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MSK 1 > 10/25 - Hip Intra Articular Pathology > Flashcards

10/25 - Hip Intra Articular Pathology Flashcards

1
Q

what are the 3 main intra-articular conditions seen

A

nonarthritic
- femoroacetabular impingement syndrome (FAIS)
- microinstability

osteoarthritis

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2
Q

what are the 3 roles of the labrum

A
  1. ext of acetabulum (enhanced joint stability)
  2. suction seal
  3. shock absorption
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3
Q

what is FAIS

A

misshapen joint leads to breakdown of intra-articular structures

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4
Q

what is a FAI-CAM lesion and what is another word for that

A

nonspherical femoral head (ie change in bone shape) rotating inside acetabulum

aka slipped capital femoral epiphysis

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5
Q

what population is FAI-CAM common in

A

peds

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6
Q

what is a slipped capital femoral epiphysis

A

aka FAI-CAM

extra bone growth at head/neck junction of femur
- can then impinge labrum there and then damage the labrum

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7
Q

what motion causes pain in CAM lesion and why

A

pain w deeper flexion or when leg crosses over body
- that’s when bony pathology engages w labrum

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8
Q

what is the alpha angle for a CAM deformity

A

> 60deg

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9
Q

what is FAI - PINCER

A

prominent anterolateral rim of acetabulum
- overgrowth of ant edge
- retroversion of acetabulum

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10
Q

describe the lateral center edge angle in normal hip vs dysplasia vs FAI Pincer

A

normal: 25-39deg
dysplasia <25deg
- under coverage
FAI pincer >40deg
- over coverage

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11
Q

what does a smaller lateral center edge angle indicate

A

smaller the angle, more shallow the acetabulum and greater risk of sublux/dislocation

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12
Q

what sign occurs when there is retroversion of the acetabulum

A

crossover sign

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13
Q

what is a crossover sign

A

there is extra coverage w ant portion of acetabulum crosses over posterior

normal: ant should be deeper, post have more coverage

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14
Q

what are 3 categories of FAIS pathomechanics which lead to symptomatic bony impingement

A
  1. abnormal bony morphology
    - CAM, Pincer, mixed
  2. susceptible populations and activities
    - prior dysplasia, SCFE, LCP
  3. abnormal hip/pelvic kinematics
    - activity w inc hip flexion (squats, drop jumps)
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15
Q

what is a “C” sign indicative of

A

deep hip pain w intra-articular path

could also be microinstability (extra-articular)

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16
Q

what are 4 characteristics of pain in FAIS

A
  1. nonspecific groin pain can radiate to medial thigh
  2. “C” sign - deep inferior hip pain
  3. pain w twisting, pivoting (aka when hip in loaded position)
  4. pain w end-range flexion
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17
Q

what is a consideration of sx of FAIS

A

cumulative effect of abnormal wear

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18
Q

what are mechanical sx of FAIS

A

intermittent sharp pain
clicking, catching, locking

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19
Q

what is a common exam finding of FAIS

A

limited hip IR
- bilateral morphology
- motion may be symmetrical

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20
Q

if someone has a bony abnormality w FAIS, what will this likely look like upon examination

A

bilateral
- will usually have limitations w ROM (IR and possibly flex)

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21
Q

what ms weakness is common in FAIS

A

glut med and max weakness

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22
Q

what ms length may be limited in FAIS

A

hip flexor length

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23
Q

why would someone w FAIS have sx when hip flex is resisted

A

hip flex close to ant portion of capsule and labrum
- if damage/irritation to that portion of ant hip capsule, will have irritation w resisted hip flex

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24
Q

what are 4 intra-articular tests that are more provocative for FAIS

A

FABER***
Scour
FADIR
log roll

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25
Q

what are 3 intra-articular tests that test more micro-stability for FAIS

A

ABD-hyperext-ER (AB-HEER)
prone instability
HEER

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26
Q

what is the most specific special test for hip injuries? what is its sensitivity?

