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COMPS:HIP Flashcards

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1
Q

Pt Reported Outcomes:

Lower Extremity Functional Scale

LEFS

A
  • GENERAL LE measure—–activity based
    • ​**no s/s or impairments
  • scores range 0-80 w/ HIGHER SCORES==BETTER FUNCTION
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2
Q

Pt Reported Outcomes

Western Ontario and MacMaster Universities Osteoarthritis Index

WOMAC

A
  • commonly used in OA outcomes research and care
    • ​HIP and KNEE
  • Subscales
    • Pain 0-20
    • Stiffness 0-8
    • Phys Function 0-68
  • HIGHER scores on WOMAC === WORSE pain, stiff, functional limits
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3
Q

Pt Reported Outcomes

Hip Injury and OA Scale

HOOS

A
  • 5 Subscales:
    • Pain: P 0-40
      • Symptoms: S 0-20
      • Act limits Daily Living: ADL 0-68
      • Function in sport and rec.: SP 0-16
      • Hip related QOL: QoL 0-16
  • LOWER scores on HOOS === WORSE pain, stiff, functional limits
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4
Q

Pt Reported Outcomes:

Hip Outcome Score

HOS

A
  • ADL and Sports Scales
  • Scores range 0-100 w/ HIGHER SCORES ===BETTER function
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5
Q

Pt Reported Outcomes

Harris Hip Function Scale

A
  • popular
  • Good for pre/post op comparisons
  • Emphasizes Pain and Function
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6
Q

Minimal ROM req’s for Basic Function:

Gait, Sitting, Bed mobility, stairs

A
  • 90deg FLEX
    • Normal==120
  • 20deg ABD
    • Normal==45
  • 0deg IR
    • Normal==45
  • 20deg ER
    • Normal==45-60
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7
Q

Problem Solve:

  • Pt recently had hip spica cast removed as he was recovering from a femoral fx. Current ROM:
    • Flexion=105
    • ABD= 20
    • IR and ER= 5
      *
A
  • When performing PROM ex’s, which motion should be emphasized for your pt if the goal is to facilitate basic function???
    • ER
  • As long as FLEX reamins limtd to 105, what functional acts will be difficult?
    • compensation w/ trunk flexion
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8
Q

Unloading of Hip using ADs

A
  • Walker OR 2 Ax Crutches—-WB restrictions!!!
    • ​unloads up to 100% BW
    • GOOD/THE choice for NWB, TTWB, PWB up to 50% BW
  • One crutch unloads up to 50% of BW
    • GOOD choice for PWB IF cleared for 50% or more BW
  • Cane unloads up to 40% BW
    • GOOD choice for PWB if cleared for 60% or more BW
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9
Q

Pathomechanics of Hip Jt Injury

Motion Deficiency

What develops?

A
  • Femoral Acetabular Impinge. (FAI)
    • Cam
    • Pincer
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10
Q

Pathomechs of Hip Jt Injury

Excessive and Uncontrolled Motion

What develops?

A
  • Structural Instability
    • Dysplasia
    • Capsular Insuff.
      • ​Global
      • Acquired
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11
Q

Pathomechanics of Hip Jt Injury

Osseous Overloads

What develops?

A
  • Traumatic
  • Cumulative (ex. Stress Fx)
    • Predisposed
      • ​insufficiency
    • Microtrauma
      • ​overuse
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12
Q

MANY roads lead to…..

A

OA

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13
Q

Explain OA….

A
  • OA
    • End-pt for MANY hip patho’s
    • Emerging evidence for FAI
    • Better estab’d relationship to dysplastic hip
    • Fxs linked to EARLIER OA dev.
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14
Q

Hip Fx and Rule of Thirds

A

1/3 Recover

1/3 Recover BUT reduced mobility

1/3 Die

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15
Q

Hip Fx is one of leading causes of death in older adults.

Why?

A
  • Fx results in comorbid condition that results in Death.
  • Cycle:
    • ​Hip Fx–> Immob. & INC sedentary time–> PNA (or other med. comps)–> Death
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16
Q

Hip Fxs– Prox. Femur

Risk Factors for Falls in Elderly:

A
  • Slower walking speed (modifiable)
  • Hx of falls
  • Sarcopenia
  • Poor balance (modifiable)
  • Cognitive decline
  • Poor vision
  • Osteoporosis
  • Household obstacles such as rugs, power cords, clutter (modifiable)
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17
Q

Hip Fxs – Prox. Femur

Hip Hemiarthroplasty (1/2)

Indications:

A
  • Acute displaced INTRAcapsular prox. femur fx
    • frail elderly
  • Failed int. fixation of INTRAcapsular fx’s
    • osteonecrosis of femoral head
  • ALSO used for SEVERE DJD of femoral head w/ healthy acetabulum
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18
Q

Hip Fx’s – Prox. Femur

Hip Hemiarthroplasty

uni vs bipolar, Sx approach, Rehab

A
  • Unipolar
    • ​stem/head is 1 piece
  • Bipolar
    • ​SOME mvmt b/w stem and head components
  • Sx Approach
    • ​POSTEROLATERAL == MOST COMMON!!!
      • Cemented OR Non-cemented
  • Rehab???
    • ​mimics rehab for THA
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19
Q

Hip Fx’s – Prox Femur

ORIF

Indications???

