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MSK Practical Exam > Hip Pathologies > Flashcards

Hip Pathologies Flashcards

1
Q

What is the acetabulum and what bones form it?

A

Hip joint socket

Ilium, ischium and pubis

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2
Q

What structures cover the acetabulum and what are their functions?

A

Acetabulum labrum and transverse ligament

Deepen the socket to increase stability

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3
Q

Name the bony landmarks of the hip

A

Anterior superior iliac spine (ASIS)

Anterior inferior iliac spine (PSIS)

Ischial tuberosity

Posterior superior iliac spine (PSIS)

Iliac crest

Greater trochanter

Lesser trochanter

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4
Q

Explain the anatomy of the femur

A

Long bone

Femoral and obturator artery

Femoral head and neck

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5
Q

Name the important ligaments of the hip

A

Iliofemoral (Y-shaped) transverse (stops add and ER) and descending (stops IR), strongest ligament - illium to femur

Pubofemoral (stops abd) - Pubis to femur

Ischiofemoral (stops IR) - Ischium to femur, blends in with the posterior capsule

Ligament of head of femur - Head of the femur to the acetabulum, branch of obturator artery

Transverse acetabular ligament - part of the acetabulum

Inguinal ligament - ASIS to pubic tubercle

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6
Q

Name the anterior muscles of the hip

A

Iliopsoas - iliacus (origin iliac crest) and psoas major (origin - transverse processes of the Lx), both insert into the lesser trochanter - Hip flexion, Lx flexion and side flexion

Rectus femoris - Origin AIIS, Insertion quadricep tendon - Hip flexion and knee extension

Sartorius - Origin ASIS, Insertion pes anserinus - Hip flexion and ER, knee flexion and IR

Adductors
3 ducks, pecking grass
Adductor Magnus - Origin ischial tubersosity, adducotr tubercle - most posterior also helps with hip extension
Adductor Longus - Origin pubis, Insertion femur
Adductor Brevis - Origin pubis, insertion femur
Pectineus - Origin pubis, insertion femur, also hip flexor and IR
Gracilis - Origin pubis, insertion pes anserinus, also knee flexion and IR

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7
Q

Name the lateral and posterior muscles of the hip

A

Glute max - Origin sacrum and ilium, Insertion gluteal tuberosity and ITB - Hip ext, upper fibres abd and ER lower fibres add and IR

Glute Med - Origin ilium, insertion greater troachanter - Abd and IR

Glute min - Origin ilium, insertion greater troachanter - Abd and IR

Tensor fascia latae (TFL) - origin ASIS, inseriton ITB - Hip

Deep Muscles
Piriformis
Obturator internus and externus
Gemelli superior and inferior
Quadratus femoris

Hamstrings
Long head of bicep femoris
Semitendinosis
Semimembranosus

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8
Q

What are the main nerves of the hip?

A

Femoral nerve (anterior)

Obturator nerve (medial)

Sciatic nerve (posterior)

Superior and inferior gluteal nerve (posterior)

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9
Q

What are the anatomical features of the hip joint and its normal movements?

A

Synovial ball and socket joint - deep so difficult to dislocate

Proxmial - acetbaulum, larbum and transverse ligament

Distal - head of the femur

Movements
Flexion - 140
Extension - 10
Abd - 45
Add - 30
IR - 40
ER - 50
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10
Q

What is the function of the glute med during gait?

A

Activates on the ipsilateral side to maintain a level pelvis

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11
Q

When there is contralateral pelvic drop during gait or single leg stance what is this called?

A

Trendeleburg gait

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12
Q

What is the Duchenne sign?

A

Trunk side flexion towards the stance leg to compensate for pelvic drop and weak glute med

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13
Q

What other structures could be contributing to hip pain?

A

Lx

SIJ

Knee and/or ankle

Non MSK

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14
Q

Name some common and less common causes of lateral hip pain

A

Common
Greater trochanteric pain syndrome (GTPS)
Glute med tears and tendinopathy
Trochanteric bursitis

Less Common
Referred pain from Lx

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15
Q

What lateral hip pain pathologies are not to be missed?

