MSK 2 Manual PDF

PT 892 - Musculoskeletal Physical Therapy II Management of Lower Extremity Pathologies Doctor of Physical Therapy Program Fall 2024 Department of Physical Therapy Michael Masaracchio, PT, DPT, PhD, OCS, FAAOMPT Board Certified Orthopedic Clinical Specialist Fellow A...

PT 892 - Musculoskeletal Physical Therapy II Management of Lower Extremity Pathologies Doctor of Physical Therapy Program Fall 2024 Department of Physical Therapy Michael Masaracchio, PT, DPT, PhD, OCS, FAAOMPT Board Certified Orthopedic Clinical Specialist Fellow American Academy of Orthopedic Manual Physical Therapists Associate Professor and Chair Director of the Anatomy Lab Co-Chair IPE Task Force Long Island University, Department of Physical Therapy Clinical Director Masefield and Cavallaro Physical Therapy President CM OrthoSports Inc. Vice-President APTA New York Vice-Chair ACAPT Teaching and Learning Institute APTA Education Leadership Fellowship, Class 2022 BONY ANATOMY  Hip (Coxal) bone o Ilium o Ischium o Pubis FEE  Ilium: ASIS, AIIS, PSIS, PIIS  Ischium: ischial spine and tuberosity hamstringorigin  Pubis: inferior/superior pubic ramus, pubic tubercle  Acetabulum o Cartilage, labrum Labrum congruency proprioception  Femur o Head, neck o Greater and lesser trochanters o Intertrochanteric line, crest o Linea aspera o Pectineal line 2  LIGAMENTOUS ANATOMY  Iliofemoral ligament o Restricts hyperextension/abduction o Supports upright posture  Ischiofemoral ligament o Restricts hyperextension/abduction o Restricts excessive hip ER  Pubofemoral ligament o Restricts hip hyperextension/abduction o Restricts excessive ER  Ligamentum teres o Restricts excessive ER during hip flexion MRI Most taut Extension terminal Esait sleigh MUSCLES Anterior Thigh o Iliopsoas hipflexion o Rectus femoris o Vastus lateralis adf.EEathuataffYks o Vastus medialis o Vastus intermedius o Sartorius archestoITB solateralit mainly NoTFLweakness o Tensor fascia latae o Pectineus is abja shortness TFC ThomastestabductionmeansTFL 3 Psoas stabilizesspine hipflexor Maintainslordosis for in anatomicalneutral  N 9 P Medial Thigh o Adductor longus o Adductor brevis o Adductor magnus o Gracilis o Obturator externus obturator nerve Tendinopathy duringactivity pain muscletests stretching Treat with Loading Actiondiffthanfunction Posterior Hip o Gluteus maximus Ext ER o Gluteus medius Abd IR o Gluteus minimus Abd stabilizer o Piriformis ER o Superior gemellus YFrafortint.in ER Abowhen flexion90 o Obturator internus ER Abdwhen o inflexion 90 Inferior gemellus o Quadratus femorisFER adduction Yffintition stabilizeproximalhipto prevent falling into fem.no ext DISCUSS FUNCTION VERSUS ACTION OF MUSCLES 4  NEUROVASCULAR ANATOMY Lumbar Plexus  L1-L4 ventral rami main nerve roots  T12 inconsistent  L5 inconsistent  Iliohypogastric nerve  Ilioinguinal nerve  Genitofemoral nerve  Lateral femoral cutaneous nerve meralgia paresthetica  Femoral nerve  Obturator nerve 1 canbeinjured inant hipreplacement 2 canbeentrapped meralgia paresthetica Sacrococcygeal Plexus  L4-S4  Cluneal nerves buttocksensation  Posterior femoral cutaneous sensation nerve bail ofthigh  Superior gluteal nerve glutemed  Inferior gluteal nerve glutemax  Nerve to obturator internus  Nerve to quadratus femoris  Sciatic nerve hamstrings  Pudendal nerve 5  EXAMINATION  Review of patient reported materials (note: ideally this occurs prior to seeing the patient but this may occur during History in the presence of the patient) a. Intake form/pain diagram b. Radiological and/or other information from other medical sources c. Functional outcome measures: LEFS, KOS, FAAM LEFS Lower extfunctionalscale KOS Initial observation  History: this can be very important especially in the hip  Review of Systems a. Cardiopulmonary, Integumentary, Musculoskeletal, Nervous, Communication ability (as needed) Decision: Refer out / continue exam / focus exam on specific structures Screening Exam: IF NECESSARY_when  comingfromspine  Structural Inspection  Movement analysis a. Demonstration of “what hurts” b. Squat c. Step down / lateral Stepney step down d. Gait e. Bridge with leg extension test f. Pelvic tilt test before ctive  or motor control Active Range of Motion b passive  Passive Range of Motion a. Osteokinematic b. Arthrokinematic c. End-feel Inspect MA Arom PROM  Resistive Tests MMT Length Special a. MMT palpate  Muscle Length (if needed)  Special Tests  Palpation for tenderness 6  CapsularPattern IR Flex Abd Boardexam LOWER EXTREMITY JOINT POSITIONS AND NORMAL END-FEELS lovesthis JOINT CLOSED- LOOSE-PACKED CAPSULAR End-feel PACKED (Resting) PATTERN Hip Ligamentous: full 30° flexion Flexion more limited Flex / Ext = firm extension, AB, IR 30° AB than AB, more limited AB = firm Slight ER than IR ER / IR = firm Bony: 90° flexion, slight AB, slight IR, more limited than ER flexion, more limited IR Flex than AB Tibiofemoral Full extension 30° knee flexion Flexion > extension Flex = soft tissue Ext = firm Patellofemoral Full knee flexion Full extension to Not defined Not defined 5°degrees of flexion Distal tibiofibular Not defined Not defined Pain when joint is Not defined stressed Talocrural Maximum DF 10° PF PF > DF DF = firm midway between PF = firm IN / EV Subtalar Supination Midway between IN > EV Sup = tissue stretch supination and Pron = tissue stretch pronation Midtarsal Supination Midway between DF > PF, and Sup = tissue stretch supination and limitation of adduction Pron = tissue stretch pronation and IR Tarsometatarsal Pronation Midway between Equal limitation in all Flex / Ext = tissue supination and directions stretch pronation Metatarsophalangeal Full extension Midway between Extension > flexion Flex / Ext = tissue flexion and stretch extension AB / AD = tissue stretch Interphalangeal Full extension Out of full Flexion > extension Flex = tissue stretch extension Ext = tissue stretch IR mostlimited Loosepacked most freeposition forjoint 7  CLINICAL EXAMINATION: HISTORY (Tibor et al, 2008)  Intra-articular vs. extra-articular  Age and gender o Transient synovitis, LCPD, JRA (4-10yo) o Slipped Capital Femoral Epiphyses (8-15yo) o Articular osteochondritis dessicans (15-25yo) o Ischemic femoral necrosis (35-50yo) o Labral lesions (18-40yo) o Osteoarthritis (> 45yo) CLINICAL EXAMINATION: HISTORY (Tibor et al, 2008) Quality of Pain  Aching pain: bursitis, tendinopathy, arthritis  Sharp pain: labral tears, articular loose bodies, accompanied by a click, giving way, and a feeling of catching or locking  Burning pain: nerve entrapment may be accompanied by paresthesias, numbness, and /or weakness, or sympathetic changes o (femoral, lateral femoral cutaneous (meralgia paresthetica), ilioinguinal, genitofemoral, obturator) thigh sensationinlat CLINICAL EXAMINATION: HISTORY (Tibor et al, 2008, Thorborg et al, 2018)  Groin pain Adductorlong GF hernia o CFJ or labrum cystetc labralo Symphysis pubiscoxo femoraljoint OA FAI lesions tear o Adductor tendinopathy o Referral from lumbar spine or SIJ Remember is anterior Hip o Non-musculoskeletal pain sources belowinguinal ligament just  Abdominal, pelvic, vascular, etc CLINICAL EXAMINATION: HISTORY (Tibor et al, 2008)  Posterior hip or buttock pain o SIJ dysfunction o Gluteal bursitis o Hamstring tendinopathy o Hamstring syndrome o Lumbosacral spine o Possibility of CFJ or labral pathology as well CLINICAL EXAMINATION: HISTORY (Tibor et al, 2008)  Posterolateral hip pain o Trochanteric bursitis greater trochanter offemur o Gluteal insertion tendinopathy glutes insertaround greatertrochanter o Component loosening in patients with arthroplasty (THR) o Irritation of the T12 dorsal ramus 8  Standing sitting supine LOWER QUARTER SCREENING EXAMINATION (Note done by position) STANDING 1. AROM of lumbar spine – looking for effect on symptoms a. Flexion b. Extension c. Side-bending right and left d. Rotation left and right (stabilize pelvis) 2. PROM of lumbar spine – overpressure at end range if pain-free Block R Tum L a. Flexion b. Extension (caution) c. Side-bending right and left d. Rotation left and right (with and without pelvis stabilization) 3. Myotomes: 5 second hold gastroc a. S1: PF: walk on toes 51 lifts aton b. L4: DF: walk on heels SITTING TESTEE.to 1. Myotomes Hold for a. Hip flexion = L2-L3 557 extofknee b. Knee extension = L2-L4 (L3) MMTS c. Great toe extension = L5 foot stablemmid seated d. Hamstring = S2stabilize 2. Reflexes to bring you peafxia a. Patellar – L3-L4 b. Achilles – S1Don'tallow pt toDFforyou restlegon 3. Special tests your knee a. Slump test (page 61) Handsbehindbackpush neckdown SUPINE sftp.t 1. AROM a. NWB: hip, knee, ankle, toes 2. Sensation a. L1 = inguinal region b. L2 = anterior mid-thigh c. L3 = distal anterior medial thigh d. L4 = medial malleolus e. L5 = thong space / great toe / lateral leg f. S1 = lateral side of foot g. S2 = medial heel 3. Special tests a. SLR (should do before SLUMP – discussed more in the spine course) 9   Specificity: the higher the value, the better the chance to rule in the condition or pathology (SpIN) (Cleland et al, 2016)  Sensitivity: the higher the value, the better the chance to rule out the condition or pathology (SnOUT) (Cleland et al, 2016) Positive LR Negative LR Interpretation > 10 < 0.1 Generates large and often important shifts in probability 5-10 0.1-0.2 Generates moderate shifts in probability 2-5 0.2-0.5 Generates small but sometimes important shifts in probability 1-2 0.5-1.0 A small and rarely important shift in probability STRUCTURAL INSPECTION  Swelling of the hip? Veryhardtosee  Swelling in the groin? concerning lymphnodes organs  Atrophy of the gluteals?  