Ortho Tx: Hip

• The acetabulum is composed of portions of the ilium, ischium, and pubis.
• The acetabulum contains the:
• Lunate surface (articular surface lined with articular cartilage)
• Acetabular fossa (non-articular surface, contains fat pad)
• Acetabular labrum (increases joint coaptation force by enclosing over half the femoral head)
• Acetabular notch (contains transverse ligament)

Bursae

• Several bursae exist at the hip; the most clinically relevant are the iliopectineal and trochanteric bursae.
• The ischial or ischiogluteal bursa is sometimes relevant for people who spend prolonged time seated or in bedrest.
• Iliopectineal bursa overlies the anterior hip/pubis and is deep to the iliopsoas.
• Trochanteric bursa include one or more over the greater trochanter.
• Many tendons attach here, including the glute med, glute min, piriformis, obturator internus, superior gemellus, and inferior gemellus.
• The glute max tendon passes over the top of the bursae posterolaterally, but doesn't attach.

Femoral Triangle

• Bordered by the inguinal ligament superiorly, adductor longus medially, and sartorius laterally.
• Contains the femoral artery, vein, nerve, and lymph glands.

Ligaments

• Iliofemoral ligament prevents excessive extension and internal rotation and is the strongest ligament in the human body.
• Ischiofemoral ligament prevents excessive extension and internal rotation.
• Pubofemoral ligament prevents excessive abduction, extension and internal rotation.
• Ligamentum teres (lig of head of femur or lig capitis femoris) has no contribution to stability, but assists joint nutrition and blood/synovial fluid.
• Transverse acetabular ligament has no contribution to stability, but forms foramen for the acetabular artery.

Acetabulofemoral Joint

• Has 3 degrees of freedom: flexion/extension, abduction/adduction, and rotation.
• The head of the femur is convex, and the acetabulum is concave.
• The resting position is 30° flexion, 30° abduction, and slight external rotation.
• The closed pack position is extension, abduction, and internal rotation.
• Capsular pattern of restriction is Flex-AB-IR > Ext-AD-ER.
• ROM and End Feel:
• Flex-120°; soft or firm
• Ext- 15°; firm
• ER-50°; firm
• IR-35°; firm
• AB-45°; firm
• AD-30°; soft or firm

MMT Review

• All of the following are of high clinical value:
• Hamstrings
• Quads group
• Rec Fem
• Psoas major
• Sartorius
• TFL
• Adductor group
• Glute med
• Glute min
• Glute max
• Internal rotators group
• External rotators group

Angle of Inclination

• Measured in the frontal plane, and is an angle between the neck of the femur and the shaft of the femur.
• Normal Adult: 125d
• Normal Child: 150d
• Decreased angle of inclination (adult less than 120) is Coxa vara and leads to genu valgum.
• Increased angle of inclination (adult more than 125) is Coxa valga and leads to genu varum.
• Coxa vara is more common than coxa valga.
• All of this can be asymptomatic

Anteversion

• Measured in the transverse plane and is the angle between the axis of the head and neck of the femur compared to the transcondylar axis of the femur.
• Describes the joint position of the hip.
• Normal: 8-15d, hence there is normal anteversion at the hip.
• Increased anteversion is 15-30d, is excessive anteversion, and creates a forward/medial orientation of the femur as a result of a positional change at the hip joint.
• Decreased anteversion is 5-8d, is retroversion, and creates a backward/lateral orientation of the femur as a result of a positional change at the hip joint.
• Can be assessed with Craig's test (Ryder's sign).
• Excess anteversion is a positional change of the hip joint.

Consequences of excessive anteversion (more than 15d)

• Apparent excess medial rotation and decrease external rotation.
• Unnatural (compensatory) toe-out stance or gait.
• Natural (noncompensatory) toe-in stance or gait.
• The greater the degree of anteversion, the more prone to degeneration or injury the hip becomes.
• Compensatory gait = anteverted hip on the Left.
• Noncompensatory toe-in gait for anteverted hip on the Right.
• A retroverted hip would be the opposite of the above.
• Apparent excess lateral rotation and decrease medial rotation.
• Unnatural (compensatory) toe-in stance or gait.
• Natural (noncompensatory) toe-out stance or gait.

Angle of Declination (Torsion)

• Measured in the transverse plane
• Angle between the head and neck of the femur compared to the shaft of the femur
• Describes the structure of the femur only and does not refer to or describe the hip joint Normal: 15d, Increased angle of declination 30d (A), Antetorsion of the femoral shaft. A medial twist. Decreased angle of declination is 5d (B), Retrotorsion of the femoral shaft, A lateral twist.