A

Fracture of neck of femur

Nerve root compression

Tumour

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16
Q

Name some common and less common causes of anterior hip pain

A 
Common
Synovitis
Labral tear
Chondropathy - early onset hip OA
OA
Femoroacetabular impingement (FAI)
Less Common
Calcification of acetabular rim
Ligament of head of the femur tear
Stress fracture
Hip joint instability
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17
Q

What anterior hip pain pathologies are not to be missed?

A

Synovial chondromatosis - non-cancerous tumour in the joint

Avascular necrosis of head of femur

Malignancy

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18
Q

What is the clinical presentation for Avascular necrosis of the head of the femur?

A

Lamb et al. 2019

Pain >6 weeks

X-ray -ve

Need MRI

Usually Males 22-55 years and older in females

Family Hx of avascular necrosis of femoral head

Heavy smoking, alcohol abuse

Overweight

Circulatory problems

HIV

Steroid abuse

Recent pregnancy

Chemotherapy

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19
Q

What are the possible causes of groin pain?

A

Doha agreeement

Adductor-related groin pain
Iliopsoas-related groin pain
Inguinal-related groin pain
Pubic-related groin pain
Hip-related groin pain

Hernia
Obturator Nerve entrapment
Referred pain from SIJ or Lx
Avulsion fracture ASIS, AIIS, Pubic bone

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20
Q

What groin pain pathologies are not to be missed?

A

Stress fracture of neck of femur, pubic ramus or acetabulum

Avascular necrosis

Intra-abdominal abnormalities e.g. UTI, kidney stones

Ankylosing spondylitis

Tumours

Reactive or infection arthritis

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21
Q

Name some common and less common causes of buttock pain

A 
Common
Referred pain from Lx or SIJ
Hamstring origin tendinopathy
Ischiogluteal bursitis
Myofascial pain
Less Common
Quadratis femoris injury
Piriformis conditions (muscle strain/impingement)
Sciatic nerve injury
Prolapsed intervertebral disc
Stress fracture of sacrum
Proximal hamstring avulsion
Glute med tendinopathy
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22
Q

What buttock pain pathologies are not to be missed?

A

Ankylosing spondylitis

Reiteir’s syndome (reactive artritis)

Psoriatic arthritis

Arthritis associtaed with bowel disease

Malignancy

Bone and joint infection

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23
Q

What or the most relevant examples of hip pathologies?

A

OA of Hip

Femoroacetabular impingement (FAI)

Greater trochanteric pain syndrome (GTPS)

Groin pain

Hamstring injuries

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24
Q

What is the clinical presentation of hip OA?

A

Most common hip pain pathology >38 years

Capsular pattern
Flex more restricted than ext
IR more restricted than ER
Abd more restricted than Add

Loss of muscle strength (Abd, hip flex and ext)

Unclear pain distribution (somatic referred pain)

Pain can be linked to central sensitisation, so screen for psych factors (Willet et al., 2020)

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25
Q

What are the risk factors of hip OA and what are the factors that predict progression?

A 
Risk Factors
Age
High BMI
Previous injury
Intense sporting activities
Genetics
Progression
Age
Symptomatic
Female
Intense sport activities
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26
Q

What is the treatment for hip OA

A

NICE Guidelines

Patient education

Strengthening and aerobic exercise

Mobilisation

Pain relief

Gait retraining

Severe OA = Hip replacement

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27
Q

Name the 2 types of femoroacetabular impingement (FAI)

A

Cam - flattening or convexity of the femoral neck

Pincer - Over-coverage of femoral head by the acetabulum

28
Q

Which is the most common type of FAI?

A

Combination of pincer and cam

29
Q

What movement is problematic for FAI?

A

Flexion and IR

30
Q

How can you diagnose a FAI?

A

Warwick Agreement

Diagnosis
Symptoms, clinical signs and imaging all be present

Symptoms
Position/motion related hip or groin pain which also may be felt in the back, buttock or thigh
Clicking, catching, locking, stiffness, restricted ROM or giving way

Clinical Signs
Hip impingement tests reproduce pain
Limited hip flex and IR

Imaging
X-ray - 1st
MRI or CT

31
Q

How can you differeniate between FAI and OA?

