Hip Common Conditions

Question 1

Strains

Answer 1

Hip muscles are easily strained in work and recreational activities.

Sudden onset of P in muscle belly or musculotendinous junction

Damage to some part of the contractile unit caused by overuse (chronic strain), or overstress (acute strain)

Strains occur at the weakest link of the muscle-tendon unit (normally, musculotendinous junction > tendon > bony attachment)

Question 2

Strains
Etiology

Answer 2

Multifactorial
Fatigue, muscle imbalances, overstretching, violent muscle contraction vs. a heavy resistance, poor flexibility, adverse neural tension, leg length discrepancies.

Question 3

Strains
Signs and Symptoms

Answer 3

Localized pain in muscle belly, the point of insertion or the origin of the muscle, and increased stiffness.
Pain on resisted movement and passive stretch (except in a complete tear)

Question 4

Strains
Common Strains affecting the hip

Answer 4

Hamstring Group
Quadriceps Group
Adductor Group

Question 5

Review History
What are our interview priorities?
Severity

Answer 5

Snap/Pop
Able to continue
Joint give way/fall over
Bruising in the days afterwards?
Need immobilization (eg crutches)

Question 6

Strains
Movement
Acute

Answer 6

Mod-sev limitation of range and pain with movement (edema and muscle guarding)

Question 7

Strains
Movement
Early Subacute

Answer 7

Generally painful throughout entire range of movement

Question 8

Strains
Movement
Late subacute

Answer 8

Generally painful at end-range and POP

Question 9

Strains
Movement
Chronic

Answer 9

Generally not painful but possible to have pain with tissue stress (load or POP)

Question 10

Stage of Healing & Treatment Plans
Two things occur following a strain

Answer 10

1/ Tissue damage
2/ Disuse

Question 11

Stage of Healing & Treatment Plans
Injured Tissue & Stage of Healing
Acute >

Answer 11

body cleans up injury site > we try to control inflammation to manage symptoms and decrease the duration of disuse

Question 12

Stage of Healing & Treatment Plans
Injured Tissue & Stage of Healing
Early subacute

Answer 12

body randomly lays down immature collagen > because it is immature, it is very fragile and prone to reinjury > we try to prevent adhesions

Question 13

Stage of Healing & Treatment Plans
Injured Tissue & Stage of Healing
Late subacute

Answer 13

> collagen is now mature and will align itself with the stresses applied to it > we try to prevent adhesions and also promote functional scar tissue

Question 14

Stage of Healing & Treatment Plans
Injured Tissue & Stage of Healing
Chronic

Answer 14

scar tissue is now present > we try to decrease adhesions and promote functional scar tissue

Question 15

Strains
Disuse, Impairments, & Goals
The consistent set of impairments we see are changes to

Answer 15

Joint integrity
Muscle balance
Neuromuscular control of the affected tissue
Muscle strength of the affected tissue
ROM of the affected joints
Muscle length of the affected tissue

Question 16

Treatment of strains
Sensible progression through rehab

Answer 16

Acute - cold hydro, elevation

Once SHARP resolved - contrast hydro, pain-free AROM against gravity, muscle setting

Once pain-free AROM is full - increase resistance for mid-range isometric contractions > progress with increasing resistance and different ranges

Once isotonic strength is in a good range - stretches to restore full ROM

Once ROM is full - continue with strengthening specific to activities; continue with restoring muscle length/balance

Advice about warming up and cooling down around activities, self-care, fatigue management

Question 17

Hamstring Strain (commonly biceps femoris)
Etiology

Answer 17

Rehab time from 2-3 weeks to 2-6 months
Injured at the origin, mid belly or less commonly at the knee.
Injuries are primarily proximal and lateral
Most hamstring injuries occur due to eccentric contraction
A pop – or snapping is often reported with the injury occurrence

Question 18

Hamstring Strain (commonly biceps femoris)
Signs and Symptoms

Answer 18

Pain (injury site) present on hip flexion (lengthening) and resisted knee flexion

Question 19

Hamstring Strain (commonly biceps femoris)

ROM

Answer 19

↓ Hip FLEX in AROM & PROM
↓ Hip EXT IN RROM
Double check ADD magnus - w/ medial hamstring P

Question 20

Hamstring Strain (commonly biceps femoris)
Special Test

Answer 20

90/90 leg raise or MMT of Hams

Question 21

Quadriceps Strain (commonly rectus femoris)
Etiology

Answer 21

Rectus Femoris is the most commonly strained of the quadriceps due to its combined action on the hip and knee.

