Hip theory Flashcards
1
Q
Classification of hip pathology
A
- Intra/Extra articular
- Location [anterior, posterior or lateral]
2
Q
When it comes to hip pathology, what should generally be ruled out?
A
Referred pain
Bursitis
3
Q
What are red flags of the hip?
A
1) Fractures [esp. elderly], avascular necrosis
2) Tract anamnesis: deep aching gnawing, vague grinding pain
[bleeding, epigastric, constipation, abscesses in obturator/psoas, appendicitis]
4
Q
Best examination tests for the hip
- FAI =
- FAI/Labral/OA =
- FAI/Labral/SI =
- Hip pathology =
- Posterior impingement =
- Instability/posterior impingement =
- Hip flexion tightness/labral =
- Instability =
A
- FAI = FADDIR
- FAI/Labral/OA = Scour
- FAI/Labral/SI = FABER
- Hip pathology = Stinchfield
- Posterior impingement = PI test
- Instability/posterior impingement = A/apprehension
- Hip flexion tightness/labral = Thomas
- Instability = ABD-E-ER, Prone ER
5
Q
A patient presents with their hip in 30 Flexion, 30, Abduction and slight ER. What might this indicate?
A
This is the open packed position of the hip, which relieves pressure on the joint, this could point to an inflammatory condition that is present, which the patient is positioned this way to alleviate pain.
6
Q
Important history taking/clinical assessment components
A
-> Pain location
-> Provocative manoeuvres
-> Mechanical symptoms
7
Q
Categories of Hip Instability causes
A
Trauma
Atraumatic [Dysplastic or idiopathic].
8
A
The order of stabilisation:
1) Static stabilisers
2) Dynamic stabilisers
3) Boney structures
When on isn’t function it relies on the next
9
Q
Pathway for static instability. What then happens once this occurs?
A
1) Overuse/micro traumatic injury
2) Labral & ILFL damage
3) Increase anterior hip translation
4) Further labral/ILFL damage
5) Capsular tension leading to labral injury and capsular redundancy and micro instability.
* The hip will then rely on dynamics
10
Q
Orthopaedic Tests for Hip Instability
A
1) Posterior apprehension
2) HEER
3) Log/dial
4) FABER
5) ABHEER
6) Prone ER
- Clustering tests, if possible = increases likely hood ratio of diagnosis
11
Q
Management of hip instability
A
- Pain focus first
- Find underlying cause
- Strengthen hip and trunk muscles, modify activity, esp. connective tissue disorders or generalised ligamentous laxity
- Activity modification
- If labrum is involved, debridement and repair
12
Q
What happens with Instability? Does it lead to long term effects?
A
- Increases movement due to unreliablity of structures
- When ligaments are unreliable, leads to favouring dynamic stabilisers. When they fail, the hip then relies on the bony structures.
- At the same time, this increase movement Increases the likelihood of damaging the labrum and or developing secondary OA
The labrum is a fibrocartilageous structure; has vascular issues. Damage leads to inflammation/quicker degeneration
13
Q
What is the overall goal with management of hip instability
A
To improve congruency of the hip when then leads to improved stability
14
Q
Characterisation of Hip Osteoarthrosis [OA]
A
Characterised pathologically by localised loss of cartilage, remodelling of adjacent bone and associated inflammation
15
Q
Hip Osteoarthrosis [OA] Clinical presentation
A
- Progressive onset
- Anterior hip/groin dull ache
- > 50
- Morning stiffness, eases with movement, disturb sleep
- Worse with weight bearing/cold weather
- Primary from trauma, or secondary to bony abnormality or
inflammation/infection - Capsular pattern [IR most limited, flexion, extension, and ABduction.
- Sometimes unilateral LBP
- Symptoms are located in L3 dermatome [groin, anterior thigh, knee, leg as far as ankle]
16
Q
What is the Diagnostic criteria [ACR] for OA
A
- Over 45
- Pain over 3 months
- Pain when loading, no increase when sitting, radiating to groin/buttock/low back
- Reduced hip rotation and flexion, with bone-bone end feel
- Weak hip abductors
- Difficulty getting going and or stiffness when moving
- Tenderness on palpation of inguinal area
17
Q
Top 3 Pain presentation regions for Hip OA - (Poulsen study)
A
- Greater trochanter
- Groin
- Anterior/lateral thigh
18
Q
3 Risk factors associated with OA – Metcalfe study
A
- Family Hx
- personal hx of knee OA
- Pain using stairs / slopes
19
Q
Why is assessing the less likely features just as important as seeing what should be there for hip OA? What are some examples of less likely features.
