Week 1 1-B - The Hip Flashcards
1
Q
Got it
A
Got it
2
Q
Sources of Hip Pain
Labral tear Loose body FAI Capsular laxity Hip dysplasia Chondral damage Joint degeneration / OA (Intra-articular/Extraarticular)
A
Intraarticular
3
Q
Sources of Hip Pain
Iliopsoas tendonitis Iliotibial band syndrome Greater trochanteric bursitis Gluteus medius or minimus tendonitis Stress fracture / reaction Adductor strain Hamstring strain / rupture Piriformis syndrome (Intra-articular/extra-articular)
A
Extra-articular
4
Q
Sources of Hip Pain
Sports hernia (core injury
Osteitis pubis
Lumbar spine / SIJ
Pain referred to hip region/Intra-articular)
A
Pain referred to hip region
5
Q
Iliotibial Band Syndrome (ITBS)
People complain of pain in the (medial/lateral) hip/knee.
A
lateral
6
Q
Iliotibial Band Syndrome (ITBS)
Most common cause of (medial/lateral) knee pain
2nd most common cause of knee pain in runners
Occurs in cyclists frequently
(15% of overuse injury)
A
lateral
7
Q
Lateral Hip / Knee Pain Differential Diagnosis
PFPS DJD lateral compartment Lateral meniscal pathology LCL sprain Superior tib-fib joint sprain Popliteal or biceps femoris tendonitis Common peroneal nerve injury
Referred pain from lumbar spine
What Level?
A
L5
8
Q
ITBS
Clinical Presentation
Pain 2 cm (above/below) lateral joint line - (femoral epicondyle)
Usually at same point (after/of) run / bike - (irritation w/ repetition)
Stabbing / sharp pain - may not be able to continue
up/down stairs
after sitting for a period of time
Pain (increases/diminishes) with rest
A
above; of; diminishes
9
Q
Got it
A
Got it
10
Q
ITB Anatomy
____ crest to (inferior/superior) aspect of lateral femoral epicondyle, then again at ______ tubercle
Unattached portion where it crosses knee joint
A
iliac; superior; Gerdys
10
Q
Got it
A
Got it
11
Q
ITB is a thickening of the _____ lata
A
fascia
12
Q
What attaches to the ITB?
Gluteus (maximus/minimus
TFL/Vastus intermedius)
(Medial/Lateral) retinaculum of the patella
A
maximus; TFL; lateral
13
Q
The ITB attaches the full length of the femur
A
Got it
14
Q
ITBS
Small portion where ITB is not attached
People have pain (above/below) the joint line
A
above
15
Q
ITB Anatomy
“Tendon” portion - Attachment to femur
“Ligament” portion - Controls tibial (EROT/IROT)
Tendon connects muscle to bone – the muscle being the TFL – bone being the femur .
Ligament attaches bone to bone – tibia and femur
A
IROT
16
Q
MR of distal femur
Layer of fat tissue deep to ITB: (Highly/Lowly) innervated (Highly/Lowly) vascular Pacinian corpuscles (BURSA/NO BURSA) PRESENT
At _° knee flexion, ITB compresses fat layer below against fem epicondyle
Lot of pain receptors due to being highly vascular
If you constantly compress that area it will be irritated.
A
Highly; Highly; NO BURSA; 30;
17
Q
Iliotibial Band Syndrome
Biomechanical Etiology – Current Concept (Fairclough et al., 2006, 2007)
IT band is attached to the distal femur and cannot rub on epicondyle
IT band is compressed against epicondyle during movement
Tibial IROT occurs on femur with knee (flexion/extension)
Tibial IROT (decreases/increases) compression
Pain due to compression of fat layer under ITB vs repetitive friction
A
flexion; increases;
18
Q
ITBS Risk Factors
Cyclists
Toe (in/out) position – pedals
Saddle too high, too far back
Bike fit?
Bike fit – can cause irritation of the IT band.
Toe in – (decreases/increases) internal rotation
A
in; increases;
19
Q
ITBS
Clinical Tests
(+/ +/-) Noble compression test
Common: (+/ +/-)Thomas test
(+/ +/-) Ober’s test?