A
  • Displaced OR non-displaced INTRAcapsular fem. neck fx
  • Fx w/ disloc’s of femoral head
  • INTERtrochanteric fx’s
  • SUBtrochanteric fx’s
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20
Q

Hip Fxs—Prox Femur

ORIF

Traction procedure

A
  • Pin THRU distal femur + traction system IN hospital bed to provide traction to leg to help w/ reduction of fx
    • typ followed by sx
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21
Q

Hip Fx’s—Prox Femur

ORIF
In Situ Fixation

A
  • Percutaneous nail thru skin from greater troch to femoral head—- NO cutting thru mm or capsule
    • ​Non-displaced fx’s
    • Impacted femoral neck fx’s
  • ***Fewer precautions vs. THA or Hemi-arthro
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22
Q

Hip Fx’s —Prox Femur

ORIF

Dynamic (MVMT) extramedullary fixation w/ a sliding (compression) hip screw and lateral compression plate

A
  • allows for sliding b/w plate and screw—> creates compression across fx w/ WB
  • mainly for stable intertrochanteric fx’s
  • MAY be combo’d w/ an osteotomy for comminuted fx’s
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23
Q

Hip Fxs–Prox Femur

ORIF

Static (NO MVMT) interlocking intramedullary nail fixation OR sliding hip screw coupled w/ an intramedullary nail