A
It’s an efficient way to DDx and narrow down your diagnosis to the likely pathology
For example.
- A Young patient is less likely to have OA
Even while presenting with morning stiffness, pain on walking, or relief while sitting.
- The absence of these features makes it less likely to have OA
20
Q
The most strongly associated physical findings for hip OA [descending order] Metcalfe
A
- Posterior hip pain caused by squatting
- Groin pain on hip abd/add
- Abductor weakness
- Decrease ADD
- Decrease IR compared to other leg
21
Q
DDX for OA
A
- Anterior pain = FAI
- Lateral hip pain = Trochanteric bursitis [patient would have pain lying of affected side], ITB tendonitis, or Gluteal Tendinopathy [movement related pain; check for tension in muscles]
- Posterior = SIJ
22
Q
Describe the presentation between early and advanced stages of OA
A
Early stages:
[capsular pattern, ligamentous end-feel and no crepitus]
- capsular stiffening [IR, flexion, ABD and Extension
- Joint play loss of elastic end feel
Advanced stages :
[noncapsular pattern, hard end-feel and crepitus]
- gross limitation. Loss of all rotatory movement
- functional loss most in F/E
- Joint play will have hard end feel[grinding], associated crepitus.
23
Q
Treatment of OA
Early Vs Advance/quick progressing
A
Early:
Capsular stretching, traction, and muscular re-education
Advanced/quick progressing:
surgery or intra-articular injections [temporary relief]
24
Q
Orthopaedic Assessment of Hip OA
A
- ROM [important to assess any decrease]
- Scour
- Long axis distraction [increase space; reduce pressure/pain]
25
If there is pain during long axis distraction (a negative finding for OA) what does this mean?
If there is pain it potentially rules out OA. They may have sprain/inflammation of ligaments because they are being stretched, so instead, it likely points to either instability, FAI, labral injury. Or even these conditions ontop of OA.
Doing a Log Roll test [which creates IR / increasing intra- articular pressure] should produce pain with OA. If it doesn’t return to anatomical position of slight ER/ no spring back, it leads you to think the iliofemoral ligament has been damaged since it limits ER = points more to instability
26
What is Femoral Acetabular Impingment
Morphological change of the hip ; overgrowth lesion; between the proximal femur and acetabular rim.
27
What are the side effects of FAI?
When movement is occurring with FAI, the impingement increases the likelihood of the acetabular being damaged
- which then leads to labral injury
28
What movement is mostly associated with FAI?
Mc anteriorly with flexion and rotation
Extreme internal rotation would cause pain
29
Warwick Agreement for FAI syndrome
**1. Triad of symptoms**
- Pain
- Clicking, catching & stiffness
- Giving away
**2. Clinical findings**
- restricted ROM
- Ve+ impingement sign [FADDIR]
**3. Imaging**
- CAM: thickening of fem head/neck junction
- Pincer: over the coverage of acetabulum
30
Aetiology/causes of FAI
- Multifactorial
- Intrinsic genetics, M/F
- repetitive microtrauma with hip rotation/flexion
[basketball or hockey]
- childhood diseases
- Femoral neck fracture malunion
- Surgical overcorrection dysplasia (abnormal tissue growth)
-> pincer
31
Typical Patient History for FAI
- 20-50 age; Male
- Gradual anterolateral hip pain
- C-sign
- Sharp pain turning
- Prolonged sitting, rising, getting out of car
- Leaning fwd
- No pain walking [no extreme movement]
- CAM: younger
- Pincer: women repetitive movement resulting in labral tear [catching pain]
32
Diagnosis of FAI = 3 Converging lines of evidence
1. Pain pattern
2. Positive impingement manoeuvres
3. Imaging studies [CAM, Pincer or mixed]
33
Orthopaedic Assessment for FAI
1. ROM [IR would cause pain]
2. FADDIR [ it does stretch the capsule which could still cause pain]
3. FABER
4. Functional tests [squatting, stair climbing]
34
DDx red flags for anterior groin pain [acute and chronic]
Acute pain:
* Tumour, infection, septic arthritis, osteomyelitis, fracture, AVN
Chronic pain
* Inguinal or adductor pathology and pubalgia
35
Treatment for FAI
1. Avoid aggravating activity
2. Muscle rehabilitation
3. NSAID for pain management
4. Surgical intervention often warranted
* Literature states that with conservative management for patients who are not athletes, quiet often the long run for ADL’s is like post-surgery
36
Conservative management for FAI - Wall et all 2016:
* Education/advice
* Pain management
* Exercise hip program
* Manual therapy
* Hip joint infection
* Orthotics
* Taping
37
Prognosis for FAI
- Studies suggest treatment improves symptoms and allows return to activity
- Long term effect is not known, or if treatment prevents OA
- Warwick agreement states that the condition will worsen without treatment
38
How is the acetabular supported?