A
+; +; +/-
20
Q
Clinical Findings in ITBS
significantly (higher/lower) Ober measurement (1.2°)
weaker hip (internal/external) rotator strength (1.2 Nm/kg)
Greater hip (internal/external) rotation motion (3.7°) Peak motion while running
A
lower; external; internal;
21
Q
ITBS Biomechanics
Increased (ABD and EROT/ADD and IROT) at mid stance
(IROT/EROT) of leg increases with fatigue during running
A
ADD and IROT; IROT
22
Q
Biomechanics to Consider
Associated with ITBS
(Narrow/Wide) Step Width - (cross over pattern)
A
Narrow
23
Q
Step Width
A
Got it
24
Narrow Step Width
Narrow: >25% of heel is medial to vertical line from L5 spinous process.
This leads to (decreased/increased) ITB peak strain and strain rate
increased;
25
Step Width
Increased Step Width:
Reduced
Peak hip (adduction/abduction)
Peak rear foot (inversion/eversion)
ITB strain
adduction; eversion
26
ITBS
Biomechanical targets for rehabilitation:
With ITBS there is a Large hip (adduction/abduction) angle / (medial/lateral) collapse of hip:
Target weak hip (adductors/abductors), poor activation / neuromuscular control of the hip
-Narrow step width:
Modify running technique
adduction; medial; abductors;
27
ITBS Treatment Concepts
Start with basic movements like lunges, squats, etc
Got it
28
No US, doesn’t work
Local pain and acute – (local as in pointing to the spot) – iontophoresis is (bad/good)
good
29
Injection - (Acute/Chronic) and painful
Acute
30
ITBS Treatment
Stretch?
1 and 2 joint hip flexors
WHY? - Restricted hip flexor length (Thomas test) demonstrated (increased/decreased) gluteal activation
Self stretch
Contract- relax
Active stretch
Thomas test is positive – restricted hip (flexor/extensor) length
People with tight hip flexors don’t use their glutes well
Maintain core stability – if go into lumbar extension when doing these stretches then it will (increase/decrease) the stretch.
decreased; flexor; decrease;
31
This relates to IT band syndrome = if you don't have motion north south, you’ll go east west. That will lead to _____ valgus.
dynamic
32
Can prob stretch the TFL, but not really the IT band.
Got it
33
What is the best ITB stretch out of the three pics?
The middle one
34
Probably not able to stretch the ITB
Got it
35
Look at the fascia all around that area.
Try to (stabilize/mobilize) the tissue
mobilize
36
Coo
Coo
37
Video
Video
38
Not the focus of treatment, but helps pts feel better.
ITB strap – redirects the force through the area that is compressed. Similar to thing used for LET. Indications - Pain that is limiting their function or trying to get through a race
Got it
39
ITBS Treatment Concepts
Prevent (sagittal/frontal and transverse) plane instability
```
Promote a “neutral” hip, knee position:
Avoid excessive (ADD/IROT/ ABD/EROT)
```
frontal and transverse; ADD/IROT
40
Blueprint to LE pathologies
Core stability – need a nice stable core to develop force through limbs
Got it
41
Progression
(NWB > Bilateral WB > Unilateral WB / Bilateral WB > NWB > Unilateral WB)
CKC activities are (less/more) functional
B – bilateral
NWB > Bilateral WB > Unilateral WB; more;
42
Activating the core (improves/declines) ability to recruit glute muscles and to generate force, for a good stable base
improves
43
Strength without stability - think of the same concept in the UE for the LE
Got it
44
LE – proximal stability comes from the ____ to stabilize the pelvis and the muscles that attach to it to generate force
core
45
Got it
Got it
46
When someone does hip extension and they extend their lumbar spine it can come from tight hip (flexors/extensors)., spine will go into extension.
Another reason might be not having hip extension strength so they extend with their back. Watch pts closely so they don’t cheat even if its’ not on purpose
flexors;
47
Got it
Got it
48
As you have resistance from UE the core (is/isn't) activated. As you do side steps have them hold a weighted ball and that will engage their TA.
Palloff press is the pic all the way to the left
is
49
Got it
Got it
50
Hip strength/stability
Got it
51
Want hips flexed more than _ degrees to increase glute max/med muscle activation
Neutral position – hips stacked, don’t want to go forward or backwards
60
52
Also works on controlling (ER/IR) to work on NM control
IR
53
Got it
Got it
54
Gluteal Muscle Recruitment
Lower crossed syndrome:
Specific patterns of muscle weakness and tightness
```
Weak (anterior/posterior) abdominals (APT)
Short lumbar (flexors/extensors)
Short hip (flexors/extensors)
(Tight/Weak) gluteals – In this position gluteals can not activate effectively
```
Restricted hip flexor length (Thomas test) demonstrated (increased/decreased) gluteal activation
“Gluteal amnesia”
If you are in lumbar extension the hip flexors are shortened and they get tight and the glutes don’t work as well.