A

FAI patients are younger

32
Q

What is the treatment for FAI?

A

Warwick agreement

Conservative Rehab
Education
Lifestyle and activity modification
Improve hip stability, neuromuscular control, strength, ROM and movement patterns

Surgery
Open or arthroscopic

33
Q

What is the prognosis of FAI?

A

Patient frequently improve and return to full activity

May be associated with hip OA

34
Q

What is the clinical presentation of greater trochanter pain syndrome (GTPS)?

A

Grimaldi and Fearon, 2015

Most are likely to be gluteal tendinopathy, bursae less likely

Pain lying on their side at night, standing, walking, climbing up or down stairs, sitting

Psychological factors

35
Q

What causes GTPS (gluteal tendinopathy)?

A

Grimaldi and Fearon, 2015

Overload (change in activity, increased load)

Decreased longitudinal TENSILE load

Excessive COMPRESSION

Psychological factors

36
Q

How can you increase compressive loading of the gluteal tendon during objective testing?

A

Grimaldi and Fearon, 2015

Place hip in adduction

37
Q

How does compressive load of the glute med tendon occur?

A

Tension of the ITB compresses the glute med tendon against the greater trochanter

38
Q

What hip and pelvic positions increase compressive load on the glute med tendon?

A

Lateral pelvis rotation away from the affected side

Increase angle of the femur away from the affected side

39
Q

What is the clinical presentation of adductor-related groin pain?

A

Doha agreement

Adductor tenderness

Pain on resisted adduction

40
Q

What is the clinical presentation of iliopsoas-related groin pain?

A

Doha agreement

Iliopsoas tenderness

Pain on resisted hip flexion and/or stretching of hip flexors

41
Q

What is the clinical presentation of inguinal-related groin pain?

A

Doha agreement

Pain in the inguinal canal region

Tenderness of the inguinal canal

No palpable hernia

Pain increased with resisted abdominals, cough, sneeze

42
Q

What is the clinical presentation of pubic-related groin pain?

A

Doha agreement

Tenderness on palpation of pubic symphysis and adjacent bone

Muscle testing -ve

43
Q

What is the clinical presentation of hip-related groin pain?

A

Hx (onest, nature, location, mechanical symptoms, catching, locking, clicking, giving way)

PROM, FABER, FADIR

(same as FAI clinical presentation)

44
Q

Name the injury classification for hamstring injuries

A

British Athletics Muscle Injury Classification

Grade 0 - Generalised muscle pain following exercise

Grade 1 - Small muscle tear

Grade 2 - Moderate muscle tear

Grade 3 - Extensive muscle tear

Grade 4 - Full-thickness tear of muscle/tendon

45
Q

What are the special questions to ask for hip pathology?

A

Clicking, catching, locking, giving way, putting on shoes, squatting, cerpitus, stiffness

Hx of trauma

46
Q

What is the 24 hour pattern for someone with hip OA?

A

Worse in the morning

Worse when seated for long periods

Eases when they start walking

Worse if they walk for too long

47
Q

During the objective assessment what other joints would you test?

A

Lx and SIJ

48
Q

What are some functional tests for the hip?

A

Single leg squat

Step down test

Squat

Jumping

49
Q

Should you palpate the iliopsoas and piriformis?

A

No, because theres too much structures inbetween so cant be sure if your palpating it or not

50
Q

What muscles attach on the clock when palpating the greater trochanter?

A

12 - Glute med

1:30 - Glute min

3 - Glute max

4:30 - Vastus lateralis

7 - Quadratus femoris

10 - Piriformis

51
Q

What could be restricting PROM hip flex?

A

Iliopsoas tightness on the contralateral side

52
Q

What combined movement can be used for articular testing?

A

Flexion and add - resistance or reproduction of symptoms

Can add compression

53
Q

What are the muscle length tests for the Hip?

A

Obers test - Flexed knee = TFL, Ext knee = ITB (inserts on the tibia)

Modified Thomas test - Iliopsoas and rec fem length

90/90 hamstring test

Remember = Could also stress nerves if these tests are positive. Use neurodynamic testing

54
Q

What position would you muscle test abd?

A

Side-lying

55
Q

What is the special test for a femoral stress fracture?