* Supported by the pubofemoral ; inferiorly
* Ischiofemoral ; posteriorly
* iliofemoral ; anteriorily
39
Effects of an absent labrum
Increase stress between the acetabulum and femoral head and increases femoral movement
40
Aetiology of Acetabular labral tears
* FAI [most often]
* Capsular laxity
* Articular cartilage degeneration
* Trauma: twisting, pivoting, and falling = shear forces
> Esp. repetitive = microtrauma -> progresses
> Hyperextension with ER = MC MOI
> Athletes; HF HE and ABD increase risk of tear
* Dysplasia.
41
Signs and symptoms of labral tear
* Frequently causes anterior hip/groin pain
- Anterior tear = anterior pain [+++]
- Posterior tear = buttock pain
- May have clicking/locking [+++], or catching/giving way
- May be asymptomatic
- Aggravated with walking, pivoting, prolonged sitting, and impact activity
- Night pain sometimes
- MC in Women
- Mc physical finding is +FAI test and limited internal rotation
42
Orthopaedic test for labral tear
1. **Impingement Test- FADDIR**
2. **Hip ROM**
3. Faber: brings hip fwd
4. Scour: Grinding test
5. THIRD: compression/distraction hip flexion IR ADD
6. Log roll:
7. Fitzgerald:
8. Long axis distraction: decrease pain
9. Resisted SLR: increases intra-articular pressure
10. General laxity: Beighton’s
43
Treatment for labral tear
- Rest not likely, temporary relief
- Physical therapy
- Surgery short term improvement, less likely to improve with arthritis or dysplasia
44
Management for labral tears:
Assessment of Hip/pelvic muscles
* Periods of rest, NSAID, conservative care at the start to reduce pain; but will come back with activity
* Essential to avoid rotational movement
* gluteus weakness in extension and iliopsoas weakness in flexion increases anterior joint hip force = can potentially lead to tear, and contribute to OA
45
When locking is present, what condition should be considered?
Osteochrondral lesion
46
Snapping Hip Syndrome
Coxa Saltans
Define
Muscle Issue – irritation on a bony surface
Audible or palpable snap when flexing or extending the hip
* EXTERNAL: ITB/TFL-> greater trochanter
* INTERNAL: iliopsoas-> iliopectineal line
47
Snapping Hip Syndrome aetiology
Secondary to lose bodies, labral tears, and fractures
48
Snapping Hip Syndrome Clinical Diagnosis
- History
- Local palpation with ROM for snap
- ROM muscle testing = reveal pain/weakness
- Orthopaedic test focus on muscle pathology
- Plain radiograph
- Dynamic ultrasonography
- MRI
49
Symptoms + Signs of Snapping Hip
- Painless is common
- Pain and weakness
- Sometimes audible or palpable snapping of tendon
50
Risk factors for Snapping Hip Syndrome
- Multifactorial
- Young, skeletal immature athletes
- Soccer, gymnastics, ballet which require end-range hip motion, esp. ER and ABD
- Deep repetitive flexion [weightlifters]
- LLD
- Developmental abnormalities
51
External Vs Internal Snapping hip
External Snapping Hip
- Posterior fibres of ITB or anterior fibres of glut max moving over trochanter during F/E
- Not always audible; easily palpable/ often visible
- Trochanteric bursitis may occur
- Landing a jump, gymnastic, basketball
Internal Snapping Hip – less common
- Iliopsoas disorders
- Occurs over anterior porting of hip
- Secondary to tendon going over iliopectineal eminence, approx. 50 of hip flex.
