MSK 1: Week 5
Strains - Occur VIA indirect trauma Contusions occur as a result of a direct blow
How can you differentiate between a strain and a contusion?
aching groin or medial thigh pain relate to a specfic incident tenderness to palpation adductor weakness
How do Adductor strains present?
MRI with gadolinium
How do you diagnoses an adductor strain?
- Relative rest - anti-inflammatory medicine - physical therapy for 6-8 weeks - Cortisone injections - Surgery has up to 80% success in chronic cases
How do you properly manage someone with osteitis pubis?
Disabling lower ab and inguinal pain, pain with sit=ups, hip adduction or valsalva aggrvated by ballistic movements
How does someone present with an athletic pubalgia?
MCID
Smallest noted clinically significant change Smallest significant change that relates to the patient noticing a difference
international knee documentation committee knee evaluation form
Studied in pts W/ ACL tear, meniscal injury, OA Design - 18 questions Function, sports, symptoms Scoring total score expressed as a % MCID - 20.5%
preoperative traction
Systematic review: no statistical benefit with pain control or surgery
Gilmore's groin
Tears in the external oblique aponeurosis and conjoint tendon
Pain with FADIR test Leg pain in sciatic nerve dist. Numbness or weakness is rare, SLR sometimes negative Sitting makes it worse Walking relieves pain Tensile stress on the piriformis will often produce pain
What are examination findings of someone with piriformis syndrome?
Limited or asymmtrical hip abduction Asymmetric thigh folds Positive Galeazzi sign Positive ortolani sign
What are clinical features of DDH?
• DVT (longer on bed rest = increase chance) • Prophylactic anticoagulants • Device failure • Leg length discrepancy • Component malalignment • Infection • Improper implant fixation to surrounding bone • Nerve palsy • Prosthetic hip dislocation
What are complications of THA?
- Infection - Injured or non-functional hip muscles - Neuromuscular disease, skeletally immature - Poor quality bone - Poor skin coverage around the hip joint
What are contraindications of someone getting a THA?
normal bone abnormal stress abnormal bone and normal stress
What are fatigue fractures and insufficiency fractures?
OA RA hip fracture AVN dysplasia SCFE
What are indications of someone needing a THA?
- Dull/ sharp groin pain, worse with activity, walking, and sitting - 50% report painful clicking - Trendelenburg gait or limp - + FADIR test
What are presentations seen in a labral tear examination?
DVT - Routine use of antithrombic agents after surgery
What are pts with hip fractures at high risk for, what can you do to lower this?
• Sports requiring repetitive twisting and turning of the thigh and trunk (hockey, soccer, skiing, rugby, and tennis) • Muscle imbalance between strong thigh muscles and weaker abdominal muscles
What are risk factors to someone with athletic pubalgia?
- Physically active - under 60 yrs of age - Hip OA, dysplasia, or AVN - Bone quality strong enough to support the implant
What are some indications for Birmingham hip resurfacing/double shell arthroplasts?
PROM - circumduction Knee to chest stretch for hip flexors Prone laying Aquatic program
What are some mobility exercises you can do with a pt after a hip impairment?
degenerative vs. traumatic
What are the 2 types of labral tears?
Maximum protection Controlled stability Strengthening Return to sport
What are the 4 phases of rehab post surgery of a labral tear?
Phase I - Reeducation/ rehab exercises 0-3 weeks Phase II- Rehab exercises slight functional standing exercises 0-4 weeks Phase III Rehab exercise - More individualized exercises (6-12 wees)
What are the Phases of THA rehab?
- made along the femur and to the glut max Return to normal abductor strength and ambulation is faster Higher rates of dislocation
What are the benefits/costs between posterolateral approach?
Initially - irritable infant Hip held in open packed position Fever, sweating, chills tachycardia, loss of appetite
What are the clinical features of septic arthritis?
iliopsoas tendon snapping iliofemoral ligament snapping hamstring syndrome iliopsoas bursal/capsular thickening
What is internal extra-articular coxa saltans?
labral or ligament tears loose bodies synovial chondromatosis displaced fractures capsular instability
What is intra-articular coxa saltans?
