Hip Examination Lecture.docx

Hip Examination Age/gender influence on certain afflictions Location Pain/symptoms Limitations or no limitations? Location of symptoms ** groin pain is indicative of arthritic hip/fx/avascular necrosis** Groin/anterior hip Hip joint pathology Arthrosis FX (acetabular, femoral neck) Avascular...

Hip Examination Age/gender influence on certain afflictions Location Pain/symptoms Limitations or no limitations? Location of symptoms ** groin pain is indicative of arthritic hip/fx/avascular necrosis** Groin/anterior hip Hip joint pathology Arthrosis FX (acetabular, femoral neck) Avascular necrosis Labral tear LCPD SCFE Muscle strain Pubalgia/osteitis pubis SI dysfunction Groin/Medial thigh Strain(adductors) Obturator nerve entrapment Anterior/lateral thigh Femoral nerve entrapment Meralgia paresthesia Strain (quad) Lateral/buttock Trochanteric bursitis Tendonitis Neve entrapment Referred from LB Iliac crest Strain (TFL, Glutes, Quads, Lumbar) Referred Disorder without limitation of movement Patients in pain don’t always come in with lack of ROM Snapping hip (coxa saltans) Tendinopathies Groin pain DD: Resistance generated vs non-resistance generated Buttock pain Posterior SIJ Sciatic nerve Hamstring syndrome Piriformis syndrome Hamstring tendinopathy Lateral Trochanteric (gluteal) bursitis Gluteus Medius tears Central Ischiogluteal bursitis Disorders with limitation of movement Capsular pattern – in hip IR, ABD, EXT Hip arthritis/synovitis Traumatic Micro/macro Non-traumatic Primary Typically occurs with advancement in age >40yo Secondary Result of another underlying disease/condition (systemic disorders such as RA, gout, ankylosing spondylosis Without capsular pattern SCFE Labral tears Loose bodies Soft tissue nerve lesions Examination Subjective Screening Lumbar spine Dural testing SIJ Knee Ankle/foot Posture Evaluation Functional testing Squat Balance Sit-stand SLS/Trendelenburg Gait analysis e.g., Ranchos Common Malalignments Asymmetric Iliac Crests Leg length or LLD SI joint dysfunction Hip flexion contracture Spasm of QL Internally rotated LE Femoral anteversion Internal tibial torsion Pronation (foot) Muscle contracture Externally rotated LE Femoral retroversion External tibial torsion Muscle contracture Supination (foot) Thigh held in flexion Hip joint pathology Contracture of hip flexors Active ROM Overpressure Resistance PROM Capsular pattern End feel Hip scouring Accessory Distal/lateral distraction Anterior/posterior glide Strength (rule out nerve) L4 – ankle DF L5 – great toe ext. S1 – PF Heel/toe walk Sensation Dermatomes Deep peroneal nerve Web space btw 1st/2nd toe. Signs predicting a hip rather than a lumbar problem Antalgic gait Groin pain Common with OA Limited hip medial rotation IR Capsular pattern of the hip (medial rotation, flexion, ABD) Positive ‘sign of the buttock’ SLR Length of hamstrings In knee to chest position (AKA hip FLX/knee LFX), positive sign: Limited ROM Pain in buttock this should free up the sciatic nerve Hip muscles and referral of pain Iliopsoas – lateral lumbar spine, anterior thigh Glute Max Lumbar/sacral area Posterior/superior thigh Glute Min Below iliac crest Piriformis Sacrum Gluteal area TFL Lateral thigh Rectus Femoris Ant. Thigh Knee Adductors Groin Medial thigh Hamstrings Gluteal area Posterior thigh and calf Gracilis Ant/medial thigh to knee Rotator cuff muscles of the ship (with shoulder equivalents) Key muscle = Glute med Weakness can result in functional impairment Responsibilities: Balancing pelvis in frontal plane in SLS - 60% of gait cycle Majority of force to keep the pelvis stable in frontal plane in SLS Psoas When tight, can lead to snapping hip Examination Strength thoughts How should we test hip muscles? MMT How can we test glute med? SLS and look for a Trendelenburg Muscles are utilized for Walking Sit to stand Stairs – up/down which is harder and why Functional Scales Lower extremity functional scale (LEFS) Harris Hip Function Scale Arthritis Dislocation or fractures Iowa functional hip evaluation WOMAC (Western Ontario McMaster University Osteoarthritis Index) Test for Hamstrings: Hamstring tightness SLR vs 90/90 Thomas test/Ely Noble compression test Functional tests of the hip Squatting Going up and down stairs one at a time