- Femoral head interaction occurs early 0-15 flexion
- ISHS can occur after hip replacement with protrusion of acetabular cup
- Half of patients will have some intra-articular pathology complicating the presentation
52
Imaging for Snapping Hip Syndrom
BEST = Dynamic ultrasonography
To see the tendon moving over while patient does movement
53
DDx for snapping hip
- Labral tear
- Bursitis
- Femoral head AV
- Tendonitis/tendinopathy [hip or iliopsoas]
- ITB syndrome
- Intra-articular loose body
- Synovitis
54
Physical Examination to differentiate between internal and external snapping hip
**External**
- Ober
- Faber
- Hula hoop standing
- Bicycle [active hip f/e]
**Internal**
- Thomas
- Modified Thomas
- Resisted SLR [stinchfield]
- Active iliopsoas test
55
Management for snapping hip syndrome
No pain = no management
Pain is present:
* Rest
* Stretching,
* Activity medication
* NSAIDS, steroid injection
If persists surgical management is warranted
56
Orthopaedic Assessment for snapping hip
1. 90-90 straight leg raise [hamstring]
2. Bent-knee Stretch test [prox. hamstring]
3. Thomas/modified Thomas
4. Fair Test [piriformis]
5. Ober/ Modified Ober
6. Active iliopsoas
7. Bicycle
8. 30 sec leg stance [weak glut med]
56
Complete lower limb biomechanical assessment for snapping hip
Including dynamic and static is essential
- Lower limb alignment [Coxa Vara / Valgus,
Genu Recurvatum...] Feet over pronation,
Evaluation of muscle weakness and tightness; Gait
57
Define Greater Trochanteric Pain Syndrome
- Originally thought to be the bursae itself, but now it’s theorised that the hip abductor tendon involvement is the main culprit which inflame the bursae.
- Glut med/min attach to the greater trochanter
[along with TFL]
- TFL tightness
- Combination of tensile and compressive overload appears to be particularly damaging
58
Common mimickers of Greater Trochanteric Pain Syndrome
- Trochanteric bursitis
- L2/L3 lumbar radiculopathy
- Lumbar facet syndrome
- Subcostal and Iliohypogastric entrapment neuropathy
59
Why are females more prone to
Greater Trochanteric Pain Syndrome
Wider pelvis; increases lever arm of the muscles on the greater trochanter = compression
60
History and Physical Evaluation of Greater Trochanteric Pain Syndrome
- lateral hip pain
- acute or gradual non-traumatic
- pain related to activity
- dull, achy, sharp or lancing pain radiating along lateral thig
- lying on affected side increases pain
- Repetitive hip F/E, I/E rotation
- Prolonged standing, leg crossing, single-legged activities
- Stiffness getting out of a chair, esp. if hips are flexed beyond 90
61
Radiological Assessment for Greater Trochanteric Pain Syndrome
- Conventional Imaging: bony pathologies, trauma, pelvic/lumbar conditions
- Ultrasonography: tendon calcification, bursal distension
- MRI = GOLD STANDARD
62
Greater Trochanteric Pain Syndrome Orthopaedic Assessment
1. External de-rotation *
2. Single leg stance *
3. Greater trochanteric palpation
patient side lying unaffected side *
4. FABER
5. Ober / Modified Ober
6. Resisted hip abduction
7. Hip lag sign
8. FADDER-R
63
Treatment for Greater Trochanteric Pain Syndrome
- activity modification
- Rest, ice, acetaminophen
-avoid lying on side
- NSAIDS and physical modalities [controversial]
- passive/active stretching
- steroid injections [temporary]
- surgery
64
What condition should always be considered if a paitent presents with lateral thigh pain, with numbness or tingling?
Meralgia paraesthetica - because of the pathway of the lateral femoral cutaneous nerve, and the similar symptoms that present with it
65
Define Hip Pointer
Contusion of the iliac crest from a direct blow or full resulting in hematoma
- TFL belly may also be involved
66
Clinical Evalutation/Management for Hip Pointer
- Pain
- Decreased mobility or explosiveness
- Antalgic gait, first 24-48hrs
- Examination should include gait analysis, palpation [tender swollen, ecchymotic]
- Measure thigh, compare both
- ROM of knee
- Conservative management [knee 120 flexion immobilised for 24-48 hrs, followed by PRICE protocol
- Complications relates to thigh compartment syndrome
67
Treatment for Hip Pointer
* Conservative
- Rest, Ice, NSAID, Compression
- Crutches
- As pain improves, increase ROM and active resistance exercises
- If significant hematoma = Aspiration
68
Muscle Contusion grades
* Grade I: min discomfort, no limitation in competition
* Grade II: increase pain, limited performance at extreme ROM or strength
* Grade III: more pain, swelling, bleeding
69
What muscle is most commonly affected by contusion?