Ecchymosis Bruise  In toe / out toe Anteversion In toe Retroversion outtoe Bodycompensate  Pelvic landmarks: iliac crest, ASIS, PSIS to getcomfyalignment o Greater trochanter to lateral malleolus: true leg length MOVEMENT ANALYSIS Rightglutemedweakness collapse Valgusdue collapsedpelvis 10  INTRA-ARTICULAR PATHOLOGIES DEVELOPMENTAL HIP DYSPLASIA  Variable age of diagnosis, females > males, increased risk with breech birth, may have genetic component  A spectrum of potential bony changes that can occur at the articulating surfaces of the developing hip joint, resulting in reduced congruency and joint function.  Severe cases often identify at birth and may be associated with congenital subluxation or dislocation.  Borderline cases may not be identified until adulthood. TREATMENT  Nonsurgical for newborns and infants Barlowteststabilizeopp pelvisthenadductleg  Surgical for nonresponsive and severe cases to optimize bony congruency and capsuloligamentous support. SLIPPED CAPITAL FEMORAL EPIPHYSIS  8-15 years old, males > females, increased risk with obesity, common bilaterally  Slippage of the proximal femoral epiphysis on the metaphysis through the epiphyseal plate TREATMENT conservative first  Nonsurgical if bony elements are stable  Surgical if osseous stability or risk to future bone health is a concern LEGG-CALVES-PERTHES DISEASE necrosis to femur  4-10 years old, males > females  Etiology not well understood  Self-limiting multi-stage conditioned occurring when blood supply to the femoral head is temporary interrupted resulting in transient necrosis  Femoral head is not spherical on radiograph erodedfemoralhead TREATMENT  Nonsurgical with surgical reserved for severe cases 11 EPIDEMIOLOGY OSTEOARTHRITIS  Osteoarthritis is among the leading causes of global disability, with hip and knee contributing most to the burden (Cross et al, 2014), affecting more than 250,000,000 people worldwide (Vos et al, 2012), half of which are younger than 65 (Deshpande et al, 2016).  Osteoarthritis is no longer considered a degenerative wear and tear disease, but rather complete joint failure with an inflammatory component (Ackerman et al, 2017, Berenbaum et al, 2013)  More and more data are demonstrating OA affecting younger individuals, with hip OA prevalence increasing steadily with advancing age (Cross et al 2014)  Costs of OA are astronomical and in a recent study in Australia, leaving the workforce early cost the system over 7 million dollars annually (Shofield et al, 2016) PATHOLOGY OF HIP OSTEOARTHRITIS  Loss of hyaline cartilage  Sub-chondral bone sclerosis  Joint space loss  Osteophyte formation OA SIGNS AND SYMPTOMS  Pain and stiffness especially in the AM  Pain with WB located in the groin  Pain in the lateral aspect of the hip? PostLat  Muscle weakness  Gait kinematics 12  OA Drehmann Sign SCREENING FOR HIP A/PROM – OA  Capsular pattern? IR Flex Abduction kneeout notenough  Drehmann Sign Inhipflexion kneemovesintoabd ER spaceforpuresag Prehmann plane sign PREDICTING RADIOGRAPHIC HIP OA FROM RANGE OF MOVEMENT (Birrell et al, 2001) # of Planes Sensitivity Specificity +LR -LR Restricted 0 100 0 NA NA 1 100 42 NA NA 2 81 69 2.61 0.28 3 54 88 4.5 0.52 13 ACR TEST ITEM CLUSTER FOR THE IDENTIFICATION OF HIP OSTEOARTHRITIS Sensitivity Specificity +LR -LR Test Item Cluster 1 86 75 3.4 0.19 Hip Pain Hip IR ROM < 15 degrees Hip Flexion ROM < 115 degrees Test Item Cluster 2 86 75 3.4 0.19 Pain with hip IR Age > 50 years Useif IR ROM 15 Morning stiffness up to 60 minutes If hip internal rotation range of motion is > 15°, use Cluster 2 Research for hip OA suggests 3/5 predictors increase the likelihood of OA (Sutive et al, 2008)  Self-reported squatting as an aggravating factor  Active hip flexion causing lateral hip pain 3 Scour test with adduction causing lateral hip or groin pain 4 Active hip extension causing pain 5 Passive IR ≤ 25° 450 is normal  4/5 present +LR 24.5 Goodevidence Clinical Prediction Rules should never be a SUBSTITUTE for Clinical Reasoning  Role of CPRs  Positives/Negatives 14 CLINICAL PRACTICE GUIDELINES HIP OA (Cibulka et al, 2009, 2017) Summary of Recommendations Level B limitationsin iinobility hipabdstrength Diagnosis  Pathoanatomical diagnosis: clinicians should assess for limitations in mobility of the hip joint and strength of the surrounding muscles, especially the hip abductors LEVEL B EVIDENCE  Risk factors: clinicians should consider age, hip developmental disorders and previous hip joint injuries as factors for developing hip OA LEVEL A EVIDENCE  Diagnosis/classification: moderate lateral or anterior hip pain during WB in adults > 50, morning stiffness < 1 hour, limited hip IR < 24 degrees, IR and hip flexion 15 degrees less that the non-painful painful side LEVEL A EVIDENCE Treatment  Patient Education: LEVEL B EVIDENCE; patient education combined with exercise LEVEL A EVIDENCE 2017  Manual Therapy: LEVEL B EVIDENCE; 2017 A Manual strength flexibil  Flexibility, Strength, Endurance Exercises: LEVEL B EVIDENCE; 2017 A  Functional Training, gait, balance: LEVEL C EVIDENCE  Weight Loss LEVEL C EVIDENCE 2017  Modalities LEVEL B EVIDENCE 2017 2012 ACR RECOMMENDATIONS STRONGLY RECOMMEND 15 The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: a systematic review and meta-analysis (Sampath et al, 2016)  There was high quality evidence that exercise therapy was beneficial at post- treatment for pain and physical function, as well as follow-up pain and physical function  There was low quality evidence that manual therapy was beneficial at post- treatment for pain and physical function, as well as follow-up pain and physical function  Low quality evidence indicated that combined treatment was beneficial at post- treatment for pain and physical function, but not at follow-up for pain and physical function  There was no effect of any interventions on quality of life Manualtherapy alone is notenough COMMON MANUAL THERAPY TECHNIQUES FOR HIP OA  Targeting impairments in pain and limited hip mobility particularly o Hip flexion, medial rotation, lateral rotation, extension.  Long axis distraction IR ER  Belt mobilization 1. Sequencing AND  Anterior to posterior glide Increases IR progression of  Posterior to anterior glideIncreases ER treatment seems to be what is missing from  Manual muscle stretching orthopedic practice 2. Could be a reason why the evidence for COMMON EXERCISES HIP OA manual therapy is NOT  Stretching beneficial at times 3. Develop a clinical o Piriformis, hip flexors, quads, hamstrings reasoning framework  Strengthening for what you do and AbdExt Abd IR RCofhip why you do it o Glute max, glute med, hip lateral rotators ER  Functional weight bearing exercises o Balance o Step up/down o Squats 16 Identifying and Prioritizing Clinical Guideline Recommendations Most Relevant to Physical Therapy Practice for Hip and/or Knee Osteoarthritis – Teo et al, 2019, JOSPT Stopsaying boneonboneyo jointisnon exi Patientwillnotm duetofear 17 INDICATIONS AND PREVALENCE OF HIP ARTHOPLASTY (CDC, AAOS, 2016)  OA most common indication for THR  OA affects 13.9% adults 25yo or older  OA affects 33.6% adults 65yo or older  26.9 million adults in the US with OA  2006 in the US o 231,000 primary THR o 251,000 hemi-THR o 38,000 revision THR  2030 in the US o 570,000 primary THR o 96,700 revision THR PROGNOSTIC INDICATIONS FOR HIP ARTHROPLASTY (Husted et al, 2008)  Excellent outcomes: pain relief, improved joint mobility, function, patient satisfaction  Pre-operative function dictates post-operative walking ability in primary and revision THR  Older individuals > 70 have lower functional outcomes, longer acute care admission, and are more likely to be referred to an inpatient rehab facility 770 bad RISK ASSOCIATED HIP ARTHROPLASTY (McBryde et al, 2008)  Mortality 0.15-2% THR; 2.4% hemi-THR; 0.87-2.6% revision surgery  Greatest factors associated with adverse outcomes o Advanced age o Medical co-morbidities: CHF, CRF, DM  Need for revision procedure (increased risk for fracture) o 90% TKR last 10 years, many last 20 years o 97% hip resurfacing lasts 8 years o Rate of revision 3x higher younger males 18 SURGICAL TECHNIQUES Total Hip Arthroplasty  Replacement of both parts of joint  Majority are primary in nature  These patients will have most predictable post-op management Hemi-arthroplasty  Femoral component of joint ONLY  Primarily used for patients with femoral head/neck fractures not treatable with ORIF Don'tlastlong notworthit  Most designs now have two articulating surfaces with smaller heads that articulate with a polyethylene cup, which then articulates with the acetabulum  Designed to reduce rate of dislocation and still permit functional ROM, and dissipate force across acetabulum 19 SURGICAL APPROACHES (Heislein, 2010) Posterior approach  Incision posterior aspect greater trochanter 20 30visitsoutpatient onavg  Fascia lata is incised, fibers glute max are split  Detachment of short ER, incise posterior capsule easier butrisky  Advantages: technically easier, less OR time, less blood loss, less impact on abductor function  Major disadvantages: higher rate hip dislocation, but meticulous repair of short ER and capsule has suggested decreased rates, less visualization of the acetabulum Lateral approach  Incision over the greater trochanter through gluteal fascia, ITB, insertion glute med to release glute min and gain capsular access  Advantages: good exposure of acetabulum to place cup, reduced risk of hip dislocation since no damage to short ER or post capsule, reduced injury to sciatic nerve  Major disadvantages: abductor weakness, superior gluteal nerve, HO development, less femur visualization Anterior approach  Between the TFL and sartorius 12visits outpatient on avg  Advantage: low rate of dislocation, no muscles cut through, no FORMAL hip precautions Resistedflexion passivehipext  Disadvantage: may have hip extension ROM limitation onlydetach deepfibers of rel fem weeks resistedhipflexion SLR Hipextension precautions for 4 Don.FI 20 COMPLICATIONS (Brander et al, 2006)  Days/weeks o DVT or PE (Homan’s sign, Wells CPR) o Pulmonary/cardiac issues: atelectasis, pneumonia, orthostatic