At risk of tearing during sprinting, kicking, and jumping

Ruptures are not uncommon at the origin or insertion

Pop/snap is often reported with the injury occurrence

Question 22

Quadriceps Strain (commonly rectus femoris)
Assessment
Hip
Knee
Special Test

Answer 22

Hip
↓ EXT in AROM & PROM
↓ FLEX IN RROM
Double check - Psoas
Knee
↓ FLex in AROM & PROM
↓ EXT IN RROM

Special Test
Ely’s Test / Thomas test / MMT Quads

Question 23

Adductors Strain (commonly adductor longus)
Etiology

Answer 23

Often involves the muscles arising at the pubis – ADD Longus / Brevis and Gracilis.

Most Frequently injured is the Adductor Longus

Inadequate stretch or strengthening can lead to chronic tearing

Injuries common in sports requiring quick propulsion or change in directions like soccer, hockey, football, or sudden slip on ice, wet ground, or overuse like ballet, gymnastics

Question 24

Adductors Strain (commonly adductor longus)
Signs and Symptoms

Answer 24

Tear usually at the musculotendinous junctions approx. 5cm from pubis (pain over the pubic tubercle which can lead to periostitis), or more rarely at the origin directly over the pubic tubercle or body of the pubis

Question 25

Adductors Strain (commonly adductor longus) HIP ROM: Special Tests

Answer 25

↓ ABD in AROM & PROM ↓ ADD IN RROM Adductor Length (PROM abduction) MMT Adductors MMT medial hamstrings

Question 26

Groin Strain (umbrella term) Etiology

Answer 26

The name is an umbrella term incorporating many structures and conditions: The anterior groin muscles (Adductors, iliopsoas, sartorius, rectus femoris) can be irritated by any activity that stretches and strains this area. Pain in the groin can be from a lesion in the lumbar spine, the hip joint or uncommonly the SI joint

Question 27

TFL & ITB

Answer 27

A tight ITB, with tight TFL or tight Glutes are often associated with postural dysfunction or an anterior pelvic tilt. Because of the vast functional roles of the TFL and ITB it is prone to overuse and sprain injuries.

Question 28

TFL & ITB Some common TFL/ITB syndromes are:

Answer 28

Sprain or Fasciitis of the IT (presents proximal) ITB Friction Syndrome (presents distal)

Question 29

IT Band Sprain Etiology

Answer 29

Trauma to greater trochanter Occurs with dancers or athletes from a fall on the hip

Question 30

IT Band Sprain Signs and Symptoms

Answer 30

Localized Pain felt in the trochanteric area. Pain with contralateral side flexion of the trunk.

Question 31

IT Band Sprain Special Test

Answer 31

Accessory test – in a standing position, the patient crosses the painful leg behind the other and bends sideways toward the painless side, taking all the body weight on the affected limb. (standing Ober’s) Pain (sometimes severe pain), indicates a lesion of the ITB. Palpation reveals a painful spot, just behind or above the greater trochanter

Question 32

IT Band Fasciitis Etiology

Answer 32

A painful condition, sometimes mistakenly diagnosed as sciatica, associated with inflammation of the fascial band from overuse of the TFL, commonly called ITB fasciitis.

Question 33

IT Band Fasciitis Signs and Symptoms

Answer 33

Pain is diffuse and may be limited to the area covered by the fascia along the lateral surface of the thigh or may extend upward over the hip

Question 34

IT Band Friction Syndrome

Answer 34

The most common presentation of pain for IT-band related dysfunction occurs at the lateral knee

Question 35

Rectus Femoris Tendonitis Etiology

Answer 35

RF is a weak hip flexor and a strong knee extender and can be overstressed in any sport or action requiring the normal action of hip flexion and knee extension. It is frequently injured by a mis-timed kicking action Lesion of RF usually occurs just below the AIIS (in the body of the tendon) Alternatively the tender point lies at the proximal part of the muscle belly.

Question 36

Rectus Femoris Tendonitis Signs and Symptoms

Answer 36

Inability of the prone patient to flex the knee more than 120*, possibly indicating a tight quadriceps Special Test, MMT, Ely’s, Thomas

Question 37

Rectus Femoris Tendonitis HIP ROM:

Answer 37

↓ EXT in AROM & PROM ↓ FLEX IN RROM

Question 38

Rectus Femoris Tendonitis Knee ROM:

Answer 38

KNEE ROM: ↓ FLEX in AROM & PROM ↓ EXT IN RROM

Question 39

Psoas Tendonitis Etiology

Answer 39

RSI of the psoas is usually caused by overactive contraction of the muscle, when the thigh is flexed and taken into forceful extension

Question 40

Psoas Tendonitis Signs and Symptoms

Answer 40

Pain @ ant hip/thigh (dull, achy, tight; poss sharp w Incrs resistance) (lesser trochanter) Pain timing indicates Tendonitis -‘snapping’ hip ant/med

