diagnosed with x-ray or MRI

The hip is strengthened by...

Articular capsule Broad ligamentous support Iliofemoral ligament - "Y" (Connects AIIS to Femur) Pubofemoral ligament (Connects Pubis to Femur) Ischiofemoral ligament (Connects Ischium to Femur)

S/S of hip adductor strain

Ath. may report a pull or tear, point tender, possible swelling, weakness. Use MMT to distinguish specific muscle involvement.

S&S of Hip Flexor Strain

Ath. may report a pull or tear, point tender, swelling, weakness

NROM and facts about Hip adduction

Athlete supine for active/passive Side-lying for resistive Normal is 30 degrees Goniometer will start with 90 degree reading

What muscles are the hip extensors?

Biceps Femoris- long head Semimembranosus Gluteus Maximum Gluteus Medius Gluteus Minimum

Hip Pointer injury description

Bruising or avulsion at boney landmark

Two Types of FAIs

Cam lesion: located on femoral head, result from abnormally shaped femoral head repeatedly contacting the acetabulum and surrounding labrum Most commonly seen young, athletic males Thought to develop in response to extensive sports participation during the high-growth period of adolescence Pincer lesion: when acetabulum is overly covering the femoral head, causing compression between acetabular rim and femoral head-neck function(especially during hip flexion) Most commonly seen in middle aged, active females

Crush Fx

Can be life threatening, since there is considerable hemorrhage

Femoral Acetabular Impingement (FAI)

Changes in femoral head or acetabulum places abnormal stress on surrounding soft tissue and bone Can cause labral tears, chondral degeneration and OA

S&S of quad contusions

Classic symptoms of most muscle bruises; pain, transitory loss of function, and immediate capillary effusion. Palpation may reveal circumscribed swollen area that is painful to touch 1st degree- mild pain, swelling, 90 degrees or better of knee flexion. 2nd degree- moderate pain, swelling, knee flexion < 90 degrees. 3rd degree- major disability, muscle may herniate, deep intramuscular hematoma; severely decreased ROM.

What is a potential secondary as a result of a quad contusion?

Compartment Syndrome and Mitosis Ossificans

TX of femoral fracture

Create as little motion at possible by spine-board and transport to ER

S&S of hip joint (acetabular femoral) sprains

Deep pain in the joint and difficulty bearing weight; pain with passive and active ROM. 3rd degree sprain= dislocation of the hip Medical emergency Most are posterior Describes feeling of "hip popping out", little to no ROM, possible neurological symptoms down leg, may or may not see observable deformity Immobilize (spine board) and transport to ER

Where is the Iliopsoas bursa located?

Deep to adductor muscles on anterior hip

MOI of hip pointer injury

Direct blow to iliac crest or ASIS

MOI of quad contusions

Direct blow to quadriceps

MOI of femoral fracture

Direct blow, falling from a height.

What movements occur at the hip joint?

Flexion Extension Abduction Adduction Circumduction Internal and External Rotation

What happens Legg-Calve Perthes Disease

For unknown reasons, vascularization to the epiphysis is diminished, causing degeneration and flattening of the femoral head articular cartilage.

TX of hip contusions

General contusion treatment, pad when returning to activity

What muscles are the abductors of the hip?

Gluteus Medius Tensor Fascia Latae Gluteus maximus (lower fibers) Sartorius

What are the internal rotators of the hip?

Gluteus Minimum Gluteus Medius (anterior fibers) Adductor Magnus, longus and brevis

What muscles are the adductors of the hip?

Gracilis Adductor Longus Adductor Magnus Adductor Brevis Pectineus Gluteus Maximum (upper fibers)

external snapping hip syndrome

IT band catching on greater trochanter

TX of hip adductor strain

Ice, gentle stretch, NSAIDS, pain-free ROM, increase strengthening exercise as pain decreases, Hip Spica ace wrap for activity

FX of hip flexor strain

Ice, gentle stretch, NSAIDS, pain-free ROM, increase strengthening exercise as pain decreases, hip Spica wrap for hip flexor.

S&S of hip pointer injury

Immediate pn., muscle spasms, pt. tenderness, trunk and hip flexion as well as trunk rotation is decreased. Sometimes hemorrhage is seen along the superficial crest.