Control pain and swelling Normalize gait Gentle AROM Neurodynamic exercise Isometrics---> PRE's---> eccentrics ---> ballistic movements
What is rehabilation progression of someone with a hamstring strain?
Suspected anterior tear - Full FABER , moved to extension adduction and internal rotation Suspected posterior tear - Full EABER, moved to FLEX/ADD/IR
What is the Fitzgerald test?
Trunk extension and thigh abduction injury to insertion of abdominal onto the pubic bone
What is the MOI for someone with athletic Pubalgia?
Single-leg stance when performing a pain provacation tests
What is the best sensitive and specific test for Glut med and minimus?
secondary outcome
are used to evaluate additional effects of the intervention
Legg-Calve-Perthes Disease
avascular necrosis of the femoral head in a growing child
reliability
consistency overtime with the same measure
GROC score
essentially asks the patient based on your presentation now compared to when you first came into the clinic how has your pain changed? Important to ask - Is the change important to them? small - 1-3 score change 4-5 moderate 5-7 large
greater trochanteric pain syndrome
has been shown to have the pain coming from the glut med/min muscles rather than bursa
osteitis pubis
inflammation around the pubic symphysis, common among athletes and pregnant women - MOI: overuse injury secondary to repetitive shear and the pubic symphysis
piriformis syndrome
irritation of the sciatic nerve as it passes the piriformis muscle located deep in the buttock - Sciatic 12% runs through priformis
1-MITHA
modification of old approach; may be less cutting of muscles/tendons Problems: - increased risk of wound complication - acetabular component malposition - poor fit/fill of femoral components
2-MITHA
new approach; use intermuscular planes to access joint
slipped capital femoral epiphysis (SCFE)
post and inferior displacement of the femoral head relative to the neck
cam type FAI
young males, femoral abnormality, loss of normal concavity - Growth abrnomality of the capital femoral epiphysis - Femoral head jams into acetabulum, shear force on labrum and diffuse articular damage
myositis ossificans
- Iregular bone gorwn - in 9-20% of quad contusions
Femoracetabular Impingement (FAI)
- young pts with Hip pain and reduced ROM in flex/IR - Caused by repetitive microtrauma, increased inc. of early OA Etiology - Abnormal acetabulum, abnormal femur, increase stress Two types - Pincer (acetabuluar) girl, Cam (femoral) male
knee outcome survey
18-72 Y/o W/ various knee disorders Ligamentous, Osteoarthritis , meniscus, PFPS Design 7 items - symptoms 10 items - functions Low score = Greater disability MDC = 8.87
septic arthritis
An acute, rapidly progressive infection of the hip Occurs < 2 years old
MDC
Change is beyond statistical error in measurement
preoperative antibiotics
Cochrane review: significant decrease in deep tissue infections and UTI
Now- admitted morning of surgery rather than 1-2 days before Mobilize day of surgery rather than being bedrested for 2-3 days Usually WBAT instead of partial weaight bearing LOS < 5 days rather than 17
Describe the difference of THA now and in the 1970s
developmental dysplasia
Hip dislocation due to poor development of the hip A result of lax musculature and from excessive uterine packing in a flexed and adducted position (Breech presentation), excessively stretching the posterior hip capsule - happens age 0-2
0-2 Congenital dislocations; septic arthritis 4-8 LCPD (Perthes Disease) 9-15 SCFE; Apophysitis 14-25 Osteochondritis Dissecans, Overuse Injuries, Strains, Osteitis Pubis 30-50 Rheumatoid Arthritis; AVN 55+ DJD and Hip Fractures
Describe the hip diagnosis based on the following ages: 0-2 4-8 9-15 14-25 30-50 55+
LEFS tests
Developed to cover broad range of LE conditions Design 20 items Scoring Each item - 0-4 points Max score of 80 pts (full function) MCID - 9 points
Active pathology --- Impairments --- Functional limitations ---- Disability Active pathology - can be shown in laboratory and imaging studies, surgical findings Impairments are found in the clinical examination Functional limitations and disability - Often observed in our evaluation or patient self reported
Explain Nagi's disablement model
15-40 years old, women slightly more than men have it - Most common cause of groin pain in runners - Anterior groin pain W/ Resisted Hip flexion Snapping while extending the hip US may show tendinopathy, bursitis