A

Fulcrum test

Place hand under thigh with patient in sitting, with other hand press down on femur = creates shear force

Positive if patient is apprehensive or reproduces symptoms

high sens and spec

56
Q

What are the special tests for Femoroacetabular Iimpingement (FAI)?

A

FADIR - high sens low spec

Anterior impingement test (AIMT) - same as FADIR but 90 degree flex not full flex - high sens low spec

FABER - high sens low spec

Foot progression angle walking test (FPAW) - moderate sens and spec (IR increases pain, ER reduces pain)

Maximal squat test - high sens low spec

Passive IR ROM - high spec low sens

57
Q

What are the special tests for Greater Trochanter Pain Syndrome (GTPS)?

A

Grimaldi et al 2017 Test Battery

Positive pain on palpation of the greater trochanter, positive FADIR-R and negative single leg stand (30 sec) = POSITIVE GTPS

Positive pain on palpation of the greater trochanter, positive ADD-R, negative FADER-R and negative single leg stand (30 sec) = POSITIVE GTPS

Positive pain on palpatino of the greater trochanter but negative ADD-R, FADER-R and single leg stand (30 sec) = NEGATIVE GTPS

Single leg stand - 30 seconds - positive if pain and/or pelvic drop

FADER-R = Resistance into IR - Positive if symptoms are reproduced

ADD-R = Sidelying, let leg drop into add and resist abd - positive if symptoms are reproduced

58
Q

What are the special tests for groin pain?

A

Adductor squeeze test in 45 degrees flex - low sens high spec

Double adductor test, supine extended knees, legs passively lifted - low sens high spec

Groin pain Doha statement - contraction and/or stretch of muscle and palpation

59
Q

How can the objective assessment affect your treatment?

A

Joint above and bellow (Lx, SIJ, Knee)

If it is stiff = mobilise it (arthrogenic/myogenic)

If it is weak = strengthen it (myogenic)

60
Q

What are the 4 key components for hip conservative treatment?

A

UK FASHiON conservative treatment (Wall et al., 2016)

Patient education and advice

Patient assessment

Help with pain relief

Exercise-based hip programme

61
Q

What exercises have the best EMG activation for glute max?

A

Neto et al. 2020

Different varieties of step ups > weighted step up

Deadlift

Hip thrust

Squat

Done in asymptomatic populations

Patients preference

62
Q

What exercises have the best EMG activation for glute med?

A

GTA Index (Selkowitz et al. 2013)

Exercises that have significantly more EMG activation of the glute med compared to the TFL

GTPS = TFL overactive because glute med is weak

Progress with thera band around legs

Clam

Bridge

Sidestep

Quadruped hip ext knee flex or ext

Done in asymptomatic populations

Patients preference

63
Q

How can you make monster walks more glute med focused?

A

Put thera band around toes not knees

64
Q

What is the treatment for GTPS?

A

Education of load management more effective than corticosteroid injection and no treatment (Mellor et al 2018)

Grimaldi and Fearon 2015
Abd strengthening progressing from iso to bilat abd and squatting

Glute strengthening e.g. bridging

Core strength

! Do not increase compressive loads during rehab ! -> Start clam with pillows between legs so patient not in add

65
Q

What is the treatment for adductor-related groin pain?

A

Prevention program

Strengthening of the add, glutes, core and other hip muscles

66
Q

What are some effective passive hip treatment techniques?

A

Flexion/add mobilisation

Mulligan mobilisation lateral glide with belt = decrease pain and increase flex/IR

METs

Traction mobilisation

67
Q

What are the general red flags?

A

Hx of cancer

Constant progressive unremitting night pain

Unexplained weightloss

Chemotherapy / Radiotherapy

IV drug abuse

Long term steroid use

Drug and alcohol abuse

Epilepsy

Asthma

Diabetes

Osteoporosis

Rheumatoid arthritis

5Ds & 3Ns - Diplopia, dysarthria, dysphagia, drop attacks, dizziness, nystagmus, nausea, numbness

Hx of trauma

Pregnancy

Poor general health

Cardiac and circulatory problems

Cauda equina symptoms

Anticoagulants

MSK Practical Exam (11 decks)

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