3 types of Snapping Hip Syndrome

Internal Snapping, External snapping, Intra-articular snapping

MOI of hip adductor strain

Involves psoas and adductor muscles, Running, jumping, and twisting activities to either concentric or eccentric contraction.

What is Osteitis Pubis

Irritation and inflammation of the pubic symphysis

The pelvis/pelvic girdle

Is formed by two innominate bones Each comprised of the ilium, pubis and ischium Anteriorly articulates at the symphysis pubis Posteriorly articulates with the sacrum on both sides forming the sacroiliac joints

SI joint sprains MOI

Jamming mechanism such as landing off balance Ex- rebounding and landing off balance on one leg with back extended.

Hip anatomy facts:

Joint is notorious for referring pain distally 22 muscles act on the hip Highly stable joint

Normal ROM for KF and KE during Hip Flexion?

KF- Normal ROM- 120 degrees KE- Normal ROM- 90 degrees

Movements of the pelvic girdle

Known as pelvic tilts Anterior Pelvic Tilt (forward)- hip flexion and lumbosacral hyperextension Posterior Pelvic Tilt (backward)- hip extension and lumbosacral flexion

Hip Contusions (can also contuse the coccyx, or lateral hip) MOI

Landing or sitting hard on the tailbone (coccyx) can contuse it.

Iliopsoas Bursitis facts and MOI

Lies deep to hip flexor muscles Mistaken for a muscular strain because of bursa location Most often caused by overuse. Chronic bursitis may cause a snaping in the groin as the iliopsoas passes over the lesser trochanter

Ligamentum Teres

Ligament of the head of the femur" serves as a conduit for the medial and lateral circumflex arteries to pass through. Provides little to no support!

How would you determine rectus femoris versus iliopsoas strain involvement?

Manual muscle testing

Where is a femoral fracture most common?

Middle 1/3 of femur

MOI of Epiphyseal Fractures

Occur most commonly at the greater trochanter and capital femoral epiphysis. Can be partial seperation or complete avulsion. MOI - insidious or traumatic

Inguinal ligament

Originates from ASIS and inserts on pubic symphysis. Serves to contain soft tissues as they course anteriorly from the trunk to the lower extremity.

S&S of hip contusions

Pain, difficulty sitting, particularly when leaning back or slouching, pt. tenderness, swelling, and possible discoloration can be observed. If pain persists refer to physician to rule out fx.

How to determine the angle of torsion

Patient prone with knee flexed to 90 Examiner 1 palpates the greater trochanter and IR and ER hip to find greater trochanter at most prominent spot Angle is measured with goniometer Stationary arm: perpendicular to table Movable arm: tibia Axis: anterior knee

Least common hip fx. In sports

Pelvic Fractures

What are the external rotators of the hip?

Piriformis Obturator externus Obturator internus Gemelli superior Gemelli inferior Quadratus femoris Gluteus Medius (posterior fibers) Sartorius

What muscles are the hip flexors?

Psoas Major and Minor Iliacus ("Illiapsoas" hip flexor) Rectus Femoris Sartorious

TX for quad contusions

RICE (ice on a stretch), crutches if needed, NSAIDS, stretching/massage

TX of hip pointer injury

RICE, possible referral, once swelling and pn. has decreased, utilize thermo-therapy; protect area with pad upon return to competition.

What is the angle of inclination?

Relationship of femoral head to femoral shaft in frontal plane Typically born with a increased angle then decreases as a result of weight bearing Normal: 125-130 degrees Coxa Vara: decreased angle Genu valgum, squinting patellae Coxa Valga: increased angle Genu varum, frog-eyed patellae Must be definitively diagnosed with use of radiographs Gluteus Medius function is effected by both due to changes in line of pull on the femur

MOI of hip Joint (Acetabular Femoral) Sprains

Results from forces that cause excessive rotation or abduction or that drive the femur posteriorly.

Angle of Torsion

Rotation of shaft of femur resulting in an malalignment of femoral condyles on the head and neck of femur Normal: 15-20 degrees Anteversion: increased angle (Squinting patellae, toe in gait) Retroversion: decreased angle (Frog-eyes patellae, toe out gait) Must be definitively diagnosed with use of radiographs

MOI of Hip Flexor Strain

Running, jumping, pushing off

Spasm and inhibition of the gluteus Medius is common with these joint dysfunctions.