Quadricep femoris
70
What are complications of muscle contusions
- Myositis Ossificans
- Compartment Syndrome
71
List some DDx for muscle contusion
- fracture, dislocation, compartment syndrome, bursitis, snapping hip,
72
What is Myositis Ossificans
- Rare benign condition/complication characterised by the formation of non-neoplastic heterotrophic ossification in extra-skeletal soft tissue.
- Idiopathic or caused by trauma
- MO mainly in young male athletes
73
Symptoms of myositis ossificans
Pain with decreased ROM
74
Complications of myositis ossificans
- Peripheral nerve entrapment
- Pressure ulcers
- Functional impairment due to ankyloses
74
Management of myositis ossificans
- Conservative
- Once lesion has fully developed, surgical intervention is indicated in patients with persisting symptoms
75
The female athlete triad
1. Prolonged period of low energy availability
2. Malnutrition or undernutrition
3. Exercises’ expenditure
All increase the risks of developing stress fractures
76
Femoral stress fracture clinical presenation
- Vague, aching, ‘tired, often medial thigh or groin pain
- Worse with activity
- Night pain
77
Incorrect management of stress fractures leads to
- Complete fractures
- Malunion / non-union
- Chronic pain
- Prolonged recovery and disability
- AVN
78
Define Osteitis Pubis
Inflammation of the pubic symphysis resulting in sclerosis/bony changes
79
Define Osteitis Pubis presents as:
- Pubic pain [usually]
- Groin pain [often]
- Lower abdominal pain
- Medial thigh pain
80
Clinical Presentation of Osteitis Pubis
- Waddling gait: weak hip adductors and flexors
- Clicking/popping when rising from seat, turning in bed, walking on uneven ground.
-Pain and weakness in active/passive hip ABD and specifically RIM hip ADD
- Point tenderness of the pubic symphysis’s
- Flamingo stance x-rays
81
Clinical evaluation for chronic groin pain/ pubic symphysis problems
- squeeze test
- single adductors
- bilateral adductor
82
Hamstring Stain and High HS tendinopathy
Locations
- Proximal ischial tuberosity is more common that distal
-> proximal myotendinous junction
-> Muscle belly
-> distal myotendinous junction
83
Hamstring Stain and High HS tendinopathy most common MOI
Rapid uncontrolled stretch or forceful contraction
84
Hamstring Stain and High HS tendinopathy Risk factors
1 most significant is previous injury
- Inadequate warm up
- Strength imbalance
- lower extremity flexibility
- core stability
- muscle weakness
- Fatigue
- Dehydration
85
Clinical presentation and evaluation of
Hamstring Stain and High HS tendinopathy
- sudden sharp pain, often audible snap associated with combination of hip flexion and knee extension, hematoma, uncomfortable sitting, normal walking affected
> Stiff leg gait
> Knee flexion angle
- Occasionally tears alter sensation or pain in dermatomal distribution.
86
Hamstring Stain and High HS tendinopathy
Physical Examination
- Gait: stiff legged pattern [avoid simultaneous hip flexion/knee extension]
- Ecchymosis may be visible
- Defects may be palpable w avulsion or rupture
- ROM assessed
- muscle strength at hip and knee
- hamstring flexibility test
- peripheral neurovascular assessment
87
Special provocative tests [proximal hamstring tendinopathy]
1. Puranen-orava
2. Bent knee stretch
3. Modified bent knee stretch
4. Taking off shoe
Neurological involvement must be assessed.
88
Treatment for Hamstring Stain and High HS tendinopathy
Done according to muscle injury site.
1. Non-insertional
2. Proximal insertional injuries
- Non operative: single tendon or multiple less than 2cm retraction
- Surgery: 2 tendons >2cms retraction, or 3 tendons
89
What is Meralgia Paresthetica
Peripheral nerve entrapment of the
Lateral femoral cutaneous n.
90
What population does Meralgia Paresthetica commonly affect?
- Common in pregnancy, people who wear belts such as police officers, construction workers etc
- no gender, race or sex predilection
91
Meralgia Paresthetica Symptoms:
- numbness over the lateral aspect of the thigh
- ++ or pain
- Walking, standing will aggravate the pain while sitting decreases
92
Meralgia Paresthetica Orthopaedic tests
1. Pelvic compression
2. Neurodynamic testing
3. Tinel Sign
93
WOMAC outcome measures is out of what?
What does a high score indicate?
Its out of 96.
- Higher score indicates worse pain
94
OSH outcome measures is out of what?
What does a high score indicate?
Global score 48
High score = better outcome
95
IHOT-12 outcome measures -
What does a high score indicate?
High score= best quality of life