Explain clinical presentations of coxa saltans and iliopsoas tendinopathy
83% 86% 60-95% 20-60% 67% 90%
FAI - ____% return to play Microfracture - ____% good to excellent Labrectomy - _____% good to excellent OA - ______% good to excellent • 88% eventually have THA Dysplasia - failure rate high as the labral loading is not alleviated Debridement -____% good to excellent Labral repair - ______% good to excellent
hip outcome score test
For younger pts, and pts with acetabulum labral tears ADL subscale: 17 items Sports subscale : 9 items For more active folks who have hip pain higher score= higher function MCID= ADL subscale = 9% Sport subscale = 6%
More common in woman analogous to rotator cuff/ shoulder
Glut medius and minimus conditions are more common in who? What are they analogous to?
Diagnosis often determined by history and Physical examination Tenderness pubic symphysis - Pain with resisted adductor testing Radiographs - Widening of symphysis, sclerosis, cyst formation, and bone scans may have "Hot spots"
How does the examination of someone with osteitis pubis present? What does imaging show?
2 years • 47% hip abductor weakness • 28% muscle contracture • 13% limb length difference • 12% malalignment
How long are ongoing impairments and functional deficits seen post THA? What are these impairments seen as?
67% surgeons said wait 1-3 months 30% would allow within first 4 weeks 5 safe positions for men and 3 for women were approved by 90% surgeons
How long should pts wait for sexual relations?
no time lost 5-12 days 3-12 weeks
How much time would it take to recover from the following sprain: Grade I? Grade II? Grade III?
Surgical IT band release or debridement results in a good outcome
If someone had symptoms of trochanteric bursitis > 6 months, what could happen and what is the outcome?
- There were no added benefits from using both therapies - Either care was highly cost effective relative to usual care
In a MOA RCT trail which used MT, exercise, a control, or both treatment which treatment helps benefit people who had hip and knee OA which one helped more?
Exercise program emphasizing weight bearing/ postural stability improved muscle strength, postural stability and self-perceived function
In a study that looked at patients who had a THA who either received control care or strength and postural stability exercises what were the outcomes?
All patients improved pain, function, and strength - Patients can benefit from nonsurgical intervention who have labral tears
In the case study that took 4 pts with labral tears and used conservative care, what was the outcome?
Group that received manual therapy had higher scores Odds ratio : MT - 81% Exercise - 50% improved
In the study that compared manual therapy to exercise treatment, on patient swith hip OA, who recieved more benefits? What was the odds ratio?
validity
Means that it measures what we intend to measure
Pincer Type FAI
Middle aged woman/ Ballet dancers - Occurs with acetabuluar abnormality / overcoverage
true
True/False: Based on a case study, 3/4 of pts had excellent/good results 1 year post op
true
True/False: Cemented and cementless techniques both show over a greater 90% surviroship Post 10 and 25 years of the implant
True it was seen that some people's level of functioning increased to a point where they were no longer in the category of having OA
True/False: MT and exercise is a disease modifying treatment when talking about hip OA
true
True/False: No test has sufficient specificity to rule in a labral tear
true
True/False: THA was showed to improve walking speed, WOMAX-PF, and and functioning 12 months post surgery
True but exercise decreases fall risks, increases bone density and thus prosthesis fixation
True/False: There is evidence that inactive people will have less wear than that in an active person
true
True/False: Treadmill training was shown to improve pts gait following a hip replacement post surgery, even if it was slower than normal walking speed
false will be less likely of returning
True/False: Waiting a year before surgically removing the MO will increase the likelihood of an MO returning
true
True/False: With a myositis ossificans, you should Brace the first 24 hours and then slowly start to increase ROM
Harris hip score
Use with pts who have Hip OA - 10 items: pain, walk, ADL, and ROM - Pt and provider score 0- high disability 100 - no disability MCID Pts W/ hip OA >8% Pts 3 month post-op= 13%
32%
What % of the dislocated hips dislocated 5 or more years after THA?