A

For SUBtrochanteric fx *******

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24
Q

Hip Fx’s –Prox Femur

ORIF

Bone force and healing

A
  • NO bone force
    • UNLIKELY to heal
  • Bone req’s FORCE to HEAL !!!
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25
Hip Fx--Prox Femur ## Footnote **ORIF** **Rehabilitation:**
* EARLY mob. possible due to **stability of fixation** * **Fx healing typ takes 10-16wks**
26
Hip Fxs--Prox Femur ## Footnote **ORIF WB status**
ALWAYS det'd by surgeon
27
Hip Fx's --Prox Femur ## Footnote **ORIF** **Procedures that usually allow for WBAT:**
* **_Non-displaced_**, rigidly fixed, OR impacted femoral neck fx's w/ **in-situ fixation** * **_Stable_ (uncomminuted)** INTERtrochanteric fx's w/ **dynamic hip screw and lateral side plate fixation** * **_Stable_** SUBtrochanteric fx's w/ **interlocking intramedullary nailing and bone-bone fixation** **NOTE: notice "non-displaced, stable, stable"**
28
Hip Fx--Prox Femur ## Footnote **ORIF** **Factors in determining WB status:**
* age * bone quality * **density** * fx loc. * fx displacement * fixation proc's * post-op stability
29
GOAL of ORIF====\>
* **Restore mobility ASAP to MINIMIZE negative local and systemic results of immobilization**
30
Hip Fx's ---Prox femur **ORIF Special considerations for exercise and gait**
* Soft tissue healing takes **@ least 6 wks; BOTH injury (fx) AND sx procedure can impact local musculature** * **​**TRAUMA from Fx * INCISION from Sx * **TFL** usually cut during Sx and has to heal\*\*\* * Return of ABD strength is BIG ISSUE----**slower if glute med cut during sx** * **​**IF glute med NOT cut-----**start ABD ex's sooner** * INTRAcap Fx's req. **incision INTO capsule during sx----pt MIGHT have post-op ROM PRECAUTIONS in order to AVOID DISLOCATION**
31
Hip Fx--Prox Femur ## Footnote **ORIF Rehab** **MAX PROTECTION PHASE**
* 90deg HIP FLEX ROM by **2-4wks** * EASY **ankle + knee ROM ex's** * UE ex. * LOW intensity mm performance ex: * **submax iso's (guide by pain)** * **progress to AAROM** * NO bridging or SLR w/ involved side early on * Be **careful** NOT to violate **WB precautions!!!**
32
Hip Fx--Prox Femur ## Footnote **ORIF** **MODERATE--\>MINIMAL PROTECTION PHASES**
* Progress to **PWB; eventually FWB** * Stretch any Tight mm's * Expand **ADL training** * Aerobic ex. * Add **resistance** for hip ex's * Add **balance ex's**
33
S/S of Failure of Int. Fixation following Hip Sx
see Box 20.8
34
Hip OA ## Footnote **Condition characteristics**
* GLOBAL cart. loss and loss of jt space * wide-spread loss of normal jt structure and **related loss of function** * often **cumulative result of an earlier injury pattern progressing over time:** * ​Prev injury * Acetabular labral tear * Dysplasia (**early onset OA)** * Avascular Necrosis
35
Normal vs. OA Hip Joint
see pics
36
Clinical Present Hip OA Cibulka et al, 2009 **Exam Findings**
* MODERATE **Ant and/or Lat. pain** * **​MOST OFTEN PROMINENT DURING WB** * Pain often prominent in **morning** * **​subsides in \<1hr** * Typ \>50yo * **EXCEPTIONS:** * **​**Prev injury * dysplasia hx * med-induced AVN * **Progressive loss ROM---CAPSULAR PATTERN** * Notable IR (\<15deg) THEN FLEX * **capsular pattern** * DECd jt mob or symptom relief w/ **long-axis distraction** * related Loss of Strength
37
Clinical Present of Hip OA **Clinical Tests:** **KNOW THESE!!!**
FABER/Patrick Scour
38
Typically..... symptomatic and functional changes related to HIP OA are\_\_\_\_\_\_\_\_\_
slow-developing
39
Prognosis of Hip OA ~ related to \_\_\_\_\_\_\_\_\_\_\_
Extent of radiographic changes
40
Well-established option for **end stage hip OA NOT responsive to non-op Tx**
THA
41
Time of progression from **initial Dx of OA to THA procedure is HIGHLY \_\_\_\_\_\_\_\_\_\_**
Highly variable AND pt dependent
42
Clinical course and expected outcomes for Hip OA current/developing interest in......
Hip preservation sx's and use of biologics
43
DJD (OA) of Hip KEY FINDINGS from **Pt Hx**
* older age * hx trauma, rep stress, hip develop. disorders/disease * **stiff in AM upon waking OR after rest** * Pain in **groin, hip, buttock, ant thigh and/or knee** * Pain WORSE w/ WB or **@ end of day** * Pain WORSE w/ squatting * Limtd functional acts: **esp WB** * **​**inc diff overtime w/ ambulation, stairs, bathing, dressing (don/doff socks, shoes)
44
DJD (OA) Hip ## Footnote **Observations**
* Antalgic gait * **lean toward INVOLVED side in STANCE phase** * **impaired balance** * **SHORT STEP LENGTH on UNINVOLVED limb** * Posture--\> **hip flex contracture**
45
DJD (OA) Hip ## Footnote **Typ. Exam Findings:** **Impairments**
* limtd mm extensibility/flex * **hip flexors, TFL/ITB, glute max** * MM weakness * **ABD's, EXT's, ER's** * Painful ACTIVE hip flex * Painful + Limtd hip PROM * **firm capsular end feel** * ROM--\> **limtd IR initially** * **​LATER:** * **​**ABD, EXT, ER also limtd
46
DJD (OA) Hip Typ. Exam Findings: **Impairments** **EARLY STAGES**
Capsular **laxity** & pt reported **instability**
47
DJD (OA) Hip Typ. Exam Findings: **Impairments** **LATER STAGES**
Cartilage breakdown Capsular fibrosis Osteophytes **Basically....STIFFNESS**
48
DJD (OA) Hip **Selective Tests**
* POSITIVE **Scour Test** * **MAYBE POSITIVE** * **​FABER** * **​**pain in Hip or Groin w/ OA * maybe limtd ROM also * **FADDIR (Flex, ADD, IR)** * **​**Ant. Labral Tear Test * **POSITIVE Labral Tests**
49
DJD (OA) Hip ## Footnote **Non-Op Tx** **Primary Goal------**
RESOLVE IMPAIRMENTS!!!
50
DJD (OA) HIP--- ## Footnote **Non-Op Tx** **2 things to do:**
* 1. GET THEM MOVING! * **Stretch tight mm's** * **Jt Mobs----if limtd mob.** * **​LOW grade===pain relief** * **HIGH grade + MWM (mob w/ mvmt)=== INC ROM** * 2. Strengthening * **LOW impact TE** * **​**aquatics, swimming, stationary bike/recumbent * PROGRESS to GREATER closed chain WB **as tolerated** * Begin w/ LOW RESISTANCE & HIGH REPS