A

log roll
NOT sensitive

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27
Q

what does a log roll test assess

A

ant laxity of hip by amt of ER

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28
Q

what are 4 other reasons intra-articular tests may be positive other than FAIS

A

arthritis (ie OA)
synovitis
labral path
loose body

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29
Q

what is a good use of FADIR special test in terms of FAIS

A

screening tool
- sensitive but not specific

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30
Q

what are 3 possible locations of pain from a FABER test and what are their MOIs

A
  1. groin pain
    - ms strain vs intra-articular (no sensitive to what intra path)
  2. SIJ (PSIS region) pain
    - sacroiliac disorder
  3. post hip pain
    - post hip impingement
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31
Q

what are 4 things that could cause the reproduced clicking in a scour test

A

psoas
labrum
arthritis
loose body

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32
Q

what does a resisted SLR test help differentiate between

A

hip flexor strength discomfort
vs
pain inside the joint (intra-articular)

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33
Q

why is the FADIR an appropriate test to use in FAIS

A

symptomatic position

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34
Q

why are intra-articular injections used

A

common dx use (intra vs extra)
- does it make sx better?

if helps - inflammation was in intra-articular joint, help to tolerate ADLs and PT

if does nothing - think extra-articular path

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35
Q

what are the 3 components of non-operative treatment of FAIS

A
  1. modify irritating positions and activity
  2. maximize mobility of joint
  3. hip/core/lumbopelvic strength
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36
Q

what are irritating positions/activities to modify in FAIS

A

limit ant pelvic tilt
- if tight hip flex and/or weak gluts

adjust seat hight to avoid inc hip flex
- deeper flex = more engagement

limit squat depth

limit incline or stair running
- inc hip flex

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37
Q

what directions should joint mobility be maximized in FAIS

A

into capsular restrictions post and inf

(if post capsular restriction, femur will shift away to ant)

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38
Q

how can PT prognosis change depending on how they present with FAIS

A

good PT prognosis:
- more capsular restriction, weakness, hip joint mobility limitations + bony abnormality
- modifiable factors w PT

poor PT prognosis:
- good strength, mobility + bony abnormality
- more likely to need surgery

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39
Q

what are 3 examples of interventions targetting hip / core / lumbopelvic strength in FAIS

A

hip ABD & rotator ms
plank variations
paloff press

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40
Q

hypermobility vs instability

A

hypermobility - greater than normal physiologic motion

instability - sx such as pain and/or apprehension are present

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41
Q

what is microinstability

A

capsuloligamentous laxity & clinical sx such as pain with/without apprehension

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42
Q

why is microinstability under-diagnosed

A

subtle
not as obvious as hip dysplasia or sublux

sx for microinstability are similar to hypomobility

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43
Q

what is location of most microinstability in the hip and why

A

usually anterior
- post portion of acetabulum has more bony congruence -> more susceptible ant dislocations

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44
Q

where and with what are hip microinstability sx present

A

sx w WBing ER and/or forceful ext

groin or deep joint pain “C-sign”

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45
Q

what are strength deficits seen in microinstability in hip and is this relevant

A

ABD and rotators

pretty much weak in everyone, isn’t helpful

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46
Q

what does ROM and ms lengths look like in hip microinstability

A

inc ER ROM

dec length of iliopsoas complex
- guarding to stabilize ant capsuloligamentous complex

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47
Q

what are 5 (+) special tests w hip microinstability

A
  1. log roll
  2. FABER
  3. AB-HEER
  4. prone instability
  5. HEER
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48
Q

if sx w hip flexion, what is it likely d/t and what is it likely not ? why?

A

hip flexors can be used to create dynamic stability
- likely d/t instability/microinstability

usually not d/t tendinitis

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49
Q

describe the use of AB-HEER in testing hip microinstability and why

A

provocative test
- basically putting head of femur as ant as possible to see if get sx

50
Q

what are provocative tests looking to recreate sx of hip microinstability

A

AB-HEER
prone instability
HEER

51
Q

describe hip microinstability cluster

A

95% chance of microinstability if 3 (+) tests:
- AB-HEER
- prone instability
- HEER

52
Q

what are 4 interventions of microinstability in the hip

A
  1. education/activity modification
  2. exercises w mid-range initially
  3. exercise progressions
  4. caution w hip flexor stretching
53
Q

what are activity modifications that should be made in microinstability

A

avoid end range ext & ER
avoid pivoting movements
modify running stride to dec ext