Crossing the legs so that the ankle of one foot rests on the knee of the opposite leg Going up and down stairs two or more at a time Running straight ahead Running and decelerating Running and twisting One-legged hop (time, distance, crossover) Jumping Hip Joint Pathology – LE Nerve Entrapment Lots of patients will come in c/o of groin pain (classic presentation) Degrees of freedom 3 planes of movement Capsular pattern IR most limited + painful Accompanied by computations of Limitations followed by Flexion, Extension, ABDuction in any order Different from other joints Open pack/closed pack position Osteoarthritis – most common condition in adults Diagnosis Limited ROM IR and Flexion (Birrell) Stiffness after inactivity Morning stiffness Pain Groin – greater trochanter During activity/WB Can progress to being painful at rest S/S during functional activities Limits in PROM possibly in capsular pattern – greatest in IR, then FLX ** Comparing PROM side to side, it’s a significant finding if there’s 15 degrees or more difference ** Joint crepitus Antalgic gait Treatment Stretching Strengthening Mini squats Leg lifts in standing Aerobic activity Non-weight bearing Bike (however still puts increased stress on hips) Swimming (takes load off joints) CPR for hip OA Limited activities hip flexion with lateral hip pain Active hip extension causes pain Limited passive hip medial rotation (25 degrees or less) Squatting limited and painful Scour test with ADD causes lateral hip or groin pain ** Four out of five variables must be positive** OA differential diagnosis Avascular necrosis RA Stress fracture of femur Aneurysm of the aorta Pelvic inflammatory disease Lumbar radiculopathy Hernia Bursitis Tests to rule in: Scour, FABER Be cognizant of periarticular factors like a tendonitis which is tested for with palpation & not reproduced with PROM Legg-Calve-Perthes Disease – tested on these Definition: osteonecrosis of the proximal femoral epiphysis in a growing child History: Jacque Calve (France), Arthur Legg 9USA), George Perthes (Germany: 1910 Incidence 4:1 M/F ratio Age 2-12 (mean age 7) Relatively small for age Pathophysiology Alteration of blood supply to femoral head Stages: 1) Ischemia/necrosis 2)Fragmentation/resorption 3)Reossification/resolution 4)Remodeling Subjective/objective findings c/o vague ache in groin muscle spasm (early on) muscle atrophy Trendelenburg ‘toe out’ Decreased ABD/IR hip flexion contracture Limited hip ABD Differential DX Septic arthritis Sickle cell disease Synovitis Hypothyroidism Slipped Capital Femoral Epiphysis SCFE Definition: Posterior and inferior slippage of the proximal femoral epiphysis on the femoral neck Incidence 3-7/100,000 Increased cases in black and Polynesian children Age Male 12-14 yo Female 10-13 yo Unilateral Bilateral 25% (early) Up to 40-60% at maturity Etiology Idiopathic Weight 95th percentile or more Increased shearing force Slope of growth plate (physeal architecture) Predisposition Involved in sports activities Obesity Rapid growth Endocrine pathology Stable vs Unstable Subjective/objective findings Pain exacerbated by activity Knee/lower thigh pain Chronic Groin/medial thigh May be no Hx of trauma May be mild weakness Antalgic gait with ER Decreased ROM Obligatory ER with hip flexion LLD (1-3cm shorter than uninvolved) Differential Dx LCPD Meralgia paraesthetica Neoplasm Femoro-Acetabular Impingement (FAI) Hip impingement More recently recognized Mechanical disorder of the hip Osseous abnormality CAM abnormality(more in men) Abnormally shaped femoral head Extra bone of femoral head where every time someone flexes their hip it bumps into socket/labrum Aka pistol grip deformity Pincer abnormality (more in women) Prominent anterior aspect of the acetabular rim Acetabulum covers too much of femoral head Causes: a) socket too deep B) or femoral head tips too forward Implications: acetabular retroversion excessive retroversion excessive ER hip impingement Mixed (most common) Causes Overuse, repetitive hip flexion Yoga, dance, ballet Running Football, field hockey, rugby, baseball, soccer, tennis Deep squatting (power lifting) Bike riding/cycling Car riding Clinical features Pain: groin, unilateral, gradual onset, hip flexion exacerbates FADIR test to reproduce symptoms Mechanical – may lock, catch, give way which may cause issues in labrum ROM: Limited flexion and IR Antalgic gait (39% patients) Trendelenburg sign (38%) Positive impingement sign Diagnosed: X-ray, MRI, CT scan Treatment Non-operative PT Strengthening hip musculature Patient education (avoid ROM extremes) Operative Arthroscopy (repair labrum, cut out torn cartilage, recontour femoral head/neck, rim trimming) Open surgery Acetabular osteotomy Pathology: Labral Tears Causes: Trauma Most common MOI = ER with hyperextension Femoral acetabular impingement (FAI) due to decreased clearance btw femur and acetabulum which leads to abnormal contact Capsular laxity Atraumatic Dysplasia Developmental Types of tears Flap, fibrillated, longitudinal and abnormally mobile Location of tears Anterior/posterior Most common tear = anterior because it has poor blood supply, tissue is weaker in this area Diagnosis Hx/Symptoms Pain (groin/anterior hip) Clicking/locking or catching Instability and/or stiffness Decreased ROM (rotation) Possible – but minimal and may be no ROM loss Long duration of symptoms > 2 years Provocative tests FABER Pain with FADIR Pain going into EXT/IR/ADD Imaging MRI Normal XR – unless associated with FAI Labral Tears Treatment Medical PT: No evidence/published articles yet Focus on reducing hip forces Avoidance of pivoting motions Increase muscle strength around hip Avoid sitting with: Knees higher than hips Legs crossed Avoid recumbent bike (Upright bike is better) PT treatment Assess gait Address motor recruitment Surgical Treatment Arthroscopic repair Labral debridement or repair, capsular modification Post-surgical Rehab Phase 1 (maximal protection 1-4 weeks) WB status Crutch training (symmetrical pattern) PROM (IR emphasis and prone position) Isometrics – progress to SLR (FLX, ABD, ADD) Aquatics (aerobics) Phase 2 (moderate protection 5 -7 weeks) Increase ROM/flexibility Strengthening (increased closed-chain) Aerobic (add resistance to bike/elliptical) Progression criteria (normal gait, no Trendelenburg) Phase 3 (minor protection, advanced exercise) Phase 4 (return to sport) Fractures Femoral Head: usu. seen with posterior hip dislocations Femoral head fractures are rare Intracapsular (high fractures of femoral neck) Subcapital Transcervical Extracapsular (low fractures of femoral neck) Intertrochanteric Good union Conservative – traction ORIF – nail and plate Acetabular Typically a result of High velocity trauma ORIF, NWB Femoral shaft ORIF or cast Good healing Stress fractures Medial femoral neck If you put patient in flexion, adduction, and internal rotation position, it puts them at risk for a posterior hip dislocation. Avascular Necrosis Hx Intracapsular fracture – s/p ORIF S/S Groin pain Decreased ROM (pain) + FABER test + Hip scouring test Difficulty walking Dx: Radiography Patchy density Tx: Bed rest with traction Surgery, hip replacement Common risk factors Cumulative steroid use Alcohol Systemic lupus Sickle cell disease Trauma Cancer Differential Dx Femoral neck fracture Lumbar disc herniation Muscle strain OA Septic arthritis Osteoporosis of the hip Ankylosing spondylitis Visceral pathology Muscle Strains/Tendinopathy Gluteals Medius is most common Hamstring Biceps Femoris most common because of the nerve supply Short head innervated by fibular branch of sciatic nerve Long head and other hamstrings innervated by tibial branch Theorized due to dual nerve supply, it leads to poor neuromuscular coordination between two heads putting it at higher risk of injury Eccentrically controls knee extension and hip flexion S/S: soreness upon palpation Pain with resisted motion in both hip flexion and extension Intervention: progressive eccentric strengthening NMS control exercises including trunk stabilization Pg 666 magee book – 2 phase protocol Adductor Adductor Longus is most commonly injured Mechanism: hyperabduction/forceful Adduction with quick external rotation Treatment: similar to Hamstrings with an active loading program Quadriceps Not common Occur after a quick stretch without a warmup Muscle Strains – depends on stage of injury Tx: Ice, rest, pain-free AROM, decreased WB TFM ES Heat Stretching Nerve mobs Isometrics Start with isometrics, then isotonics, back into weightbearing activities and back to sports again