51
DJD (OA) HIP ## Footnote **NON-OP Tx**
**MUST PROGRESS TO HIGHER LOADS** **(**assuming does NOT inc symptoms) * do NOT stick w/ easy things * **more benefits in pushing them** * Overcome **inhibition== INC strength** * Strengthening INCs **capacity== raises ceiling** * **​**Stronger you are==LESS effort needed for basic tasks
52
DJD (OA) Hip **Non-Op Tx**
* PRIMARY GOAL: * **Resolve impairments** * **Biomech. Interventions:** * **​**Unloading (single pt cane) * Heel lift OR orthotic if LLD * Elevated seats IF flex limtd + painful * Improve aerobic capacity * Balance ex's
53
2 most often situations for THA
1. when guys can no longer play golf 2. Women
54
DJD (OA) Hip ## Footnote **Sx Tx** **THA** **Indications?**
* SEVERE hip pain w/ **motion and WB** that has been **WORSENING over time** * Impaired **function** and reduced **QoL**
55
DJD (OA) HIP Sx Tx ## Footnote **THA** **Prosthetic Components**
* **Acetabulum**: * high density **plastic or ceramic** * **Femur:** * **​**metal alloy
56
DJD (OA) HIP Sx Tx **THA** **CEMENTED Polymethylmethacrylate** **Cemented PMMH** **explain...**
* good for **older pts** * those **not able to follow WB precautions** * OK to **WBAT RIGHT AWAY** * ​**ADVANTAGES:** * **​**earlier WB * shorter + faster rehab * **DISADVANTAGES:** * **​**GREATER risk of **loosening over time** * **​**cement degrades
57
DJD (OA) HIP Sx Tx **THA** **UNCEMENTED** \*\*Bone grows INTO prosthetic\*\*
* better for **younger & more active pts** * ​**ADVANTAGES:** * **​**LESS chance prosthetic loosening over time * **DISADVANTAGES:** * **​**protected WB **initially\*** * **​**historically **up to 6 wks TTWB,** recently more of a trend for **faster progression of WB** * LONGER course of rehab * slower bc waiting for bone to grow into prosthetic
58
DJD (OA) HIP ## Footnote **THA** **Hybrid THA:**
* LESS COMMON * Cemented **acetabulum** * Press-fit **femoral component**
59
DJD (OA) Hip Sx Tx **THA**
Various approaches to gain access to hip jt affect **post-op rehab** ## Footnote **see pics**
60
Posterolat Approach THA vs. Anterior Approach THA
**Advantages vs. Disadvantages**
61
Ant Approach THA vs. Posterolateral Approach THA **Precautions**
see pics
62
DJD (OA) HIP ## Footnote **THA** **Posterolateral Approach**
* ROM: * **​No FLEX \>90deg, No IR beyond neutral, No ADD beyond midline** * **​​**DO NOT CROSS LEGS * ADLs * Transfers: **lead w/ UNINVOLVED side** * **​bed--\> chair or chair--\> bed** * keep knees LOWER than hips when sitting * RAISE toilet seat, bed, chair * **\<90deg hip flex** * Avoid bending trunk over legs when rising or lowering to chair or dressing * shower chair * Stairs * UP w/ GOOD, DOWN w/ BAD * Pivot on **sound extremity** w/ walker, turn AWAY from involved side when pivoting * Avoid IR toward INVOLVED extremity when standing * Sleep Supine w/ ABD pillow
63
DJD (OA) HIP ## Footnote **THA** **Anterior Approach**
* ROM: **Avoid Hip EXT, ADD, ER past neutral** * **​**also avoid combo of **ER w/ Flex and ABD** * avoid excess. FLEX * IF **glute med disrupted OR trochanteric osteotomy done----\>** do NOT perform anti-gravity hip ABD for **6-8 wks OR until approved by surgeon** * ADLs * Do NOT cross legs when sitting * **avoid ADD, avoid ER** * Early ambulation: **step-to rather than step-thru op'd side** * Avoid rotating AWAY from op'd side when **standing** * **​ex.** turn TOWARD op'd side so as to avoid ER of op'd side
64
**THA** **Post-Op Precautions**
* Typ no **"hard stop"** end date for ROM precautions * Typ after few mo's ==== **pt begins violating or forgetting about precautions and is OK** * BUT even down the road..... * **still not good to combine Hip Flex and ADD** * **​**bending to tie shoes **-- combine FLEX w/ ABD** * **​"Froggy Style"**
65
THA **Post-op Education or "Pre-Hab"**
* educate pt on expected **ROM precautions** * rehearse **proper gait pattern w/ AD** * instruct pt in ex's that will be done **immed. post-op**
66
DJD of HIP Sx Tx **THA EARLY PROTECTION PHASE** **1 Day to 2 Weeks Post-Op**
We want them as mobile as possible!!! No complications + More Mobile==Go Home * **Prevent pulm./vascular complications** * **​**ANKLE PUMPS * DEEP BREATHING * **Prevent dislocation or subluxation** * **​**Educate pt and caregivers about precautions * ABD pillow * higher chairs; commodes * monitor s/s * **Achieve independent functional mobility** * **​**bed mob + transfer training * ambulate w/ AD * **rolling walker==most common**
67
DJD (OA) HIP Sx Tx **THA** **EARLY PROTECTION PHASE** **1 Day to 2 Weeks Post-Op** **continued**
* **Maint strength + function UEs and UNoperated LE** * **Prevent reflex inhibition and atrophy of the operated LE** * **Regain active mobility and control of the operated LE** * _**​**In Bed_--\> AAROM for hip, assist. heel slides, assist ABD/ADD * _In Sitting_--\> Knee Flex/Ext, **emphasis on TKE** * _In Standing_--\> NWB hip AROM w/ knee FLEXED (**easier) &** EXT (**harder)** * **​**_In Standing_--\> B/L squats, heel raises * \*\*\***Delay in UNCEMENTED\*\*\*** * **Prevent Flex contracture of the operated hip** * **​**AVOID use of pillow under knee of operated hip * _Posterolateral Approach_ * lying prone when permit'd * **Thomas Stretch** of the UNoperated side * single knee to chest but keeping it LESS than 90deg w/ involved side * _\***if abso. necessary**_ * _Anterior Approach_ * _​_Do NOT stretch into EXT
68
DJD OA of HIP **THA** **MODERATE AND MIN. PROTECTION PHASES** **1-12 WKS POST-OP**
NO PROGRESS. TO END RANGES * **Regain strength and endurance ALL extremities** * **​**ESP hip ABD and EXT * **improve aerobic endurance--**LOW IMPACT * **Restore functional ROM of operated hip** * **​**Do NOT exceed ROM precautions/restrictions * **Prepare for full return to functional acts.** * **​** Carrying stuff--- carry on OPERATED side \*\*NOTE: younger pts will return to sport w/in 1 year