People with lower crossed syndrome don’t activate their glutes as well.
Have pt do clamshells on both sides. Involved side – they don’t get muscle fatigue because they are using hamstrings or something else to compensate
anterior; extensors; flexors; Weak; decreased;
55
Got it
Got it
56
Gluteal Activation
Activate gluteal muscles (prior/after) to dynamic activity
Reinforces motor program
prior
57
Got it
Got it
58
Side steps – someone who has weak hip (adductors/abductors) will cheat by rocking back and forth and not keeping their pelvis level, will see hip hiking (QL)
abductors
59
Pt should feel exercise on the side (on/off) the ground
on
60
Coo
Coo
61
Can make exercises harder – unstable surfaces, change BOS – make more narrow, close your eyes, tandem stance, have them reach for something like a ball that you are throwing to them, etc.
Got it
62
Got it
Got it
63
Added rotation
Got it
64
Got it
Got it
65
Got it
Got it
66
Training hip extension and starting with a flexed hip to generate more force (muscle-length tension relationship – more of a mid range position so muscle works better)
Got it
67
Got it
Got it
68
Got it
Got it
69
Pt had a hard time controlling IR in video
Got it
70
Making sure it doesn't go into a (varus/valgus) position
valgus;
71
```
Stability
thru
(External/Internal)
Rotation
of the
Femur
```
External
72
Running with it for a couple of weeks and helped her not run with so much (valgus/varus)
valgus
73
Pronation distally affects what is happening up the kinetic chain
Got it
74
What is Plyometrics?
Technique to develop ____ (speed-strength)
To train the muscles to become (less/more) explosive
(Concentric/Eccentric) muscle contraction immediately followed by a (concentric/eccentric) muscle contraction causes (decreased/increased) force production of same muscle
power; more; eccentric; concentric; increased
75
Plyometrics
Benefits:
Improved neuromuscular control
(Increased/Decreased) rate and magnitude (peak impact) of loading
Decreased peak hip (abduction/adduction)
Decreased; adduction
76
Plyometrics are done at the (beginning/end) of rehab.
end
77
Land on box - Start pts with landing (before/after) jumping
Leg press – do much (more/less) than body weight and try to land softly.
Alternate legs - Working on quickly absorbing impact and exploding
before; less;
78
Got it
Got it
79
Coo
Coo
80
Got it
Got it
81
Return to Run
Run (at/under) threshold of pain
Asymptomatic (during/during and after)
Increase run volume (mileage / time) as (mobility/stability) improves
Return to run
Start with intervals - run/walk
At volume that is (not too symptomatic/asymptomatic)
Increase volume (mileage / time) as (mobility/stability) improves
Monitor for symptoms
If pain comes on at 4 miles , run underneath that
under; during and after; stability; asymptomatic; stability
82
If you don’t correct their mechanics it comes back. Treat it like someone who has ITBS.
Got it
83
Trochanteric Bursitis
Between what two gluteal muscles?
Between greater trochanter and (TFL/Rectus femoris)
medius and minimus; TFL
84
Got it
Got it
85
Trochanteric Bursitis
Clinical presentation:
Pain: (medial/lateral) aspect of thigh
Tenderness over/around (lesser/greater) trochanter
Onset: typically (trauma/insidious), may be (trauma/insidious)
```
Pain with
Contraction of (adductors/abductors)
Passive stretch of (adductors/abductors)
Full passive (flexion/extension), (adduction/abduction), and (internal/external) rotation
Pressure on (lateral/medial) hip
```
MMT will be painful with abduction, stretching into adduction will be painful.
lateral; greater; insidious; trauma; abductors; abductors; flexion; adduction; internal; lateral
86
Trochanteric Bursitis
Clinical presentation:
Snap in the (anterolateral/posterolateral) hip region may be reported.
May report pain with ascending or descending stairs
Weak hip (adductors/abductors)
(+/ +/-) Trendelenburg
Gait deviations - Compensated trendelenburg
posterolateral; abductors; +;
87
Trochanteric Bursitis
```
Pain in (medial/lateral) hip with possible radiation of pain down to (ankle/knee) region.