Isotonics Trochanteric Bursitis – inflammation in fluid-filled sac commonly non-traumatic with an insidious onset Hx S/S: Lateral hip pain Pain with STS, stair climbing Inability to lie on affected side Pain on palpation ROM – WFL Dx: Differentiate from muscle strain, ischial bursitis/ glute med tear Rule out: femoral neck fractures, TFL or ITB syndrome (tissues sit right above bursae) Tx: NSAIDS Ice US Iontophoresis Malalignment issues (orthotics) Pt education Stretch (TFL, ITB) Snapping Hip/Coxa Saltans/Iliopsoas Syndrome S/S: Snapping/clicking noise when going from flexion to extension May be painful (‘jolt’) Typically over trochanteric region Population: More common in athletes Females who are dancers Eval: palpation OBER test Thomas test Tx: Symptom relief Treat muscular imbalance if found PT treatment: Conservative Address muscular imbalances if found Glute med/min tears Hx: Abductor tendinopathy Trochanteric bursitis External Coxa Sultan Clinical presentation: Women > men (40-60 yo) Lateral thigh pain Stairs and squatting increase symptoms Trendelenburg gait Hip lag sign Decreased PROM Diagnosis of Glute med Tear Gold standard: MRI/US Manual exam/special tests Trendelenburg sign Pain with resisted Hip ABD Hip lag sign – has high specificity/sensitivity 30 sec SL Hip Lag Sign Position: Patient in Sidelying Test: Passively extend hip 10 degrees and ABD 20 degrees Max IR Knee flexed 45 degrees Ask pt to hold position If foot drops > 10cm + sign If foot drops, the foot is dropping into ER Means glute med can’t hold the hip at this angle Pathology: Hip Hip pointers Hx Direct blow(s) S/S: Bruising Pain upon palpation and mm contraction Gait deviations Tx Ice, pain-free AROM Increased activities Nerve Entrapments Femoral nerve (L2-L4) Causes: DM s/p Hip Fx birthing process tight psoas S/S: Medial thigh Weakness in quads Knee instability Patella DTR Lateral Femoral Cutaneous nerve (LCFN) (L2,L3) Purely sensory and blamed for anterior thigh sensory issues Meralgia Paresthesia Causes: Tight belts/waistbands Direct trauma S/S: Lateral/anterior thigh sensory complaints No weakness Saphneous nerve Can be compressed within Adductor Canal (Hunter’s Canal) Increased with deep squatting, knee extension exercise Pt reports: pain and/or paraesthesia in medial lower leg/foot Sartorial branch: supplies skin on medial aspect of knee and leg Vulnerable to injuries with valgus type stresses or surgical procedures in the medial knee (e.g., knee replacement). Test: + Ely test or prone knee bend Sciatic Nerve Entrapment Sciatic nerve (L4-S2) – doesn’t supply any of the gluteal muscles Causes: Disc herniation Pirifomis Proximal hamstring/IT Wallets S/S Gluteal region to posterior thigh/shin/foot DTR + Slump Gait deviation with weakness in L5/S1 – ankle DF/PF Branches of the Sciatic Nerve Tibial nerve (tarsal tunnel) Medial plantar Lateral plantar Common peroneal nerve Deep Superficial Piriformis Syndrome Hx Mechanical irritation of the SN Gradual onset S/S: Pain in buttocks which worsens with WBing or prolonged sitting Tenderness over area + trigger points + piriformis test Put patient over 90 degrees of hip flexion and full IR will produce pain Reports of pain in hip or lateral thigh Pain worsens with prolonged activity/posture Pain worse with sit to stand Usually unilateral Pain with resisted ER or ABD (dependent upon hip position) May have +SLR or SLUMP test Dx Tx Symptom relief heat, US STM Stretching Pt education Correct poor posture Neuromobilizations Hamstring Syndrome – SN entrapment as it courses around the Ischial Tuberosity (IT) Associated with active individuals Distance runners, sprinters, jumping athletes Clinical triad: Increased pain with sitting Pain upon palpation along lateral IT Pain with resisted knee flexion with 90 degrees hip flexion in supine with knee extended to its limit No pain with resisted knee flexion in prone position Provide Differential Diagnosis for hamstring tendinopathy Pain isolated to the IT and gradually worsens after persistent activity Clinical pearl: hamstring stretches don’t ameliorate symptoms Treatment: Gentle neural mobilizations at distal portion Iontophoresis Gradually return to activity When palpating, make sure you’re poking lateral to the Ischial Tuberosity if suspecting hamstring syndrome