hypotension, anemia, arrhythmias, MI Vitals o Acute care PT: screening and prevention  Auscultation of the lungs, BP, HR  LE alignment checking for hip dislocation usually accompanied by increased pain  CPR for assessment of DVT Hip dislocation: related to surgical approach  Hip precautions vary from surgeon to surgeon  Consensus is 4-12 weeks Precautions are for softtissuerepai  Causes of dislocation with posterior approach o Bending forward while putting on shoes o Twisting the trunk sit/standing with feet planted o Rising from a low toilet with hip in ADD/IR position REHABILITATION PRECAUTIONS SURGICAL APPROACH PROHIBITED MOTION Posterior or posterior lateral Hip flexion > 90 degrees IR past neutral Adduction past neutral Combination Anterior or anterior lateral or lateral Hyperextension ER past neutral Combination Weight-bearing dysplasia bilateral w cement  Mostly decided on the type of implant Congenitalhip  Cemented implants FWB immediately erode  Cement-less designs usually had WB Mayrestrictions but advances now allow FWB  If WB restrictions are recommended 8-12 weeks Therapeutic exercises  Need to be considered if WB restrictions exist 21  PREOPERATIVE REHABILITATION (Wang et al, 2002, Gilbey et al, 2003, Wang, et al, 2016)  Educational programs (1-2 weeks prior) o Patients who fully understand post-operative expectations and clinical care protocols have demonstrated better coping strategies  Exercise programs o Address impairments associated with OA o Exercise prior to surgery demonstrates improved strength and functional recovery more quickly o Overall evidence is inconclusive ACUTE CARE REHABILITATION  Average length of stay 3 days Rehab  PT interventions begin either POD 0 or POD 1 o Education: THR precautions o Functional training: ambulation 100 feet; independent transfers, stair negotiation o Therapeutic exercise to improve motor control  Important to document physiological status o Low hematocrit o Fever Blood clots o Elevated anti-coagulation levels o Orthostatic hypotension ACUTE CARE REHABILITATION CONTINUED  Therapeutic Exercise o Quadriceps isometrics, heel slides First o SLR and gluteal isometrics should only be initiated if there are no WB restrictions since they create high contact pressures in the hip o Progress to short arc quads, OKC knee extension o Progress to standing hip exercises when there is good postural control and FWB o Progress to mini squats, sit to stand Last Start to finish Quadisos heelslides SLR gluteisos noWB restrictions chain kneeext standinghipexercises whengoodposture 5A Q open FWB Mini squats STStransfers 22 Quadriceps isometrics  Extremely important to initiate quad return 100x  Patients should be instructed to perform 100 reps a day  Need to watch for substitution from the glutes Quad sets  Heel needs to be lifted off the table Heeloff Quadriceps Progression  SAQ, SLR extremely important 504  Patients should be instructed to perform 50 reps a day  Ensure quad set first before SLR or SAQ set Quad before  Do NOT perform if there is an extension lag this 23  Standing Hipabductio Later in treatment WB exercises when FWB permitted and adequate control Minisquats STS  Patients should be instructed to perform 30 reps a day  Sit to stand for concentric/eccentric glute activation ACUTE CARE REHABILITATION CONTINUED (Heislein et al, 2010)  D/C to either inpatient facility or home? o Independent transfers (bed, chair, toilet) o Independent ambulation of at least 100 feet with AD UsuallyRW HomeDKI o Independence in stair climbing o Adherence to hip dislocation and WB precautions  Research suggests functional milestones for independence home o 5.5-9.5 treatment sessions 5 10 sessions SUBACUTE REHABILITATION  Length of stay inpatient facility 7-10 days with D/C home occurring at POD 14  Exercises can be increased with weights and bands  Aerobic exercises are important to overcome deconditioning o Bike (seat height) o Treadmill o NuStep 24 OUTPATIENT REHABILITATION  Goal: return to previous level of function  Focus of interventions are to o Improve muscle weakness Strength balance gait o Improve postural stability o Normalize gait deviations  Persistent weakness and/or altered motor patterns contribute to decreased balance, altered gait patterns, and fear of falling  Outcome measures: HHS, LEFS, WOMAC OUTPATIENT HIGH PRIORITY CHECKLIST (courtesy of Dr. Caronia) 1. Hip extension ROM needed for steplength 2. Neuromuscular control of gluteal muscles need forgait 3. Lumbopelvic control 4. Balance and proprioception safety 5. Gait considerations 6 Strengthtraining How long should all of this take? Should the order matter? Clinical reasoning? Progression and sequencing within and between sessions? 