Sacroiliac Joint Dysfunction

Where to place the goni when assessing hip extension

Same landmarks as hip flexion: Stationary Arm in line with torso/parallel to table Movable arm in line with IT Band/Lateral femoral condyle Axis on Greater Trochanter

Pelvis/ Pelvic girdle facts

Serves as attachment site for trunk and lower extremity muscles Small amount of distraction(spreading), compression, and rotation occurs between innominates at Pubic Symphysis Limited mobility in SI joint due to strong boney articulation

Hip Flexion

Should be performed Athlete Supine With knee flexed for joint motion With knee extended for hamstring muscle length

Sacroiliac Joint Dysfunction MOI

Similar to SI sprains

Where is the trochanteric bursa located?

Sits between IT Band and Greater Trochanter

Where is the Ischial bursa located?

Sits on Ischial Tuberosity

Treatment of quad and hamstring strains

Stage 1- RICE, gentle stretching, NSAIDS, ace wrap, possibly crutches. Stage 2- Ice w/stretch, increase ROM w/heat therapy, isometrics, isometrics w/increase in ROM Stage 3- Isotonic and isokinetic exercise, heat therapy, functional exercise program

Where to place the goniometer when assessing hip flexion

Stationary Arm in line with torso/parallel to table Movable arm in line with IT Band/Lateral femoral condyle Axis on Greater Trochanter

MOI of quad and hamstring strains

Sudden stretch or contraction, muscle imbalance, fatigue; occurs most often in pre-season.

What is in the Femoral triangle?

Superior portion- inguinal ligament Lateral portion- Sartorius Medial portion- Adductor longus Within the triangle run the femoral nerve, artery and vein

Facts about slipped Capital Femoral Epiphysis

The capital femoral head is displaced at the epiphysis Results from progressive weakening of the epiphysis and not directly from activity Complications include avascular necrosis and synovitis

True vs Apparent Leg length discrepancy

True/structural- characterized by a bilateral difference in measurable length of the femur or tibial shaft. Measured from ASIS to medial malleolus Difference of 10-20mm is considered significant Apparent/Functional- may result from pelvic rotation or a hemipelvis. Measures from umbilicus to medial malleolus Only useful if true leg length measurements were insignificant

Altered gait and functional leg length discrepancies will be noted with....

Up slip

What is Hemipelvis

When one side of the pelvis is smaller than the other.

The head of the femur fits into the deep cavity of the...

acetabulum

TX for FAIs

activity modification and symptom treatment, stretching of adductors and internal rotators When conservative treatment does not work sx may be needed

Iliopsoas Bursitis S&S

anterior groin pain from hip flexion

S&S of labral tears

anterior or medial hip pain, catching or locking of hip

The hip joint is what type of joint?

ball and socket

S&S of piriformis syndrome

buttocks pn., sciatic nerve irritation, and decrease of ROM. Muscle tightness and spasm of the piriformis can compress the sciatic nerve. This will refer pain, numbness, tingling down the posterior thigh/buttocks 12% of the population the nerve splits and partially runs through muscle

TX Legg-Calve Perthes Disease

cannot re-create shape of femoral head Treat symptoms with traction, wheelchair/crutches, casts, therapy to retain motion Goal is to prevent further changes or to allow bone to remodel as it continues to grow

MOI of Femoral Stress Fracture

chronic and repetitive overload due to WB. More prevalent in athletes who have poor dietary habits, osteoporotic bone, leg length discrepancy or biomechanical abnormality

Possible secondary injury resulting from Epiphyseal fracture

chronic synovitis

The acetabular labrum

deepens acetabular cavity, and creates friction free surface and cushion

Pelvic Fractures result

from high-impact or crush mechanism( things like skiing or horseback riding)

Piriformis Syndrome results

from overuse or repetitive activities.

S&S of FAIs

groin pain that is sporadic at first then becomes constant, pain may radiate to lateral thigh, pain increases with athletic activities, walking and prolonged sitting, limited internal rotation with hip flexed to 90 degrees

S&S of Femoral Stress Fracture

groin pain that may radiate out the lat. Hip or down the thigh. Intially athlete will complain of pain with WB activity and it will diminish or disappear with rest. Palpable pt. tenderness and pain with percussion to greater trochanter may occur.

