Week 3 Lecture 3B Intra Articular Hip Disorders Flashcards by Michael Obi

7-6-22 LECTURE START

Hip dysplasia – abnormal presentation of the hip

Capsular laxity – loose hip joint

Loose body – cartilage potentially floating around

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Innervated – can hurt

Synovial fluid helps dissipate some of those forces – good for decreasing joint stress and lubricating joints

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Majority of tears are in the anterior superior part of the joint.
From 12-3 is where (least/most) ppl tear their labrum (anterior superior labrum)

Posterolateral is less frequent – from 10-7.

most;

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Labral tear – cartilage is not in good shape.

People who have labral tears have more injury to their cartilage.

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Labral tears are pretty common, can be asymptomatic. It is very common! Pretty common to have a labral tears that doesn’t bother you.

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If you have an acetabulum that is not normal in orientation it can wear away the labrum which would make it a symptom of abnormal morphology.

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Labral Injuries

Clinical Presentation:
Pain
(Anterior/Posterior) hip (90%) and/or groin pain
(More/Less) common in lateral or posterior regions
may radiate to knee (ant)
Anterior pain = (anterior/posterior) tear; posterior pain = (anterior/posterior) tear
Described as dull ache; intermittent sharp pain that worsens with activity - Walking, pivoting, prolonged sitting aggravate symptoms
Catching, clicking
Adductor / groin pain

Posterolateral tear will be on the posterior hip and it is less common.

Have to rule out lumbar spine – LQ screen

Prolonged sitting with the leg in hip flexion.

Anterior; Less; anterior; posterior;

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Labral Injuries

Clinical Presentation:
71% (Beginning/End) of day pain

Functional limitations
Limping (89%)
Need bannister to climb stairs (67%)
Limitation of walking distance (46%) - Painful when walking too far
Sitting tolerance limited to 30 min (25%)

End;

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Most labral injuries are (traumatic/insidious).

Sitting in a car and dashboard drives femur in a posterior direction and then it subluxes out the back (posterior labral tear)

Hockey players get a lot of labral tears

Fall on flexed knee and hip – (anterior/posterior) labrum

insidious; anterior

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Traumatic – easy to sort out – pain as a result of the injury

FAI – Bones of the femur and acetabulum – something is wrong with how they were made.

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Abnormal shape of the bone creates the mechanical impact of the femur on the acetabulum.

As your femur comes into flexion you get the conflict between the neck of the femur and the acetabular rim. Something can be weird there between those two structures.

Cam – less space there and it butts into the acetabular rim

Too much bone on the acetabular rim and it’ll cause that mechanical conflict.

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(Cam/Pincer) – damages the labrum more severely
(Cam/Pincer)– injure the cartilage between the acetabulum

https://www.youtube.com/watch?v=A-_r8FyJwTQ

Pincer; Cam

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Cam – extra bone and then the extra bone engages in flexion

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Pincer

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Cam on the left pre op , post op on the right – took bone out (osteotomy)

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You lose the space and the femoral head migrates. Loss of gap creates the impingement.

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The distance is a normal offset. If the gap is small it is a problem – indicative of a cam lesion.

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Alpha angles can impact tx
If you have extra bone, the angle will be bigger.
Measure of the sphericity of the femoral head – this is a cam

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ALPHA ANGLE

DEFINITION: angle formed by: (1) a line parallel to the femoral neck axis and (2) a line from the center of the femoral head to the transition of the femoral head into the femoral neck
ABNORMAL: if > _ degrees then associated with CAM type femoral acetabular impingement

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If the number is big, too much acetabular coverage.

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Center Edge Angle

The acetabulum typically overhangs the femoral head.
NORMAL: The degree of overhang typically ranges between _ to _ degrees and is termed the Center Edge Angle (Angle of Wiberg).

OVER COVERAGE (pincer/cam):  > _ degrees
UNDER COVERAGE: Smaller Center Edge Angles - < _  degrees have been associated with congenital dislocations (under coverage)

Less than 20 there is not enough coverage and the hip can be unstable.

30 to 40; pincer; 45; 20;

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Femoral Neck

Angle of Inclination: Angulation of the femoral neck in the frontal plane
Facilitates motion by orienting the femoral shaft more lateral and provides a greater lever arm for the hip abductor muscles

Values/Variations:
Normal: approximately _ degrees
Coxa Valga: Angle of Inclination > _ degrees
Coxa Vara: Angle of Inclination < _ degrees

This impacts the way the femoral head sits in the acetabulum . The way the femoral head sits in the acetabulum will be different.
Small contact area – degeneration of their joint OR can be unstable – variations ^^

125; 135; 120;

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Femoral Neck II Angle of Declination (Torsion / version): Angulation of the femoral neck in the transverse plane relative to the femoral condyles Values/Variations: Normal Adult Value: (_-_°) Increased anteversion (> _ °) Retroversion (< _°)

8-15; 15; 8

Femoral version

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People with anteversion will be toe (in/out) | People with retroversion will be toe (in/out).

in; out

Excessive anteversion – feet straight ahead won’t put femoral head smoothly in the acetabulum – only comfortable when toe in.