Question 41

Psoas Tendonitis ROM Findings

Answer 41

↓ EXT- sometimes FLX & ADD in AROM & PROM ↓ FLEX IN RROM

Question 42

Trochanteric Bursitis Etiology

Answer 42

Most commonly inflamed bursae of the hip Reduces friction between glutes over the greater trochanter Could be traumatic (fall on trochanter) Could be overuse (eg too much cycling)

Question 43

Trochanteric Bursitis Signs & symptoms

Answer 43

“Snapping” hip post/lat, Pain, irritation over ITB Aggravating: Stairs Getting in/out of cars RROM abduction Compression

Question 44

Trochanteric Bursitis ROM Findings

Answer 44

Pain with AROM/PROM Abduction/Adduction Pain with RROM Abduction Depending on severity, most movements may provoke localised pain Movement restricted by pain

Question 45

Trochanteric Bursitis Special test

Answer 45

Tendon-Bursa differentiation Ober’s will provoke a trochanteric bursitis but is not strictly positive Accessory test Ddx SI joint pain Glute tendinopathy TrP

Question 46

Ischiogluteal Bursitis

Answer 46

Associated with prolonged sitting, especially in folks with low tissue mass Pain with sitting which decreases when standing Possibly with direct trauma Pain also with walking and climbing Pain refers to hamstrings Sitting should be minimized for those who suffer and use chair padding and other appropriate positioning to prevent aggravation

Question 47

Iliopectineal Bursitis

Answer 47

Less Common Insidious onset Pain felt in the groin area with a tendency toward radiation into the L2 or L3 segments Communicates with the hip joint therefore it is appropriate to ascertain whether involvement of the bursa is a manifestation of hip joint effusion

Question 48

Hip Fractures

Answer 48

May be traumatic and spontaneous Risk for avascular necrosis Surgical repair often requires pins, plates, screws

Question 49

Hip Fractures Types Femoral head fracture

Answer 49

Usually the result of high energy trauma and a dislocation of the hip joint often accompanies this fracture.

Question 50

Hip Fractures Types Femoral neck fracture

Answer 50

aka Neck of Femur (NOF), subcapital, or intracapsular fracture

Question 51

Hip Fractures Types Subtrochanteric fracture

Answer 51

Femoral shaft

Question 52

Hip Fractures Types Signs and Symptoms:

Answer 52

Marked bony displacement Extensive hemorrhage Nerve damage Vascular compromise

Question 53

Hip Fractures & Avascular Necrosis

Answer 53

Compromised Circumflex Arteries which ascend proximally along the neck of the femur to innervate the head Subject to interruption in the case of a femoral neck fracture Also, they are intracapsular- it is believed that increased intracapsular pressure caused by joint effusion may stop blood flow.

Question 54

Hip Osteoarthritis

Answer 54

Degenerative joint disease (DJD) affecting weight bearing joints that often progresses to a point at which it results in significant disability. This is true at the hip more so than at any other joint.

Question 55

Hip Osteoarthritis Etiology

Answer 55

1˚ = Idiopathic (results from aging alone) 2˚ = altered biomechanics/alignment, trauma, immobilization (associated with previous damage) Etiology varies and in many patients is unclear Degenerative tissue changes occur

Question 56

Hip Osteoarthritis Signs and Symptoms:

Answer 56

Insidious onset Stiffness w long periods of rest (AM upon waking) Initially, IR and EXT reduced; progresses to Capsular Pattern of Restriction Pain with extensive use, relief with rest Dispersed achy pain over the inguinal region - groin and adductors Compensatory low back pain - mm spasm

Question 57

Hip Osteoarthritis Special Tests:

Answer 57

If suspected, but not diagnosed - Scouring test If already diagnosed and confirmed by MD/imaging - do not do scouring test Faber’s / Stinchfield may indicate hip joint pathology

Question 58

Rheumatoid Arthritis at The Hip

Answer 58

RA is an inflammatory, destructive, chronic autoimmune disease of multiple joints and connective tissue throughout the body, and can affect the Hip Joint RA is a systemic disease, during flare-ups pain, fatigue, low grade fever, weight loss, anemia and visceral swelling are likely experienced.