Intrinsic Stability

• Contributing factors are:
• The acetabulum & labrum: enclose more than half the femoral head.
• Coaptation force: large surface areas in contact with one another, creates 25kg of pressure holding the femoral head in the acetabulum and hip joint remains articulated passively even without muscle contribution.
• Strong ligaments: medial twist to their fibers creates a kind of screw home mechanism in extension, approximating surfaces closer together
• Unlike other joints, the hip is difficult to dislocate in a closed pack position (Extension, Abduction, Internal rotation).
• The position of most vulnerability is Flexion, Abduction, & Internal rotation.
• Flexion creates ligamentous laxity
• Abduction and internal rotation create poor congruency of joint surfaces
• This is the typical position of a dashboard injury (MVA)

Weight bearing forces acting on the hip

• On two legs: each femoral head receives force equivalent to half the weight of the upper body
• On one leg: each femoral head receives 3 times the weight of the body.
• This is because the centre of mass is midline (S2), whereas the femoral heads are lateral to the midline.
• Creates a rotary force around the femoral head.
• Strong abductor muscles are needed to counteract this rotary force.
• With abductor weakness, the stance leg dips into adduction, which appears as the non-stance leg dropping.
• Abductors primarily responsible for single-leg stance strength are glute med, glute min, and TFL
• Weak abductors in walking gait: two common gait patterns occur with weak abductors
• Pelvis Drops: the pelvis will drop noticeably to the opposite side of weakness => short swing phase on the unaffected side (aka Trendelenburg gait)
• Torso lurches: the person may 'lurch' their upper body toward the side of weakness attempting to shift the centre of gravity lateral to the fulcrum (S2), to prevent dropping of the opposite side of the pelvis
• Both can occur due to weakness or as antalgic responses to pain
• Using a cane can prevent the torso lurching towards the side of weakness, if the cane is held in the hand of the unaffected side.

Arthritis

• High prevalence of OA at the hip
• In normal stance, the acetabulum and femoral head are both oriented anteriorly; this exposes a portion of the femoral head (ie, it is not enclosed by/in contact with the acetabulum)
• As such, the posterosuperior aspect of the femoral head is weight bearing and the anterior aspect is not
• Alternating cycles of compression/decompression (weight bearing) nourish a joint by circulating synovial fluid
• The anterior aspect of the femur is effectively undernourished, leading to degeneration and arthritis over time
• Abnormality of the structural or biomechanical concepts above (especially anteversion and antetorsion) would increase incidence and likelihood of developing arthritis

Assessment

• True hip joint pain is felt in the area of the groin (not the glutes or trochanter).
• The term lumbopelvichip complex is helpful because it makes clear that the hip, pelvis, and lumbar spine function as one unit; clinically, we need to consider how the three are functioning together.
• Asymmetry at the AF joint specifically is suggested if all of the landmarks up to the greater trochanter are symmetrical, and then there is deviation.
• If the trochanters are level, but then there is asymmetry above such as ASIS, PSIS etc
• high side may have coxa valga or long femoral neck
• low side may have coxa vara, short femoral neck, cartilaginous narrowing from hip joint degeneration

Nelaton's Line

• A line drawn from ASIS to same side isch tube
• A positive finding is that the trochanter is palpated well above this line
• This can check unilaterally for extent of coxa vara or cartilaginous narrowing from hip degeneration

Pathologies: Strains

• Sudden onset / clear MOI
• Elther overstretched, overloaded, or both (heavy eccentric force)
• Most commonly at musculotendinous junction or in the muscle belly (not the tendon)
• Aggravated by lengthening (stretch), contracting against resistance, or palpation (may palpate a gap or discontinuity in muscle)
• Treatment is framed by the stage of healing of the injury

Stages of Healing

• Acute
• Just happened with mod-sev loss of function/ADLs.
• Signs of Sharp
• Mod-sev limitation in range and pain with movement (edema and muscle guarding).
• Early subacute
• Swelling has gone down with sli improvement in function but hasn't really improved since swelling dissipated.
• If bruising, red/blue/purple
• Generally painful throughout entire range of movement.
• Late Subacute
• Function has improved since the injury, eg, where previously it was difficult to dress, now it is easy.
• If bruising, yellow/green/brown
• Generally painful only at end-range of movement/POP.
• Chronic
• ADLs would be back to normal unless the injury was very severe.
• No bruising
• Generally not painful, but possible to have pain with tissue stress (load or POP).