• Recommended/allowed - e.g., swimming, walking • Allowed with experience - e.g., canoeing, hiking, XC skiing • Not recommended - e.g., high impact aerobics, jogging • No conclusion - e.g., speed walking, downhill skiing,
What activity is recommended? Allowed with experience? Not recommended? What activities have no conclusion for patient who had THA surgery?
Don't cross legs/ ankles Don't raise knee above hip Don't bend at the waise >90* Don't sleep on side without pillows btw knees NO ER if anterior approach NO IR in posteiror approach
What are THA precautions? What's specific to anterior and posterior approach?
Clinical: - Hip pain - limp - referred pain to the superior knee - decreased abduction, rotation and flexion contracture common Radiologic: - early - capsular swelling - Mid - ossific nucleus Management: - bracing - casting - surgery - PT ---> ROM , gait training, education
What are the clinical features, radiologic features, and management for Legg-Calve-Perthes Disease?
Clinical: - gradually increasing hip pain & limp - decreased ROM for IR in extension and abduction - Passive flexion presents with abduction & ER - Chronic slip can be present for 3-12 months or longer Radiologic: - imaging = gold standard - AP view - 3 grades: 1. < 33% slippage; 2. 33--50% slippage; 3. > 50% slippage Management: - reduce acute slip by traction or gentle manipulation (for Grade 1) - subacute slip treat with traction in extension and IR - ORIF - severe slips treated with proximal osteotomy
What are the clinical features, radiologic features, and management for SCFE?
Clinical: - hip pain - walks with limp - won't walk - decreased Hip ROM (especially IR) - fever possible Radiologic: - Bone scan may be positive Management: - bed rest - partial WB with crutches - F/U radiographs
What are the clinical features, radiologic features, and management for acute transient synovitis?
extra-articular: external and internal intra-articular (external most common)
What are the different types of snapping hip syndrome/Coxa Saltans?
Aspiration, surgical drainage, and intravenous antibiotics Skin traction or spica cast immobilization
What are the interventions for septic arthritis?
Dull lateral hip pain, focal tenderness at gluteal insertion, weak hip abduction, and provacative tests
What are the presentations in an examination of Glut medius and minimus conditions?
less risk of dislocation Allows immediate normal ROM Higher revision rates Higher risk complications
What are the pros/cons between anterolateral approach?
Higher rates of post op limp due to gluteal nerve injury or avulsion
What are the pros/cons between lateral & transtrochanteric approaches?
Ischial - direct trauma or movement in sitting position Iliopectinal - anterior Hip pain, difficult to Dx from hip flexor Strain Trochanteric - 2/3 have OA or LBP, usually woman > men
What are the three types of hip bursitis you can have?
NSAIDSs Physical therapy - address muscle imbalances/ MT US-guided injection with lidocane and corticosteroid
What are treatments for internal coxa saltans?
Muscle relaxants PT addressing muscle imbalances Guided local injections
What are treatments for someone with Piriformis syndrome?
birth to 9 months - abduction diapers/ Pavlik harness 9 Months + - abduction orthosis/ surgical treatment
What are ways to treat DDH?
Labral tears Loose bodies Femoraoacetabular impingiment Capsular laxity ligamentum teres rupture Articular cartilage Fractures
What can cause pain around the hip intra-articularly?
Iliopsoas tendonitis Iliotibial band Glute medius/ minimus Greater trochanteric bursitis Stress fracture Adductor strain Piriformis sundrome Greater trochanteric pain syndrome
What can cause pain outside the hip?
Compartment syndrome or myositis ossificans
What can contusions lead to?