54
Q

what are 2 interventions of initial exercises in mid-range for microinstability

A

prone manual resist IR/ER
- alternating isometrics
quadruped external perturbation

55
Q

what is the goal of initial exercises in mid-range for microinstability

A

to create dynamic stability

56
Q

how should mid-range exercises be progressed in microinstability

A

hip ABD and rotators
lumbopelvic stabilizers

57
Q

why should there be caution w hip flexor stretching

A

spasm d/t overuse
avoid tension on ant capsuloligamentous structures

58
Q

what may be a more preferred way to dec hip flexor irritation in microinstability other than stretching

A

create better strength w other ms

59
Q

what is OA

A

disorder of synovial joint
- deterioration of articular cartilage & new bone formation

60
Q

what are radiograph findings of OA

A

joint space narrowing
osteophyte formation

61
Q

what are sx of hip OA

A

stiffness
pain

62
Q

where will the pain be and what will cause the pain d/t hip OA

A

groin, ant, lat hip
inc w amb, stairs, squatting

63
Q

is primary or secondary hip OA more common

A

secondary (80%)

64
Q

primary vs secondary hip OA

A

primary
- no predisposing mechanical factor

secondary
- end result of dz process

65
Q

what are 6 examples of secondary OA causes

A

osteonecrosis
legg-calve-perthes dz
dysplasia
slipped capital femoral epiphysis
congenital coxa vara / valga
hip fx

66
Q

what is the general takehome for OA diagnostic cluster

A

stiffness in morning
stiffness gets better w movement
the more WB activity, sx get worse
capsular pattern of pain

67
Q

what are the 2 main clinical presentations of hip OA

A

gluteal weakness
balance deficits

68
Q

what are 2 functional tests for hip OA

A

6MWT
TUG

69
Q

what are two components that interventions for hip OA are working to maximize and why

A

strength
- offload joint
- stabilizing structures can absorb force

mobility
- larger SA distribution

70
Q

what are 6 interventions in management of hip OA

A

pt education
manual therapy
strengthening
flexibility
balance
aerobic exercise

71
Q

what is included in the pt education for hip OA

A

avoid end-range positions, sitting cross-legged

72
Q

what are 2 indications for manual therapy

A

low grade pain
high grade mobility restriction

73
Q

what ms should be targeted for strengthening in hip OA and how

A

glut med
single leg tasks
- be cautious early on w WBing

74
Q

what should be considered of aerobic exercises in hip OA

A

consider impact of forces & irritability
- dec pain

depending on severity of sx, think ab amt of WBing you want them to do (running vs biking)

75
Q

what are balance progressions

A

DL -> SL
EO -> EC
static -> dynamic

76
Q

what are 4 goals of PT management of hip OA

A
  1. maintain function
  2. relieve sx
  3. prevent deformity
  4. education (ie hip joint protection)
77
Q

what are 6 treatment principles of hip OA

A
  1. inflammation (responsible for pain)
  2. joint alignment
  3. ROM
  4. ms length
  5. ms strength
  6. joint protection
78
Q

what are 3 techniques to protect the hip joint from OA

A
  1. body wt reduction
  2. load carry modification
  3. AD use
79
Q

what is an ideal way to modify the load carry in hip OA

A

posterior (backpack) better than a shoulder bag
- also balance sides out

80
Q

THA cemented vs cementless

A

cemented - tolerate load right away
- potential for loosening d/t cement

cementless - WB restriction early on while bone heals

81
Q

what is a precaution of trochanteric osteotomy if done during THA

A

no activve/resisted ABD

82
Q

what are the 3 types of surgical approach to THA

A

ant
post
direct lateral

83
Q

how are precautions related to the surgical approach of THA

A

avoiding motion that will load the area of the capsule that was cut

84
Q

what are precautions of a post THA and why

A

avoid flex, ADD, IR

-> ERs divided

85
Q

what is a complication from during a THA

A

femoral stem fx

86
Q

what is the composition of a hybrid THA

A

acetabular component - cementless
femoral - cement

87
Q

outcomes in cemented vs uncemented

A

no significant difference

88
Q

what are precautions w an ant surgical approach and why

A

ext, ER
- minimal incision

89
Q

what precautions are associated w a direct lateral surgical approach

A

none
low dislocation rate
ABD mechanism impacted

90
Q

what are 3 early complications of THA

A

thromboembolic event (ie DVT)
infection
dislocation

91
Q

what THA surgical approach is dislocation the most common in? when does this inc risk decline?