69
Other Hip Sx's ## Footnote **LESS invasive/aggresive vs. THA**
* Hemi-arthro * Hip resurfacing * **prosthetic "cap" over femoral head** * Arthroscopic mgmt labral tears * **repair vs. resection** * Sx debridement of osteophytes for **Ant Acetabular Impingement**
70
Other Hip Sx's ## Footnote **When THA Fails...**
* REVISION of THA * **Girdlestone Procedure** * **​**saw off head of femur
71
Femoral and Pelvic Stress Fx's Describe
* Mech. induced fx of prox. femur or pelvis
72
Femoral and Pelvic Stress Fx mech. induced fx of prox femur or pelvis as a result of what?
* **Repetitive overload** that overcomes normal structural properties * **EX. overtraining** * **Loading** that overcomes compromised structural properties (something already compromised and you make it worse by loading it) * Fx occuring w/ **osteopenia**
73
Femoral and Pelvic Stress Fx ## Footnote **Differential Dx**
* Acetabular labral tear * Hip flexor strain * Hip ADD strain * Iliopsoas bursitis * Osteochondral lesion * Hip OA
74
Femoral and Pelvic Stress Fx's FACTS
* MANY cases w/ **delayed dx-----**avg 14wks * NO reliable clinical tests to **diff. TYPE of stress fx** * **​**imaging will tell you * if suspected==\> immed. referral
75
Femoral and Pelvic Stress Fx ## Footnote **Dx Imaging** **Plain Radiography** **AP, Frog-Lateral**
**R/O** **other conditions (**OA, tumor, etc.) Examine for **Displacement**
76
Femoral and Pelvic Stress Fx Dx Imaging **Bone Scan**
Demos INCd **focal uptake of radiotracer @ site of fx aka "HOT SPOT"** **MAY read NEG. for first 24hrs after fx dev.**
77
Femoral and pelvic stress Fx **Dx Imaging** **MRI**
Idea in **Sn and Sp** Yields info about **surrounding tissue (Diff. Dx)**
78
Femoral neck stress Fx and runners
account for 6.6% of stress Fxs in **runners**
79
2 Anatomical classifications of **Femoral Neck Stress Fx**
* **Compression sided (pinching down)** * **​**INF region of femoral neck * **non-operative mgmt** * **Tension sided (stretched)** * **​**SUP region femoral neck * ORIF (if caught late)
80
Femoral Neck Stress Fx **Clinical Presentatin** **PAIN**
* Groin + Ant. thigh * **Potentially Lat. thigh** * **​RARELY in glute region** * **Potentially MED. knee pain** * OFTEN **reproducible w/ END RANGE IR + OVERPRESSURE** * **​**MAYBE **reproducible** w/ **SLR or MMT for FLEX and/or ABD**
81
Femoral Neck Stress Fx **Clinical Present** **FUNCTIONAL**
* INITIALLY **pain during OR after strenuous act.** * **​**ex. running * PROGRESSES to **affect lower lvl act.** * **​**ex. walking * **In Acute stages......** * **​**painful OR restful **@ night** **\*\*\*\* takes time to get stress on bone\*\*\***
82
Pelvic Stress Fx
* 1.6% of stress fxs in **distance runners** * Pubic Ramus * **Palpable rami pain**
83
Femoral and Pelvic Stress Fx's ## Footnote **If running... 2-3 miles in they can go thru diff dx's**
* BOTH stress fx's present **closely to number of diff. dx's** * Thoroughy discuss **act. lvl + med. hx** * Missed dx can be SEVERE------**referral when unsure** * **Appropriate dx + follow-up----**majority of hip + pelvic stress fx's resolve * **TENSION SIDE (sup. side) neck stress fx's are MORE LIKELY to req. ORIF** **\*\*\*Prev. stress fx===MORE likely to have stress fx's** **\*\*\*CATCH THEM EARLY!!!\*\*\***
84
Osteitis Pubitis What should you remember???
DIFF bone stress injury **Can LEAD TO stress fx**
85
Osteitis Pubitis ## Footnote **Description + Causes**
* Inflamm. of **Pubic Symphysis** thru **several pot. mech's** * **​**REPETITIVE athletic act. * Degen OR rheumatic causes * Urological/gynecological procedures OR **pregnancy (non-infectious)**
86
Osteitis Pubitis ## Footnote **Differential Dx**
* Athletic Pubalgia * **extra-articular component** * Adductor strain * **bc SO close to insertion** * Lower abdominal strain * Pubic ramus stress fx * Pelvic floor dysf. * Infectious pubic inflamm. * **Osteomyelitis**
87
Osteitis Pubitis **Clinical Presentation** **ONSET**
Acute Gradual
88
Osteitis Pubitis ## Footnote **Clinical Presentation** **PAIN DISTRIBUTION**
* Central symphysis region * Prox. ADD region * **stresses pubic symphysis** * Lower abdomen * **stresses pubic symphysis** * Genital region
89
Osteitis Pubitis ## Footnote **Clinical Presentation** **FUNCTIONAL LIMITS.**
* Gait * **Swing Phase** * Pivoting * Sport Specific: * **cutting, jumping, kicking** **​**
90
Osteitis Pubitis **Clinical Present.** **MUSCLE IMBALANCES** **\*\*remember location!!!**
* **TIGHTNESS** * **Rectus abdominus\*** * ADD * Iliopsoas * Rec Fem * **STRENGTH ASYMMETRIES** * ​**Adductors\*\*\*\*** **\*NOTE: Rectus abdominus + ADD's=== Antagonistic imbalance==Asymmetrical pull** **\*NOTE: mm's attach in proximity to ea. other and can create** **_antagonistic imbalance_**
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Osteitis Pubitis ## Footnote **Clinical EXAM**
* Hx is **imperative** * R/O other structures * **Hip---do clinical tests** * **Extra-art.---do MMT, length-tests, palpate\*** * Clinical Tests: **min description** * ​**Multiposition ADD. Squeeze** * **​**try to recreate pain * **No sig. data on testing methodology** * **Often not apparent UNTIL pt does not respond to non-op tx** * **IMAGIING** * **​**Plain Radiography * **looking for surf. irregs and degen.** * MRI * **Edema**
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Athletic Pubalgia & Sports Hernia ## Footnote **what should you remember???**
Pubic "pain" ---\> **NOT ACTUALLY A HERNIA** **There is NO hernia!!!!**
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Athletic Pubalgia "Sports Hernia"
* NOT hernia in trad. sense * Disruption of **Post. Inguinal Wall OR Ant. Pubic attach's** * General term describing **chronic pubic/inguinal pain that is NOT INTRA-ART.** * Syndrome: **mult. causes poss.** * 1980's----more recognized today * **Diff Dx is imperative and imaging interp. can be diff.**