Often resembles Lumbar Spine pain referral pattern.
```
How do you differentiate?
```
Reproduction with L spine movement?
Dermatomes? Sensation changes?
Myotomes?
DTR’s?
Dural Tension signs? (SLR)
Palpation Gr trochanter
Hip motion (compression)
```
You know its not from the lumbar spine – based on the repeated motions
LQ screen – do that to rule out the spine as the source of pain
If palpating the greater trochanter and there is pain it (is/is not) lumbar spine
lateral; knee; is not;
88
Trochanteric Bursitis
Treatment
```
Remove stress:
Change lying position/padding (pillow between knees)
Modify activity level
Stretch tight tissues
(Distal/Proximal) strengthening
```
Anti-inflammatories:
NSAIDS
Modalities
Proximal;
89
Trochanteric Bursitis
Early: resisted (isokinetics/isotonics) may be painful
isotonics
90
Got it
Got it
91
Hamstring Strain
Occurrence:
2nd most common cause of injury in NFL
(knee sprain first)
1st for Elite level soccer
```
Re injury rate:
High - (1/3 / 2/3) !!!!
Greatest risk during first _ weeks of return to sport:
Inadequate rehab
Return too early
both
```
1/3; 2
92
Mechanism of Hamstring Injuries
(Low/High) speed running
(Initial/Terminal) swing phase of gait
Hamstrings are active (accelerating/decelerating) shank in prep for foot contact
Large (concentric/eccentric) demand
(Acceleration/Deceleration) injury
(Semitendinosus/Biceps femoris) more often injured
```
Simultaneous hip (flexion/extension) and knee (flexion/extension)
Kicking
Dancing
Stretch injury
Semimembranosis
```
Hamstrings have to decelerate the tibia and it is a large eccentric demand
Most peoples quads are a lot stronger than their hamstrings
High; Terminal; decelerating; eccentric; Deceleration; Biceps femoris; flexion; extension
93
Got it
Got it
94
Hamstring Strains
Grades
Grade 1 - (mild/moderate)
Grade II - (mild/moderate)
Grade III - (moderate/severe)
```
Based on amount of:
Pain
Damage
Loss of motion
Reflects underlying amount of tissue damage
```
Can be used to estimate recovery period
More damage - the longer it takes to heal
mild; moderate; severe;
95
Hamstring Exam
History
Sudden onset of (anterior/posterior) thigh pain during activity (running)
Audible pop - (distal/proximal) tendon
Usually unable to continue activity
Purpose of exam:
Location and severity of injury
Mechanism and location have prognostic impact on time to return to pre injury level
Biceps femoris - (high speed running/kicking)
(Shorter/Longer) recovery period
Semi membranosis - (high speed running/kicking)
(Shorter/Longer) recovery period
posterior; proximal; high speed running; Shorter; kicking; longer
96
Hamstring Exam
Palpation:
Palpable defect - grade (1/3)
Measure length of palpable pain region - Healing reassessment
Location of pain - distance from point of maximal pain to IT
More proximal the site of the point of maximal pain, the (shorter/greater) the time needed to recover
IT - Ischial tuberosity
Palpate where pain is
Complete rupture – can feel where it is torn
The larger the area is the longer the healing
Distal hamstring tears equate to a quicker recovery
3; greater;
97
Longer Recovery
Injury involving (biceps femoris/semimembranosis)
Proximity of injury to IT
Size of tissue damage - Length and cross sectional area
semimembranosis;
98
Differential diagnosis:
Lumbar radiculopathy - Lumbar spine screen
```
Adductor strain – gracilis, adductor magnus
How do you know?
Pain with:
Resisted (ADD/ABD)
Passive (ADD/ABD)
Palpation (ADD/ABD) tendons
```
Combined injury: semi M and Add Magnus
Lateral Split / lunge (tennis)
ADD; ABD; ADD
99
Got it
Got it
100
T2 weighed MRI – White - fluid – black – swelling and scar
Got it
101
Scar Formation
Changes tensile properties / length of hamstring muscle
Increases (active/passive) stiffness
May change force generating capabilities
Less capable of withstanding (concentric/eccentric) loads
(Decreased/Increased) susceptibility to re-injure.
passive; eccentric; Increased