A

inc risk w post approach

pseudocapsule formed at 6mo

92
Q

what is a late complication of THA

A

implant loosening
- or if person falls and damages the construct

93
Q

what is involved in joint resurfacing and how is this different from THA

A

acetabular component replaced
cap over fem head

fem neck/shaft spared

94
Q

when is joint resurfacing indicated over THA

A

joint resurfacing if arthritis only on one surface

replacing both if arthritis on both surfaces

94
Q

when is joint resurfacing indicated over THA

A

joint resurfacing if arthritis only on one surface

replacing both if arthritis on both surfaces

95
Q

what are determining factors of whether hip fx will be treated as ORIFs or closed

A
  • location
  • displacement

inc displacement -> inc likelihood to have ORIF

96
Q

why is there an inc mortality risk with hip fx

A

d/t sequelae of care afterwards
- pressure sores
- wounds
- infections
- poor mobility post

97
Q

what surgery is indicated fro a displaced femoral neck fx

A

hemiarthroplasty

98
Q

what are 5 things examined in an acute care setting s/p hip fx

A
  1. DVT risk
  2. bed mobility
  3. WB status **
  4. transfer ability
  5. gait safety
99
Q

what are 4 acute care interventions s/p hip fx

A
  1. ankle pumps, quad and glut sets
  2. plan room for transfers and gait
  3. appropriate assistance w gait
  4. AD choice
100
Q

what makes basic LE isometrics important as an acute care intervention s/p hip fx

A

prevent DVTs

101
Q

goals in acute care (3) vs sub acute (5) vs chronic (4) s/p hip fx

A

ACUTE
1. OOB
2. safe gait
3. d/c planning

SUB ACUTE
1. gait
2. transfer ability
3. endurance
4. ADL adaptations
5. plan to return home (if possible)

CHRONIC
1. strength
2. gait
3. balance
4. ADL issue

102
Q

why is hip ABD strengthening a post-acute phase goal in s/p hip fx repair

A

depending on what was cut w surgery

103
Q

what are 2 ms groups targeted w strength interventions s/p hip fx

A

knee ext
hip ABD (post-acute phase)

104
Q

what is a test used to monitor fall risk in s/p hip fx

A

TUG

105
Q

what are 3 physical performance tests used in s/p hip fx

A
  1. gait speed
  2. 30’’ STS test (post-acute)
  3. 6MWT (post-acute)
106
Q

what are 2 factors that inc mortality and poorer outcomes w hip fx

A

inc age (>75yo)
co-morbidities (DM, chronic illness)

107
Q

what does inc age (>75yo) inc the risk of s/p hip fx (3)

A

inc mortality & poorer outcome
inc time to dc
inc risk of subsequent fall

108
Q

what is legg-calve-perthes disease

A

blood supply to head of femur disrupted
- subsequent fx w poor healing

109
Q

what population is LCPD most common in

A

4-10yo boys (not exclusively)

110
Q

what is the cause of LCPD

A

unknown

111
Q

what does recovery look like in LCPD

A

recovery may take 2 yrs
- bone remodeling

112
Q

how does LCPD present (2)

A

gradual onset of pain
short leg

113
Q

why is it important to get imaging if suspicious of either LCPD or SCFE

A

sequelae of either of these are bad
- catching it is the biggest piece
- kids will heal easily and well

114
Q

what is the population that slipped capital femoral epiphysis (SCFE) is most common in

A

adolescent males (8-15yo)

115
Q

what inc the risk of SCFE

A

obesity

116
Q

how does SCFE present (3)

A

knee or groin pain
short limb
may be bilateral

117
Q

what is the main thing to look at to determine how likely hip dysplasia is

A

how shallow the depth of the acetabulum is

118
Q

what are 3 factors that have an inc likelihood of developmental hip dysplasia

A

female > male
(+) family history
womb position (breech = inc risk)

119
Q

what is the cause of developmental hip dysplasia

A

unknown

120
Q

what is the typical age of dx for developmental hip dysplasia

A

variable age of dx

MSK 1 (31 decks)

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