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Athletic Pubalgia **Involved Structures**
* Pubic Symphysis AND.... * **Musculotendinous insertions in proximity:** * **​**abdominals * hip flexors * hip ADD's * **most often function to CONTROL some combo of excess. EXT or ROT. of the abdomen and excess. ABD of thigh\*\*\*\***
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Athletic Pubalgia and ROM loss
ROM stopped due to **pain===** **empty end feel (meaning they stop you before you get to ANY end range so NO END FEEL==EMPTY END FEEL)**
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Athletic Pubalgia ## Footnote **Mech. of Onset**
* More common in **males** vs. females * **Repetitive** forces to **pubic symphysis OR tendinous insertions of** **adductors and rectus abdominis** * **"**High energy **twisting activities** **and thigh hyperABD** in athletes w/ **strong ADD mm's over-powering lower abdominals** * **​**ex. football, hockey, soccer
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Athletic Pubalgia ## Footnote **Clinical Present.** **S/S**
* **Chronic pain---\>** often only during **exertion** * Sharp, burning pain **local to lower abdomen & inguinal region** * **​**\*\*\*later will radiate to the ADD region and pot. testicular region\*\*\*
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Athletic Pubalgia ## Footnote **Diff. Dx**
* **Pain and/or weakness w/ strength testing** * **Tightness and/or weakness w/ flex. testing** * Pot. pain w/ **palpation of specific suspected structures** * ​\*\*\***NEGATIVE TESTS FOR INTRA-ARTICULAR INVOLVEMENT**
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Athletic Pubalgia ## Footnote **Cluster Approach Summary**
Confirming Regional Involvement and Dx * **​**Symptoms: * **deep groin, lower abs (unilateral) W/ ACTIVITY OR EXERTION** * Lower abdomen: * **leg lowering** * **resisted sit-ups** * **pubic tub. palpation** * Thigh: * **Flex. tests:** iliopsoas, ADD's, abs, rec fem * **MMT:** hip flexors, ADD's, glute med * **ADD. origin palpation** * R/O **primary hip involve.** * **​**NEGATIVE: **FABER, FADDIR, SCOUR** * **​\*\*\*FAI has shown assoc. w/ athletic pubalgia** * R/O Lumbosacral & SIJ involve * **LQS as approp.**
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Athletic Pubalgia ## Footnote **Prognosis and Tx Implications**
Proper dx is **imperative** and **syndrome class.** necessitates an effective screening process for **mult. regions**
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Athletic Pubalgia **Prognosis and Tx Implications** **Trial of Non-Op Tx typ. indicated...**
* impairment-based interventions * Rest * NSAIDs * Corticosteroid injections * Biological agents **considered**
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Athletic Pubalgia **Prognosis and Tx. implications** **Various Sx proc's ...**
* Laparoscopic * Open vs. "Mini" Open
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Athletic Pubalgia ## Footnote **Prognosis and Tx Implications** **Outcomes???**
* Non-consistent outcome reporting BUT **post-sx studies report \>80% "return to sport"** * Further outcome studies req'd for **both non-sx and sx tx**
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Meralgia Parasthetica \***Painful parasthesias** **What is it and who is @ risk???**
* Irritation or entrapment of **Lateral Femoral Cutaneous Nerve** in the area of the **anteroLAT. hip** * **​~1cm medial to ASIS** * **@ Risk:** * **​**baseball catchers * English-style equestrians * obese indiv's * pregnant women * **bc in hip flex. all the time**
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Meralgia Parasthetica ## Footnote **How to Test:**
* Push down w/ thumb I**NTO abdomen and UP towards umbillicus** @ lvl **just prox. to and 1" medial to ASIS** * **​**IF this **relieves** pt's symptoms of **lateral thigh burning, pain, parasthesia** * **​== suggests Meralgia Parasthetica**
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Meralgia Parasthetica ## Footnote **Intervention:**
* Apply **same pressure to nerve w/ pt in SIDELYING---_while you simultaneously passively EXT hip_** * **_​_**push POST and SUP on the nerve (and surrounding tissue) **as you EXT hip, then move back and forth**
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Femoral Acetabular Impinge. or FAI ## Footnote **occurs when?**
Occurs when there is **DECd joint clearance b/w femur and acetabulum**
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FAI 3 types:
* 1. CAM * **_Femoral_ deformity** * **​**bony overgrowth * 2. Pincer * **_Acetabular_** **deformity** * **​**acetabular overgrowth * 3. MIXED
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FAI ## Footnote **CAM** **aka "Pistol Grip" Deformity**
Excessive bone @ **head-neck junction** **\*\*bone grows OUT**
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CAM FAI
**Delamination** separation b/w layers in the acetabulum
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Pincer FAI ## Footnote **Cross-Over Sign** **Acetabular RETROversion** **Acetabulum covers TOO MUCH of femoral head**
* Presentation of **Focal anterior over-coverage of hip** * **Acetabular Retroversion==** ant. wall (AW) being **more lateral that** post wall (PW) * **In normal hip** * **​**AW lies **more medially** * **Cranial acetabular retroversion** described also as **Fig. 8 Configuration**
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Cam vs. Pincer
https://www.youtube.com/watch?v=ENjq5Is94PE
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FAI and Acetabular Labral Tears
* **Most often FAI is NOT initial dx of interest** * Pt symptoms MOST LIKELY result from **2\* labral tear, chondral damage, or degen changes IN labrum** * Changes result in **pain+functional limitation==SYNDROME** * **​**FAI (mechanical) + Clinical Findings (pain, function limits) ==\> **SYNDROME**