25 GAINING HIP EXTENSION  hipext Essential for terminal stance of the gait cycle (at least 10 degrees), increasing step length, cadence, and overall efficiency passiverecoil  Allows proper function of gluteal group  Elongates anterior soft tissues moreflexibility  Unloads the lumbar spine (anterior pelvic tilt/lower cross syndrome) lesslordosis PSOAS RELEASE  Add hip ROM, pelvic rocking during soft tissue SoftTissue mob mobilization  Can perform soft tissue mobilization during stretch Psoasstretch JOINT MOBILITY ASSESSMENT  Therapist position  Patient position  Clinical reasoning? o Grade? o Dosage?  Goal of the mobilization Clinical Pearl: your assessment becomes your treatment  Remember the reasons behind manual therapy o Increase mobility o Deform collagen and the capsule o Neurophysiological changes  Tap into the nervous system 26  Flexion Supine INDIRECT TRACTION TO INCREASE HIP FLEXION  Patient: supine with pelvis secured with a belt  Clinician: standing on the side being treated, grasping the lower leg on skin (towel)  Instructions o Place the hip in 30° flex, submax AB, and submax ER o Perform oscillatory non-thrust mobilizations o Patient MAY contract their ipsilateral quadratus lumborum if there is too much motion coming from the pelvis abd slightER Loosepacked 30 flex 30 Indirect tug Extension Prone INDIRECT TRACTION TO INCREASE HIP EXTENSION  Patient: prone with pelvis secured with a belt  Clinician: standing on the side being treated, grasping the lower leg on skin (towel)  Instructions o Place the hip in the position of max extension, submax AB, and submax ER o Perform oscillatory non-thrust mobilizations o Patient MAY contract their ipsilateral quadratus lumborum if there is too much motion coming from the pelvis 27 DIRECT TRACTION / INFERIOR GLIDE TO INCREASE HIP FLEXION  Patient: supine with opposite leg straight  Clinician: standing on the side being treated  Instructions o Sink into the soft tissues in the anterior/medial groin and get as close to the joint line as possible (purchase) o Place the hip into the limit of flexion, submax ER and submax AB o Perform oscillatory non-thrust mobilizations o Repeat in a position of hip flexion limit, submax AB and different positions of IR o Do not put front leg in front of patient’s hip your DIRECT MOBILIZATION TO INCREASE HIP EXTENSION / EXTERNAL ROTATION  Patient: prone with opposite leg straight goodfor postTHA o Inreaseextens  Clinician: standing on the side being treated  Instructions o Place a towel under the ASIS o Bend the patient’s knee (please note MUST check RF length) Recfemlimit o Lift the patient’s hip with one hand to extension limit (please note can also be done with a towel or half foam roll) o Place the other hand (mobilizing hand as close to the joint line as possible (medial to the greater trochanter) o Perform oscillatory non-thrust mobilization to stretch the capsule o Can repeat in a FABER position to stress different parts of the capsule FABER to hipext 28 10 10 24 fine MOBILIZATION TO INCREASE HIP AB can'tperform  Patient: supine with opposite leg straight  Clinician: standing on the side being treated  Instructions o Place hip joint into AB until the point of resistance is felt o Cradle upper thigh against clinician’s body for stability o Add trunk rotation to provide a slight distraction force o Perform an inferior/medial away fromnon- Turnglide using pt thrust mobilizations (increase AB) MOBILIZATION TO INCREASE HIP IR/FLEX Gaitcycle extension 010hip 0 30 hipflexion  Patient: supine with opposite leg straight 0 60 kneeflexion interminal  Clinician: standing on the same/opposite side being treated Weneedhip IR stance  Instructions o Place hip joint into flexion until the point of resistance is felt o For pictures 2 and 3 you should also place the hip into ADD to point of resistance o Make sure not to mobilize directly through the patella o Perform a posterior glide using non-thrust mobilizations Chestcradle 29 GLUTEAL NEUROMUSCULAR CONTROL  Must overcome deleterious effects of surgical approach, longstanding deficits (i.e., from OA)  Expect autogenic inhibition early after surgery  Begin with simple exercises  Patience is important, don’t assume exercises are too easy and don’t progress too quickly  Enhance muscle recruitment Can mobilize 6 weekspost THA onlyextension GLUTEAL ACTIVATION DURING THE GAIT CYCLE (Neumann, 2016) 1 Patientedu 2 Exercise swing Stance 30 GLUTEAL NEUROMUSCULAR CONTROL Don'tassumeexercisesaretooeasy  Therapeutic exercises (Sets? Reps? Weight?) o Glute sets, supine or standing abduction o Side-lying AB (COMPENSATIONS), bridging, and clam shells leaningback o CKC exercise as strength improves, no WB restrictions o Step ups, lunges, mini-squats CKCexerciseonceprogres THERAPEUTIC EXERCISES GLUTEUS MAXIMUS AND MEDIUS (Boren et al, 2011)  EMG activity crampingin itsduringbridg XX o Front plank hip extension: max: 06.22; med: 75.13 o Side plank DL up: max: 72.87; med: 88.82 o Side plank DL down: max: 70.96; med: 103.11 o Single leg squat: max: 70.74; med: 82.86 StrengthenGlutemednot QL I 31 SLB onleft sacralrhythm onright Cambro  LUMBOPELVIC CONTROL  Improve lumbopelvic dissociation  Improve lumbopelvic rhythm  