Question 59

Rheumatoid Arthritis at The Hip Treatment - Between Flare-Ups

Answer 59

Relaxation Context – positioning is for comfort, hot hydro to control pain and spasm, contralateral and compensatory structures are treated to reduce tone, especially in muscles that cross the joint. TrP’s and NMT to these muscles as well. Gentle passive movements of the affected joints to maintain ROM. Gentle joint play may be used with caution on affected joint capsule to reduce adhesions

Question 60

Rheumatoid Arthritis at The Hip Treatment - During acute flare-ups

Answer 60

No hot hydrotherapy or local massage on acutely inflamed joints. Deep vigorous techniques used between flare-ups may provoke inflammation in some clients. Prevent kickback P with lots of swedish ↓ atrophy/spasm - work into scar tissue MILD heat - cautious if hardware TX potentially atrophied glutes

Question 61

Total Hip Arthroplasty

Answer 61

Femoral Head and Neck replaced with metal prosthesis Doesn’t sit quite as snuggly as a normal healthy joint It takes eight to twelve weeks for the soft tissues injured or cut during surgery to heal. During this period, the head can come out of the socket. Avoid Motions with ADDuction past neutral and Flexion past 90° for at least 3 months post-surgery

Question 62

Hip Dislocations Require massive trauma

Answer 62

High stability at the hip make it difficult to dislocate Most joints - eg shoulder, elbow - usually dislocate in a closed packed position (high congruency of the joint surfaces) It is the opposite of the hip. The hip dislocates in open pack position. Position of flexion (ligaments lax) with abduction and IR (low-congruence)

Question 63

Hip Dislocations MOI

Answer 63

Dislocation would occur with a driving force of the femur backward on the pelvis (motor vehicle dashboard injury) The head of the femur is driven posteriorly through the relatively weak posterior capsule

Question 64

FAI (Femoroacetabular Impingement) Definition

Answer 64

Impingement of tissue between the femur and acetabulum due to bony deformity

Question 65

FAI (Femoroacetabular Impingement) Etiology

Answer 65

Usually congenital or developmental during adolescence

Question 66

FAI (Femoroacetabular Impingement) Essential components There are 5 essential components to FAI:

Answer 66

(1) abnormal morphology of the femur and/or acetabulum; (2) abnormal contact between the two structures; (3) vigorous, supra-physiologic motion which causes abnormal contact; (4) repetitive motion resulting in the continuous insult; and 5) the presence of soft tissue damage

Question 67

FAI (Femoroacetabular Impingement) Abnormal morphology

Answer 67

(1) Cam-type - an abnormal bony growth on the femur (2) Pincer-type - an abnormal bony growth of the acetabulum (3) Combined - both femoral and acetabular abnormalities

Question 68

FAI (Femoroacetabular Impingement) Diagnosis

Answer 68

(1) A symptomatic hip (usually, pain, especially during movement, and stiffness) (2) Positive FADIR test (or similar) (3) Positive x-ray findings

Question 69

Joint Capsule Sprains Etiology

Answer 69

Insidious cause OR via minor twisting movement while weight bearing Common in athletes or dancers Contributing factors include Hx of groin or hip pain, bursitis, ITB fasciitis May be caused by hip hypermobility (leads to articular inflammation, which then leads to ‘capsular changes’); possibly via altered mechanics at lumbosacral complex Chronic capsular tightness may lead to OA

Question 70

Joint Capsule Sprains ROM Findings

Answer 70

Typical loss of FLX and Med RotN Treat/REMEX as per sprain protocol

Question 71

Piriformis Syndrome Etiology

Answer 71

Compression of the sciatic nerve by the piriformis muscle Anomalies in the course of the nerve Direct & indirect trauma Inflammation Overuse Postural/positional concerns Trigger points

Question 72

Piriformis Syndrome Signs and Symptoms

Answer 72

Unilateral (usually) Pain (varies from sources) - posterior thigh referring to calf and sole of foot; lumbosacral/gluteal pain If compression is severe = loss of proprioception, muscle strength, ataxic gait, foot drop, paresthesia Pain decreases with ER (passively) SI joint dysfunction accompanies

Question 73

Piriformis Syndrome Special Tests

Answer 73

Piriformis Test SLR

Question 74

Piriformis Syndrome DDX

Answer 74

Facet Irritation - Kemp’s/Quadrant Test Stenosis - Bilateral pain w/ Valsalva Maneuver Herniation - SLR

Question 75

Prone Hip Extension Coordination Indication

Answer 75

Often low back pain, especially with walking; prominent ESG; difficulty with sagittal plane movement of hip

Question 76

Prone Hip Extension Coordination Reason

Answer 76

To infer muscular coordination in hip extension movement

Question 77

Prone Hip Extension Coordination Assessment:

Answer 77

Patient prone Group 1 – gently palpate (just touching, no pressure) glute max and hamstrings. Ask patient to lift leg into hip extension. Observe which muscle fires first. Group 2 - gently palpate (just touching, no pressure) left and right ESG. Ask patient to lift leg into hip extension. Observe which muscle fires first. Compare Groups 1 & 2 - gently palpate (just touching, no pressure) the 1st muscle to fire from each group. Ask patient to lift leg into hip extension. Observe which muscle fires first. Now, maintain palpation on the muscle which fired 2nd, and palpate the 2nd muscle from the other group. Repeat hip extension. (Example next slide) Summarise firing pattern