Piriformis hypertrophy spasms or muscular fibrosis prolonged compression
What causes piriformis syndrome?
1.5 points
What change is considered small but meaningful for the Numeric pain relating scale?
Challenging to treat and overcome Higher incidence in: adductor weakness, abductor-adductor imbalance or decreased preseason hip ROM - Significant cause of groin pain in athletes Most at risk is the adductor longus
What do adductor strains cause? Which muscle is the most at risk?
Involved musculotendinous region/Swelling and bruising
What do hamstring strains typically cause?
Provacate pain with exercise, Hop test + in 70% Risk factors: - Female - low aerobic fitness - overuse - smoking - steroid use Imaging: - MRI - bone scan sensitive Treatment: - Compression 6-8 wks of limited WB
What do you look for in a stress fracture exam? What are the risk factors? What is the imaging we use and the treatment?
Disruption of blood supply to the femoral head, high incidence of healing complications
What happens if you have a femoral neck intracapsular fracture?
MRI - Most specific US - Most sensitive
What imaging is most sensitive and specfic for Glute medius and minimus conditions?
advanced age general anesthesia delayed surgery
What increases chance of getting DVT?
Hip fracture 30% 20%
What is 2nd leading cause hospitalization in older pts? What % of Hip fractures are D/C to SNIF? People over 50 have what % mortality after the first year of hip fracture?
Compression trauma - direct lateral impact of hip Femoral neck - 45% Intertrochanteric - 45% Subtrochanteric - 10%
What is MOI of a hip proximal femur fracture? What regions are mostly fractured?
High velocity quick thrust giving movement in the hip
What is a long axis technique used for pts with Hip OA?
• Stretch TFL/Iliopsoas • Strengthen hip abductors / improve lumbopelvic motor control • Corticosteroid injections • Shockwave therapy - can progress to snapping hip syndrome
What is conservative care for someone with Trochanteric bursitis? What can it progress too?
posterior ITB anterior glut max trochanteric bursitis
What is external extra-articular coxa saltans?
- Sharp groin pain with Flexion IR - Lateral/ post pain with ER - Difficulty squatting , Limited Flexion and IR - groin pain @ 90* of flexion with IR (FADIR) - Pain or asymmetry with FABER
What is the clinical presentation during an examination of someone with an FAI?
Epidemiology: - 3-12 years (4-5 most common) - boys > girls - whites > blacks - bilateral involve = 5% (usually unilateral) Etiology: - self-limiting (unlike acute transient synovitis, intervention is required) - sometimes preceded by transient synovitis - initial stage = avascularity of femoral head
What is the epidemiology and etiology for Legg-Calve-Perthes Disease?
Epidemiology" - 2:1 boys to girls - 10-16 years of age most common - ~ 50% bilateral - Obese - More common in black/polynesian Etiology: - majority idiopathic - endocrine disorders - radiation therapy
What is the epidemiology and etiology for SCFE?
Epidemiology: - 2-10 years of age - usually no other health problems - often preceded by upper respiratory tract infection - later develop AVN or LCP Etiology: - unknown ---> may be related to infection
What is the epidemiology and etiology for acute transient synovitis?
Epidemiology: - Happens 1 in 100 live births (subluxatable) 1 in 1000 dislocations - 6:1 ratio girls to boys - 30:1 ratio whites to blacks - 1.5:1 ratio left to right - When bilateral, left more severe Etiology: - mechanical ---> malposition in womb - physiological ---> in utero-hormones (estrogen and relaxin) - environmental ---> positioning of infants (swaddling)
What is the epidemiology and etiology of developmental dysplasia (DDH)?
Epidemiology: - occurs < 2 year-olds Etiology: - progenitor bacteria
What is the epidemiology and etiology of septic arthritis?
Four fold 1. to reduce hip irritability 2. restore and maintain hip mobility 3. to prevent the ball from extruding or collapsing 4. TO regain a spherical femoral head
What is the goal of treatment for Legg-Calve-Perthes disease?