Osteitis Pubis S&S

groin pn., palpable tenderness of pubic symphysis, additional pn. with passive abduction and active adduction.

MOI of Labral tears

hip dislocation/subluxation, or with repetitive compression of labrum in external rotation, hyperabduction, or hyperextension

Special Tests of labral tears

hip scouring Requires MRI for definitive diagnosis

TX of Osteitis Pubis

ice, NSAIDS, Rest (in severe cases may require non-weight bearing

TX of athletic pubalgia

if no bulge or complication typically will heal with rest and muscle focused rehab (4-6 weeks) Must differentiate between muscle strain Typically diagnosed after muscle strain treatment fails

internal snapping hip syndrome

iliopsoas tendon catching the femoral head or other structure

Trochanteric Bursitis MOI

irritation over the bursa from repetitive stress or a single direct blow.

Sacroiliac Joint Dysfunction S&S

joint stiffness, pain with unilateral weight bearing, and an altered gait. Dull ache that becomes sharp with motion, altered level of ASIS, PSIS or Iliac Crest

Intra-articular snapping

labral tear, loose bodies in joint, or synovial fold

S&S of Epiphyseal fracture

limp and complaints of intermittent groin pain that radiates down the medial thigh to the knee, with no specific recall of injury.

TX of labral tears

most require surgical removal May result in possible instability

S&S of Slipped Capital Femoral Epiphysis (SCFE)

noticeable limp, groin pn. , and decrease of ROM, may have medial knee pain Avascular Necrosis and synovitis are possible complications Must be confirmed with x-ray

Osteitis Pubis MOI

overuse and repetitive stress of the adductor muscles.

S&S of athletic pubalgia

pain and point tenderness, may or may not palpate or observe bulge, pain and weakness in hip adduction, pain with coughing

Trochanteric Bursitis S&S

pain over lateral hip, possibly radiating down to the knee; noticeable crepitus; pt. tenderness and swelling and redness occur if the bursa is acutely inflamed. Must differentiate from femoral neck stress fracture

Ischial Bursitis S&S

pain with sitting, palpable tenderness, and pain with passive hip flexin and AROM or RROM of hip extension.

S&S of hip syndrome

patient complains of snapping sensation with hip flexion/extension, may or may not create pain, may be able to feel snapping on palpation

S&S Legg-Calve Perthes Disease

pn. in hip or groin that may radiate to the knee. Limping, decreased ROM , and hip flexor tightness. Often results in early onset of hip arthritis, permanent loss of abduction and rotation

S&S of femoral fracture

pn. over site, inability or unwillingness to move involved site; swelling; possible crepititus.

SI joint sprain S&S

pn., swelling, point tenderness over the joint and it's ligaments Unilateral or bilateral hip flexion and unilateral leg stance increases pain. Pn. With FABER test May note up slip of pelvis on affected side.

S&S of Pelvic Stress Fracture

radiating pain with aching in the thigh; not able to weight bear on one leg Initially pain increases with activity and decreases with rest; if stress continues, pain becomes more constant

Ischial Bursitis MOI

repetitive hip flexion and extension with pressure. Such as cycling.

MOI of Pelvic Stress Fracture

repetitive pounding force, usually from the ground; again most common in long distance runners; common site is the pubic ramus.

TX of Avulsion Fx. / Apophysitis

rest, treat symptoms, immobilization if avulsion fx is stationary

MOI of Avulsion Fx. / Apophysitis

sports that have sudden acceleration/deceleration causing a sudden and forceful muscle contraction.

TX of Piriformis syndrome

stretching, ice, possible steroid or anti-inflammatory injection

S&S of Avulsion Fx. / Apophysitis

sudden localized pn. that increases with muscle movement; swelling and point tenderness; may hear a snap or pop. Abnormal gait pattern

MOI for Athletic Pubalgia

tensile force caused by pull of adductor and lower abdominal muscles, from twisting, cutting, running and kicking

TX of hip syndrome

treat based on location and cause

Up slip occurs

when both the ASIS and PSIS sit higher on the involved side as compared to the uninvolved side.

Sacroiliac Rotation occurs

when the ilium rotates on the sacrum unilaterally.

TX of Slipped Capital Femoral Epiphysis (SCFE)

with sx or hip spica cast