Common Strains of the hip

• Hamstrings:
• Commonly occurs proximal or mid-belly; rarely distal
• Biceps femoris most common
• Most common and classic MOI is eccentric contraction (terminal swing phase of sprinting gait)
• What active, passive, and resisted movements would provoke somebody who has a strained hamstring ie, is undergoing a strong eccentric force?
• Assessments: 90-90 leg raise and Hamstrings MMT
• Differential to rule out is adductor magnus strain
• Rectus Femoris:
• Most common quad because of two-joint action
• Sprinting, kicking, jumping
• What active, passive, and resisted movements would provoke somebody who has a strained rec fem
• Assessments: Modified thomas test, Ely's test, and Quads MMT
• Differential to rule out TFL, iliopsoas strains (if location is quite high close to ASIS)
• Adductors:
• Most commonly adductor longus (could be brevis, gracilis)
• Either at the origin on the pubic tubercle or musculotendinous junction about 5cm distal to pubic tubercle
• MOI is cutting movements/rapid change of direction, or sudden loss of balance such as on ice
• What active, passive, and resisted movements would provoke somebody who has a strained adductor longus?
• Assessments is trying to differentiate which adductor (long or short / flexor or extensor) and Adductor MMT
• Differential to rule out is hamstring (especially medial hamstring) strain
• Groin strain
• Lay person's term for any medial/anterior thigh pain (aka nonspecific umbrella term)
• May be referred pain; not uncommon to be of lumbar origin

Iliotibial Band & TFL Injuries

• ITB Sprain:
• Localised pain around greater trochanter (can be confused for bursitis)
• MOI normally a fall or blunt impact (can be confused for bursitis)
• Aggravated by lengthening tissue over the top of it (can be confused for bursitis)
• Assessment via the Accessory test
• ITB Fasciitis:
• Diffuse pain around lateral thigh
• Associated with overuse of TFL
• Can be (poorly) misdiagnosed as sciatica because it involves diffuse radiating pain through the thigh
• ITB Friction Syndrome is studied in the knee module

Tendonitis (Tendinopathy)

• Rec Fem:
• Overuse of combined hip flexion/knee extension such as running, jumping, kicking
• Most commonly the proximal tendon just below AllS
• Same assessment and provocation as the strain above; the difference is the MOI
• Psoas/iliopsoas:
• Overuse of hip flexion
• Pain felt anterior thigh/hip/groin area over lesser trochanter
• If tendon thickens due to overuse, may experience some anterior snapping/clicking sensation with hip movement
• What active, passive, and resisted movements would provoke somebody who has a psoas tendinopathy?

Bursitis

• 3 clinically relevant bursae at the hip
• Trochanteric
• Iliopectineal
• Ischiogluteal
• Trochanteric bursitis:
• MOI - bursa irritated by overuse of glute med, min, & max (as well as external rotators of hip)
• MOI - trauma to greater trochanter
• If inflamed, may experience snapping sensation around trochanter, painful to go up stairs, painful to get in/out of car or chair, and painful to lie on side
• Assessment: Bursitis-tendonitis differentiation test (Pain with compression that does not get worse with load, especially eccentric load) and Secondary finding to accessory test or Ober's test
• POP adduction, RROM abduction, AROM abduction also possibly provocative
• Iliopectineal bursitis:
• Pain felt deep in the groin (just over hip joint)
• MOI - overuse of iliopsoas, especially when trying to flex against resistance (rugby scrum, MMA) Hence,decreasing use of and tone of iliopsoas can relieve symptoms and help offload the iliopectineal bursa
• Due to location, can mimic hip joint pathology
• Assessment: Pain with POP extension and pain possible with Iliopsoas MMT or RROM hip flexion
• Ischiogluteal bursitis:
• Normally only as a result of trauma or prolonged compression
• People who are bedridden or sitting for excessive periods of time (immobilised for example) and have low amounts of tissue superficial to bursa
• If inflamed, use of hamstrings, walking, stairs would all be provocative

Fractures

• High risk of avascular necrosis following hip fracture due to compromised circumflex arteries
• Following fracture, joint effusion within the capsule will occlude the circumflex arteries (which are intracapsular) and further predispose to avascular necrosis
• Femoral head fracture: often also involves a hip joint dislocation and therefore massive trauma
• Femoral neck fracture: aka subcapital or intracapsular fracture and a high risk of avascular necrosis (above)
• Subtrochanteric fracture: femoral shaft fracture