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Clinical Course and Outcomes for FAI
* if clinical present leads you to FAI----**non op tx recommended** * outcome studies still early in dev. * If pt **unresponsive to non-op tx-----ADD. IMAGING** * **​**Radiographs (**FAI)** * MRA (**labral tear)** * **​A=arthrogram-local dye leaks if tear** * Dx Injection (**confirms source of sx's)**
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Clinical Course and Outcomes for FAI ## Footnote **Sx Options**
* Sx avail. for pts w/ **ongoing pain and function limits** related to INTRA-art. patho of FAI * **Arthroscopy** * **​**Osteoplasty (prox femur OR acetabular rim) * **remove the bone** * **​**Labral debridement, repair (**usually most restricted after)**, or reconstruction (**putting something else in like bone- can do mvmt earlier w/ reconstruction)** * **Open osteoplasty correction of FAI**
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FAI Progress to Early Arthritis??? EXPLAIN...
* Bedi et al---\> examined cart. degradation markers in athletes w/ FAI * Compared to controls, **found elevated lvls of:** * **​Inflamm C-reactive PRO** * **Cart. oligomeric matrix PRO** * Basically..... **cartilage breakdown even if looks GOOD on imaging** * **These changes indicate cartilage turnover and stemic inflamm. assoc'd w/ OA**
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Spectrum of FAI-related Jt. Patho \*\***one pot. mechanism only\*\***
* FAI==\> altered jt mechs==\> labral lesions==\> chondral damage==\> OA
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The FURTHER a labral tear goes ___________, the LESS _______ it is
Labral tear further INTO JOINT== LESS REPAIRABLE
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HIP LABRAL TEAR
SEE PICS
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Acetabular Labral Tears ## Footnote **Pt Reported Symptoms**
* Hx of **hyperEXT or pivoting/twisting or fall** * pain, click, locking and/or catching * may feel **unstable ("giving way")**
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Acetabular Labral Tears ## Footnote **MOI**
most are in **Ant/Sup region of labrum**
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Acetabular Labral Tears ## Footnote **Typ. Exam Findings** **Imaging**
* **Typical Exam Findings/+ Tests** * **+** FABER (opp of FADDIR) * **pulls labrum** * **+** FADDIR---ant labrum test (opp of FABER) * **pinches labrum** * **+** SCOUR test * **+** Labral tests * \*\***Pain w/ resist. SLR ---** * **​**compensated hip flexors\*\*\* * **Imaging** * MRI or MRA (angiography)
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Acetabular Labral Tears ## Footnote **Interventions**
* Ex's for **hip stability and strength** * **Core stabilization** ex's * AVOID pos's or tx that would **further stress labrum:** * **​**HyperEXT * End-range OVERpressure * HIGH GRADE **ant. glides** * AVOID sheering, pivoting, extreme EXT * MAY need **arthroscopic repair OR resection**
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Structural Instability vs. Hypermobility
* Structural instability * **what the pt reports** \*\***These two are NOT always EQUAL!!!**
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Components of Jt Stability 3
* 1. Neural (**proprioceptive/sequencing)** * **​**Rehab Focus * 2. Active (**muscular)** * **​**Rehab Focus * 3. Passive (**ligamentous/boney)** * **​**Sx Focus
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The **Structurally Unstable** Patient \*know **underlying cause\***
* boney architecture * **Femoral deformities** * **​**Coxa valga, INCd femoral version * Mis-shaped femoral head * Shallow acetabulum * **Anteverted acetabulum** * **Primary Capsulo-labral Compromise** * **​**ligament/capsule tear in hip * **Universal** laxity * **Focal** laxity * Ligamentum Teres deficiency * **the "head ligament" ----- blood supply!!!**
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Dysplasia **_Labrum_ does MORE work** **_Bone_** **does LESS work**
* SHALLOW acetabulum * Predisposes hip to **sublux. AND abnorm contact stresses on femoral head** * Assoc'd w/ **hyperplastic labrum AND degen** * Dysplastic hip can LOAD labrum **up to 5x above normal** * \*\*\***Cannot treat underlying bony patho arthroscopically\*\*\***
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Capsulo-ligamentous Laxity aka **Ligamentous Laxity**
* MAY be noted **in conjuction w/ OR instead of boney abnorms**
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Capsulo-ligamentous Laxity ## Footnote **aka Ligamentous Laxity** **2 Categories:**
* 1. **Generalized** * **​**connect. tissue disorders * **Ehler's-Danlos** * **Marfan's** * **etc..** * 2. **Focal** * **​**iliofemoral ligament attenuation/damage
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How do we **measure** Generalized/Universal Laxity?
Beighton's Scale
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Repetitive **Micro-Trauma &** **_Acquired_ Capsulo-ligamentous Laxity**
* Abnorm forces thru hip transmit forces to **iliofemoral ligament AND labrum** * **Results:** * **​**_Focal_, rotational instability * _Elongated_ capsule * _Associated_ labral tear
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Repetitive Micro-Trauma & Acquired Capsulo-ligamentous Laxity ## Footnote **MOI**
* Repetitive ER on a **loaded limb ==\>** * Weakening/disruption of **anterior structures ==\>** * **​**iliofemoral lig. * capsule * labrum * INCd load thru **soft tissues** * **​**labral tearing--**stress** * irritation of ABDs and hip flexors * **as they work to stabilize**
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Hypermobility Prognosis & Tx Implications \*\***if clinical presentation leads to impression of HYPERmobility-----NON-op tx measures recommended**