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SCFE (slipped capital femoral epiphysis) – femoral head comes down in an inferior direction and reduces the head-neck offset AVN – Avascular necrosis

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Anteverted – to the front

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Acetabular retroversion may lead to .. (Cam/Pincer) impingement and a + cross over sign.

Pincer

Anterior rim will be more prominent in retroversion. Anterior rim crosses over posterior rim. A retroverted acetabulum creates the pincer because you have more coverage on the front and will bang the anterior wall of the acetabulum.

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Limited in hip (flexion/extension) for retroversion

flexion;

Coxa profunda – (shallow/deep) acetabulum . The acetabulum got really deep. That creates a (cam/pincer) all around the acetabular rim.

deep; pincer

If you have one of these hip dysplasia's it will wear out quicker

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Terminology Under-coverage: Excessive acetabular (anteversion/retroversion) Coxa (Valga/Vara) Developmental Dysplastic Hip DDH - (shallow/deep)acetabulum Over-coverage Acetabular (anteversion/retroversion) Coxa Profunda- Acetabular fossa is too (shallow/deep)

anteversion; valga; shallow; retroversion; deep

Something wrong with the makeup of the cartilage – primary Goal for FAI surgery is to preserve the hip joint

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AIIS – Rectus femoris attaches to the AIIS.

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IFI – if you go into (flexion/extension), (add/abduction), and (IR/ER) , you can impinge the lesser trochanter on the ischial tuberosity. That will be the test to look for it as well. Fx – trauma that changes the position of the lesser trochanter on the femoral neck.

extension; adduction; ER

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Iliopsoas passes in front of the anterior hip. The iliopsoas is 1-3 o clock on the clock face and passes in front of the anterior labrum

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L – labrum C – capsule IP – iliopsoas They are right on top of each other and when you get inflammation in that space you get development of adhesions. When you flex your hip everything will be stuck together and it hurts.

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Gpt ot

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People with groin pain have poor trunk stability When you initiate limb movement, first muscles to activate are the multifidus and TA.

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When you stabilize your core it makes your hips work better.

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Etiology - NM Control (Short / increased tone / PAIN/ Weak / poorly recruited) - Soft tissue mobilization iliopsoas Adductor group ``` (Short / increased tone / PAIN/ Weak / poorly recruited) - Strengthening Gluteus max Gluteus medius TA Obliques ```

Short / increased tone / PAIN; Weak / poorly recruited

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Log roll test Feeling for how much resistance is there. Passive IR and ER of hip With external rotation of the hip in neutral, the (iliofemoral/ischiofemoral) ligament and (anterior/posterior) capsule are the limiting structures and are, therefore, being assessed (Neumann). With internal rotation, the end-feel can be assessed for the (iliofemoral/ischiofemoral) ligament and (internal/external) rotator muscles as well.

iliofemoral; anterior; ischiofemoral; external;

Examiner manually rotates hip into IROT and then releases the limb allowing it to passively rotate externally. + test = when there is external rotation (below/beyond) 45° from vertical in the axial plane on the affected limb, and it lacks a definitive mechanical endpoint. Should flop back to EROT

beyond

(Hyperflexion/Hyperextension) + (IR/ER) - Looking for apprehension

Hyperextension; ER;

Posterior apprehension test (Extension/Flexion), (Abduction/Adduction), (EROT/IROT) – posterior force + = Pain or apprehension

Flexion; Adduction; IROT;

Stability Issues Factors contributing to reduced stability: Capsule and ligament laxity Bone Architecture: (Increased/Decreased) center edge angle (below 20 degrees) Increased acetabular (anteversion/retroversion) (Shallow/Deep) acetabulum Coxa (vara/valga) * Clinical Issue: - The hip is an inherently stable joint. A relatively small amount of instability in the hip may prove problematic versus a joint such as the shoulder. - Hip is a weight bearing joint Anteversion- more open in the front so it will be less stable Instability of the hip can create problems because you have to WB on it. A little bit of instability can cause a big problem.