Start simple, progress accordingly  Incorporate into functional activities o Supine/quadruped is a great way to teach neutral spine, but it is not functional o Move to functional positions when the patient is independent in spinal neutral and maintaining transversus abdominus contraction without substitution o The addition of UE and LE movement patterns on a stable base will set the foundation for exercises sitting on a physioball, as well as standing with Theraband Bird dog 32 BALANCE / PROPRIOCEPTION (Maloney et al, 2004)  Balance training is important to facilitate ambulation without AD Stable Twolegs o Begin bilateral activities Twofeeteyesclosed stable Oneleg o Progress to unilateral activities Unstable Twolegs Onefoot o Progress to unstable surfacesFoampad Unstable oneleg o Progress to multi-plane directions DYNAMIC  Gait training to increase symmetrical step length and stance time Sepicalsidemaybe a littlelonger Waitforfemoralhea  Leg length discrepancies? I GAIT CONSIDERATIONS (Ewen et al, 2012)  Loss of gait speed o Normal 1.2-1.4m/s 3 MPH o < 1.0m/s require rehab o < 0.6m/s increase fall risk  Decreased stride length  Decreased step length  Hip abductor weakness  Lateral trunk lean to involved side  Decreased hip extension SPORT PARTICIPATION RECOMMENDATIONS (Jacobs et al, 2009) DON'T  Permitted: golf, swimming, walking, stationary bike, dancing, elliptical, bowling, stationary skiing, treadmill, low-impact aerobics, speed walking, memorr road bicycling, hiking, stair climber, double tennis, rowing, weight machines  Permitted with experience: Pilates, cross country skiing, weight-lifting, ice skating, roller blading, downhill skiing,  Not permitted: baseball/softball, racquetball/handball, football, basketball, snowboarding, jogging, high impact aerobics, contact sports, singles Abd rollsback turned on TFL as mainabductor SC Hip Hip 33 HIP LABRAL PATHOLOGY (Martin et al, 2006, Shearer et al, 2011, Philippon et al, 2013, Kahlenberg et al, 2014) Hip Acetabular Labrum  Hip labrum Tear saltpetre o Analogous to the meniscus of the knee and the labrum of the glenohumeral joint  Enhances joint stability o Deepens the acetabulum Jle o Acts as a seal to maintain negative intra-articular pressure ETIOLOGY OF LABRAL TEARS  Trauma  Repetitive motions, sports  Structural hip abnormalities. o Femoral acetabular impingement o Hip dysplasia o Laxity  Average cost per patient $2,500  Average cost for arthroscopy $21,000  Traumatic lesions 46%  Degenerative lesions 49%  Congenital lesions 5%  Traumatic vertical tears or degenerative horizontal tears  Occur in the ant/post superior region SOFTTISSUEISSUE GROIN PAIN 34  FAI: FEMORAL ACETABULAR IMPINGEMENT (JOSPT April 2018) overgrey fem Motion Related Clinical Disorder – based on international consensus statement  FAI: decreased joint clearance between l the femur and acetabulum BONEISSUE  Cam impingement: femoral head/neck junction with increased radius o Less prevalent in adolescents than adults and has been shown to gradually increase during skeletal growth o Possible adaptation to sport/activity o More common in males 30 50yearsold Asymptomati a lot adaptation o More prevalent in professional athletes natural o Does appear to play a role in the development of hip OA Eiiing Pincer impingement: abnormal acetabulum with increased over-coverage t.PE tear labral o Prevalence rates even more variable with inconsistent age, gender, and activity levels a hot o Does not appear to play a role in the development of hip OA GROIN PAIN DIAGNOSING FAI AND LABRAL TEARS (Martin et al, 2006, Philippon et al, 2013) History  Groin pain +/- posterior/lateral hip pain.  Clicking (+LR 6.67), snapping, catching, giving way.  History of repetitive use o Running o o Pivoting Cutting FAI FADIR pain o Twisting  Possibly trauma related  FAI: increased pain with hip flexion, adduction, IR (FADIR)  Labral: increased pain with similar activities if FAI related, also symptoms with hip extension (running) Labralincludes painw ext 35 EXAMINATION LABRAL TEARS AND FAI (Martin et al, 2006)  Diagnosis of exclusion  FAI: limited hip flexion and internal rotation  Special tests o Anterior Impingement Test (FADIR) o FABER o Log Roll G o Check multiple planes  FABER/FADIR  EABER/EADIR  Rule out extra-articular pathology: o Tendinopathy: selective tissue tension o Rule out lumbopelvic region  Groin pain, limp, limited IR suggest hip vs spine  Rule out Hip OA  FAIR/FABER – weak evidence when (-) r/o FAI (Enseki et al, 2023) ANTERIOR IMPINGEMENT TEST (Narvani et al, 2003)  The examiner passively moves the patient’s lower extremity into a position of hip flexion, adduction, and internal rotation  A positive test is reflected by increased hip or groin pain Diagnostic Accuracy:  Sensitivity =.75; - LR =.58 Betterto ruleout  Specificity =.43; + LR = 1.32. akadoes  Reliability ICC =.87 nothury 36 LOG ROLL TEST (Byrd et al, 2009)  The log roll test is used to assess the amount of hip external rotation range of motion, comparing the involved and uninvolved sides  An increase in the amount of external rotation range of motion on the involved side potentially indicates iliofemoral ligament laxity  A click during the test indicates a possible labral tear ERwouldmeanilio femoral laxity ligament FAI OR LABRUM: SURGERY VS CONSERVATIVE CARE  No head to head studies.  