* IF pt unresponsive to NON-op Tx---- **add. imaging warranted:** * **​**Radiographs * **ID of dysplasia** * MRA---dye into tear if tear * **labral pathology** * Dx Injection * **confirms source of sx's**
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Sidenote: ## Footnote **Hip Dysplasia**
* Medical term for a hip socket that does NOT fully cover the ball portion of the proximal femur. * allows hip jt to become **partially or completely dislocated** * **mostly congenital**
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Structural hypermobility OR laxity DOES NOT ALWAYS result in\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Clinical Instability!!!
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Extra Articular Hip Injuries ## Footnote **What is KEY to effective Tx?**
Accurate Dx
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Extra-articular hip injuries ## Footnote **Multi-structural involvement**
* **Co-existence** w/ **INTRA-articular involve.** * **​**FAI * labral tears * Lumbopelvic component * **Syndromes** * **​**COMBINED **core and hip musculotendinous structure involve.**
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Extra-articular Hip injuries ## Footnote **"Outliers"**
Pelvic floor Nerve entrap. syndromes
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Extra-articular Hip injuries ## Footnote **Give some examples...**
* Greater troch pain syndrome * ADD-related groin injuries * Prox. HS injuries * Hip flexor injuries * **iliopsoas** * Assoc'd core patho/Athletic pubalgia (sports hernia **not really a hernia)**
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Greater Trochanteric Pain Syndrome ## Footnote **GTPS**
* labeled **trochanteric bursitis in past** * Trochanteric inflamm IS POSSIBLE BUT.... * **Other structures often involved.....** * **​**Glute Med. * tendinopathy * tear * Glute Min. * tendinopathy * tear
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Gluteal Tendinopathy FACTS
**MORE common in FEMALES** **40-65yo**
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Gluteal Tendinopathy ## Footnote **Functional Diff's**
* Pain variable w/ walking, S/L, sitting * Fatigue and **possible gait disturbance**
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Gluteal Tendinopathy ## Footnote **Clinical Findings:**
* R/O **intra-articular involve as 1\* source** * Palpable **tendon attach.** pain * POST/SUP trochanter== **glute med.** * ANT == **glute min.** * Pain w/ **resisted ABD** * **+** De-rotational test * Pain w/ **30s SLS**
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Trochanteric Bursitis ## Footnote **Pt Report**
PAIN loc'd over **lateral hip** w/ **referral to lateral thigh to knee**
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Trochanteric Bursitis ## Footnote **Mech. of Patho.**
* Aggravated by **ITB rubbing over trochanter**
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Trochanteric Bursitis ## Footnote **Risk Factors:**
* Risk on **"downhill leg"** if running on banked road
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Trochanteric Bursitis ## Footnote **Aggravating Acts:**
* lying on **affected side,** standing asymmetrically w/ hip in **ADD.,** walking/running on **uneven surf. (crested road)**
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Iliopectineal Bursitis ## Footnote **Pt Report**
Pain loc'd in **inguinal region referring to the ANT thigh as far as knee**
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Iliopectineal Bursitis ## Footnote **Mech. of Patho**
* bursa lies DEEP to **iliopsoas tendon** as it crosses hip joint * CLOSELY assoc'd w/ **hip jt patho** * **​**DJD * RA * etc..
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Iliopectineal Buritis **Aggravating Factors**
* Rep'd **hip flexion, rising to stand after prolonged sitting, prolonged walking** * ​Pts report pain w/ **crossing legs OR ADD affected LE**
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Iliopectineal Bursitis ## Footnote **Interventions**
* Focus on **stretching iliopsoas** * **hip mobs** * **soft tissue mobs** * **therapeutic modalities**
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Ischiogluteal or Ischial Tuberosity Bursitis ## Footnote **"Weaver's Bottom"** **Pt Report**
* Pain over **ischial tubs--esp in sitting** * **​**MAY spread to **sciatic distribution due to swelling**
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Ischiogluteal or Ischial Tuberosity Bursitis ## Footnote **"Weaver's Bottom"** **Mech. of Patho**
* Sedentary indiv's OR direct trauma to region * **bursa lies DEEP to glute max over isch. tubs.** ## Footnote **​**
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Ischiogluteal or Ischial Tuberosity Bursitis ## Footnote **"Weaver's Bottom"** **Aggravating Acts**
* Resisted **hip EXT and HS's painful**
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Ischiogluteal or Ischial Tuberosity Bursitis **"Weaver's Bottom"** **Diff. Dx**
referral from **LS** or referral from **hip** may cause pain in same area
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Ischiogluteal or Ischial Tuberosity Bursitis ## Footnote **"Weaver's Bottom"** **Specific Intervention**
* Using a **doughnut** **pad** to relieve pressure while **sitting**
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Hip/Pelvis Bursitis ## Footnote **Interventions**
* STRETCH tight structures around hip * **ITB/TFL, Glutes, HS's** * MOBILIZE tight hip/lumbar spine/pelvis structures * **Foam rolling over ITB and other structures** * **​**don't care WHY it works as long as it WORKS! * Therapeutic Modal's MAY enhance pain relief and better tolerance to mvmt----**implement if they allow MORE EXERCISE!!!** * US * heat * e-stim
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MSPT I (10 decks)

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