Decreased; anteversion; Shallow; valga;

Association between Non-Contact Posterior Hip Subluxation and Femoroacetabular Impingement Decreased functional flexion of the hip due to FAI (Cam, pincer, or both) - Can cause (anterior/posterior) hip subluxation Subluxation – as the femur bangs into the acetabular rim it can sublux posteriorly. Added hypermobility increases risk of subluxation.

posterior;

Clinical Exam- Intra articular hip pain Subjective ``` Pain with (minimal/prolonged) sitting Anterior hip pain with active hip (flexion/extension) - End range pinch or pain Pain with (flexion/extension) phase of gait Sharp pain, clicking, locking with pivot movements Groin pain (adductors) ``` Questions: History of low back pain / SIJ pain ? Traumatic or insidious onset? Imaging? Observation: pattern recognition Anterior problem – pain with extension when walking because the femoral head goes anteriorly when you go into extension History of low back pain – if you bang the femur in the acetabulum you won’t have enough space to keep doing that over and over again. It can create excess motion in the pelvic ring. Imaging – guides what you do and gives a tx plan. Pattern recognition – core, gluteal muscles, adductors, decreased tone, hip flexors, etc

prolonged; flexion; extension;

Lot of ER, not a lot of IR – Femoral (anteversion/retroversion)

retroversion;

Femoral (anteversion/retroversion) – Lot of IR, but not ER

anteversion

Tilts: APT (increases/decreases) coverage PPT (increases/decreases) coverage (reduce contact of femur on acetab rim). Will impinge (earlier/later) in hip flexion when in APT. Pelvic Rotation: Toward (symptomatic/asymptomatic) side

increases; decreases; earlier; asymptomatic;

Shallower squat depth because it hurts Long strides hurt in these pts.

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Trunk rotation to the right but he is actually side bending – that is a compensation – not a lot of rotation in their trunk. Need to improve their trunk mobility

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People who wanted to do higher level sports went on to have surgery

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A period of nonsurgical management is recommended, of at least (4/8) to (6/12) weeks, prior to consideration of surgical intervention.

8 to 12

If you do a squat – 120 degrees of hip flexion pain, do a squat at 90 degrees. Ex – driving while sitting on pillows so you aren’t in deep hip flexion.

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Conservative Tx Modify movement patterns and limit symptom provocation Avoid positions of pain Patient education Avoid Postures and Maladaptive Motions Standing with hip (hyperextension/hyperflexion) Sitting with legs crossed or hips rotated Lack of knee flexion at heel-strike and prolonged foot flat during stance (long strides) - Walking in hip hyperextension can increase the angular hip flexion impulse, thereby (decreasing/increasing) the demands on the anterior hip joint Prolonged foot flat during stance – long stride . Take a shorter stride. Have pts push off with plantarflexors – helps (increase/shorten) stride and bring legs forward to unload their hip flexors.

hyperextension; increasing; shorten

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Hip arthroscopy – surgical approach – labral repairs, osteotomies,

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https://www.youtube.com/watch?v=pOAmATL_KEs

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Big black post is to create traction Nerve issues after the procedure – numb or sensation changes for potentially up to a month. Fluoroscope – real time xray (it is the Phillips white thing in the back)

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Rim is irritated, bloody, beat up.

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Take the bone right out of there

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Good looking labrum

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bad labrum – pincer FAI

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They used to open the hip and pop it out of the socket, now they do arthroscopic

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Hip – right | Shoulder - left

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Extra bone on the femoral neck

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More normal shape after done

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Take the hip and put it into flexion to see if it still impinges, if it does, they’ll take out more bone

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Prognosis – the more layers involved the (easier/harder) the rehab is going to be.

harder

Layer 1 is the bone. Take out the extra bone (FAI) and correct that morphology, they do well

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Still going to have problems post op even if bone is removed. if they come pre op to address these issues they’ll do better.

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Go tit

F - This is all expert opinion !!

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Labral Procedures Debridement or repair? Labral Debridement (alone): Usually the least conservative, often guided by patient symptoms Labral Repair/FAI: Usually 10 days – _ weeks PWB If it is just debridement, don’t have to worry too much. Have to let labral repairs heal. Don’t wanna put shear force through the labrum.

Capsular Procedures Capsular plication / shift Early, limited motion is indicated Concern with limiting (ER/IR), (flexion/extension) early in rehabilitation process due to the potential stress placed on the capsule with this movement Typical: ER limit (_ degrees) Extension limit (_ degrees) _-_weeks WB = varies Tighten up the capsule because it is too loose.

ER; Extension; 30; 0; 4-6

If someone has a big chunk of cartilage missing Microfracture – create scar tissue Osteochondral – take a plug of bone cartilage and put it into that defect or it is a donor graph Be careful of shear forces.

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If you activate their hip flexors it will irritate all of that tissue so lightweight with crutches is solid.

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ROM Limitations Limit hip flexion PROM to _ for 10 days Safe for labrum 0-_ flex, 0-_ abd, 0-_ ER (Stalzer) Hip Extension? Use of a brace? 0-90 not impacting the labrum. Hip extension – long stride is irritating Some surgeons use a brace, some don’t, depends on the preference