Joint Pathologies

• Osteoarthritis:
• Degenerative arthritis
• Very common at the hip
• Primary is idiopathic (aging)
• Secondary follows trauma or immobilisation
• Pathophysiology of OA is erosion of articular cartilage and subchondral bone
• Leads to Wolff's law > creation of osteophytes
• Pain because of decreased articular cartilage
• immobility due to osteophytes
• Signs & Symptoms: insidious onset, AM stiffness (due to articular gelling; synovial fluid becomes more viscous and takes longer to lubricate the joint after a period of immobility (eg, sleep).
• Painful with prolonged use, relieved by rest
• Pain should be deep in the groin area where the hip joint is
• Stiffness begins as internal rotation and extension (approximates joint surfaces which do not have protective cartilage)
• Over time, develops into full capsular pattern of restriction
• Assessment: If undiagnosed, hip scouring test and if diagnosed, assess per chief complaint
• Total Hip Arthroplasty (replacement): Very common!
• Vulnerable to dislocation, complications, or injury for 12 weeks post surgery
• In these 12 weeks, must avoid Flexion past 90, Adduction past neutral (such as sitting cross-legged or in deep car seats or soft couches
• Best to avoid lying on the operated side
• Hip dislocations
• Usually occurs in open pack position - Flexion creates ligamentous laxity, ABD and INT ROT create poor congruency of joint surfaces
• Classic MOI Dashboard injury (MVA)
• Pretty much always posterior
• FAI (Femoroacetabular Impingement)
• FAl is due to bony deformity in the femur, acetabulum, or both, combined with vigorous, repetitive movement, especially those which occur at extreme ranges (athletics, dance)
• 5 essential components to FAI:
• abnormal morphology of the femur and/or acetabulum
• abnormal contact between the two structures
• vigorous, supra-physiologic motion which causes abnormal contact
• repetitive motion resulting in the continuous insult
• the presence of soft tissue damage
• The abnormal morphology could be 1 of 3 types could be normally present at birth or develop in adolescence:
  • Cam-type - an abnormal bony growth on the femur
  • Pincer-type - an abnormal bony growth of the acetabulum
  • Combined - both femoral and acetabular abnormalities
• Diagnosis of FAI is based on
  • a symptomatic hip (usually, pain, especially during movement, and stiffness)
  • Positive FADIR test (or similar)
  • Positive x-ray findings
• Approach in massage is similar to hip OA: trying to maintain maximum muscle function so there is maximum muscular support around the hip joint. Precautions including taking the hip to end range and taking the hip into flexion and internal rotation/adduction
• Capsular Sprains
• Would normally present as restriction in Flexion & Internal Rotation
• May develop into full capsular pattern (Flexion > Abd > Int Rot)
• Difficult to assess (almost a diagnosis of exclusion)
• Can be insidious or MOI involves twisting
• Occur in dancers and athletes
• Treated as for any other sprain
  • don't stretch or challenge tissue early
  • decrease edema
  • give it time to heal
  • treat compensatory soft tissue structures

Orthopedic Tests

• Craig's test

• Hip scour test

• FABER test

• FADIR test

• Ely's test

• 90-90 Straight leg raising test

• Ober's test:

  • Relevant Condition: ITB or TFL contracture or shortness
  • Secondary: may provoke Trochanteric bursitis or ITB sprain
  • Tertiary: femoral nerve compression
  • Positive: leg remains abducted indicated contracture
  • Pain over trochanter indicates bursitis
  • Paresthesia during test may indicate femoral nerve compression
  • Indication: Lateral thigh pain, pain around TFL, decreased hip extension, pain around lateral hip

• Modified Thomas test:

Home Care

• Principles Programs must
• Not cause pain/inflammation
• Be progressive and gradual
• Start as early as possible (no inflammation)
• Exercise selection
• If in doubt, strengthen glutes
• Loaded exercises performed in mid-range
• Exercises which try to increase range performed unweighted
• In other words, we do not load at the end-range
• Isometric before eccentric before concentric before plyometric
• Gravity removed (such as a theraband exercise like clamshells) before gravity added (such as squat)
• Bilateral before unilateral
• Signs that program is too challenging
• Discomfort post exercise lasting more than 2 hours in acute/subacute stage
• Discomfort post exercise lasting more than 4 hours in the chronic stage
• Need pain medication to control discomfort after activity or exercise
• Pain @rest, extreme fatigue, rebound muscle spasm (not DOMS)

Hip OA or joint pathology ideas

• Supine with band above knee to activate and strengthen glute muscles feet on floor 1 min and feet on wall 1 min
• Seated with band above knees, each 5-15s holds, all:
• hip abduction
• hip flexion
• hip adduction
• Sit to stand out of chair
• Standing short lunges for load acceptance in quads
• PROM or pain-free AROM (Supine, with towel or similar if possible)
• Sit in rocking chair with gentle oscillations to general LPHC area
• Warm-up in bed to decrease joint stiffness (Hip circles, pelvic rocking or similar
• Know a stretch for each of the commonly affected muscles
• Glutes
• Quads & hip flexors
• Hams
• Adductors
• External Rotators

Glute strengthening

• Clamshells are the best glute isolation exercise (ratio of glute activation compared to hamstring and erector)
• Fire hydrant also good, but challenging and harder to progress
• Bridges are good general strengthening, but be aware that they activate a lot the hamstrings and erectors, meaning that people can do them using those muscles and not the glutes as primary drivers
• Two-legged squats
• Crab walking with band above knee
• Beyond this is athletic specialisation (single-leg exercises, plyometric exercises)
• In other words, not required for the kind of rehab (pain-free ADLs) that most people seek out from an RMT (we are not S&C coaches)