Location Displacement Reduction Stability Whether it requires fixation
What is the prognosis of a femoral fracture dependent on?
MRI - gadolinium enhanced
What is the reference standard for looking at labral tears?
Sensitivity 100% - 6.7 Specificity - 85% -0.01
What is the sensitivity and specificity for labral tears?
Surgical procedure - Hemiarthroplasts, Dynamic hip screw - WBAT, may depend on the stabilty of surgical fixation
What is the surgical procedure and weight-bearing status of someone who had a femoral neck displaced fracture?
ORIF with a blade plate and Screws - Delayed until fracture demonstrates evidence of healing
What is the surgical procedure and weight-bearing status of someone who had a fracture of the subtrochanteric region?
Surgical - treated operatively with multiple pins or screw and side-plate devices Weight- depends on degree of fracture stabilization
What is the surgical procedure and weight-bearing status of someone who had a intertrochanteric undisplaced, displaced two-part fracture?
- Imaging - MRI - relative rest - PT - surgery - 2-6 months recovery
What is the treatment and gold standard for diagnosing athletic pubalgia?
• Decrease compressive and tensile loads • Therapeutic exercise and motor control training • Corticosteroid injections • Endoscopic debridement or repair
What is treatment for someone with Glut medius and minimus conditions?
- Relative Rest and NSAIDS - PT focus on hip flexibility and motor control - Injection - Surgery - Preseason adductor strengthen & hip ROM
What is treatment for someone with an adductor strain?
hip flexors TFL adductors
What muscle activity should you demote?
Glut medius Glut maximus Hamstrings Quads Transverse abdominus
What muscle recruitment should you promote?
Obturator nerve - medial thigh pain/ adductor wkness Femoral nn- Diff, walking, using stairs, standing from chair Lateral femoral cutaneous nn- thigh burning, tingling - Pain/ Paresthesia/ hyperesthesia/ Weakness
What nerves are most likely to be entrapped near the hip/thigh What are the main symptoms?
48%
What proportion of PT's use standardized outcome measures?
Flexion to 120* ER to 0* Abduction to 45* Extension 0* Foot flat WB to 30% x 3-4 weeks Microfracture = NWB
What should you be cautious with when a patient just had hip surgery?
Groin pain with/without click Clicking hip: +LR of 7 Risk factors: - Perthes 'disease - Previous trauma - Slipped capital femoral epiphysis - Femoroacetabular impingement (FAI) - Repetitive pivoting or hip flexion
What suspects you to believe a pt has a labral tear What are risk factors to a labral tear?
Cementless, especially in younger patients Better for the acetabuluar component
What technique is used more often cemented or cementless and why?
the first year - hip precautions should be adhered for 3 months
When are you at highest risk of Hip dislocation post surgery?
Ip sport test - 20 pts possible, 17/20 passing score - single knee bends x 3 minutes ( 6 pts total) - Lateral agilty W/ 100 seconds (5 pts total) - Diagonal lateral agility W/ 100 seconds (5 pts) - Box lunge X 2 min (4 pts)
When rehabbing someone to return to full activity, what test do you perform?
Femoral neck - Tension side (superior side)- unstable - Compression side (inferior side) : stable - Pubic rami - Acetabulum - Femoral head - Sacrum
Where are common locations for stress fractures?
high compliance HEP
Which group performed best when looking at strength on operated side, walking speed, and functional score on Harris hip score when talking about a low compliance to a high compliance to a HEP?
Sir John Charnley in the 1960s
Who introduced THA and what year was it?
acute transient synovitis
self-limiting condition (meaning it will resolve on its own) in children 2-10 years old - not septic
PSFS?
specifically asked 3 questions on performing three patient-selected activities MCID 2.3 = small change 2.7 = Medium to large change
primary outcome What are seconday outcomes
the outcome of greatest importance
outcome measure
the process of data collection, analysis and interpretation of the effectiveness and efficiency of patient treatment for the purpose of improving the quality of care and lowering health care costs