Need better guidelines on conservative management  Differential diagnosis is essential to avoid unnecessary surgery  Trial of conservative management recommended  If left untreated would FAI/labral tears lead to OA? Can 37  CONSERVATIVE MANAGEMENT  Differential diagnosis is IMPORTANT  FAI Avoid FADIR o Improve hip mobility  Posterior glide Femoral headaway fromacetabulum Increase IR o Educate patients to minimize hip flexion with adduction, internal rotation during activities FADIR o Improve strength and control around the hip Patientneedsto changelifesty o CPG – Enseki et al, 2023 oftennevergetbetterafterga Strength stretching Multimodal interventions – B combine education  Therapeutic exercise, movement re-training, patient education – C  Manual therapy, neuromuscular re-education – F  Labrum Avoid hyperextension pivotinginWB improvestrength o Minimize stress on anterior labrum during activities  Reduce hip hyperextension  Reduce pivoting on hip in weight bearing  Improve strength and control around hip Nonsurgical Management Acetabular Labral Tears: Case Series (Yazbek et al, 2011)  4 patients with MRI confirmed labral tears +/- impingement and extra-articular pathology  3 phase rehab program  All with improved strength, pain, and function post rehabilitation Labral Rehabilitation Program  Phase I: segmental trunk stabilization training, pain control, education on correction of faulty alignment Trunk  Phase 2: hip muscle strengthening, recovery of hip ROM, sensory-motor training Hipstrong Dynamic changingof  Phase 3: sport specific functional progression directions 38 Clinical Outcomes Analysis of Conservative and Surgical Treatment of Patients with Clinical Indications of Prearthritic Intra-Articular Hip Disorders (Hunt et al, 2012).  Case series  N= 58, 49 women, Age 18-50  Clinical findings suggesting intra-articular hip pain, pre-arthritic  3 phase program o I: education and PT x 3 months o II: injection & MR Arthrogram o III: Surgery Results  49 of 52 had PT, average 6 sessions, range 1-19  14 patients satisfied with condition at 3 months Majority hadsurgery  9 went on to phase II but did not choose surgery Equaloutcomes  56% went on to have surgery: debridement or repair +/- osteotomy  Baseline osseous abnormality on imaging did not differ between groups  Surgical group more active at baseline  Surgical and non-surgical group equally satisfied and equal improvement in all outcomes at 1 year  No differences between groups Rehabilitation Protocol Phase I  Education o Activity modification o Decrease acetabular rotation on femur under load o Decrease hip hyperextension o Decrease hip anterior glide Decrease ER  Exercise o Decrease quad and HS dominance Use glutes coremore o Improve coordination of abdominals, gluteals and hip lateral rotators 39 Nonoperative Treatment for Femoracetabular Impingement: A Systematic Review (Wall et al 2013)  5 observational studies included, no RCTs  Low level evidence for conservative management  Recommendation: attempt conservative physical therapy led management before surgery  Need for prospective RCTs in this population Short-Term Outcomes of Conservative Treatment for Femoracetabular Impingement Syndrome: A Systematic Review and Meta-Analysis (Mallets et al, 2019) FAI conservative  PT had significant positive changes in pain and function  Intra-articular injections were inconsistent in their resultscortisonemightworknotguaranteed  Overall literature demonstrated that PT and injections have moderate to large effect sizes and significantly impacted self-reported pain and function in patients with FAI. SURGICAL MANAGEMENT OF ACETABULAR LABRAL TEARS (Enseki et al, 2006)  Arthroscopic surgery is most common debridement  Labral repair may be superior to debridement Repairs  Outcomes vary: moderate to good especially in the short-term o Worse outcomes if chondral damage/OA present  FAI: osteoplasty usually performed o Always necessary? No  Capsular laxity: capsular tightening procedures performed 40 SPECIFIC TECHNIQUES TO LABRAL INVOLVEMENT  Hip IR mobilization through contralateral pelvic rocking  Prior to mobilization, the end range barrier of IR in the contralateral hip should be established Get opphipat IR limit  Posterior tissue stabilization of the femur with manual ER of the hip to lengthen the IR’s of the hip early in joint ROM Early in ERROM softtissue work Enhances Ir Rom  Anterior right hip capsular mobilization with rectus femoris and iliopsoas stretching  Shoulder block allows for contract-relax interventions  Placing the hip in AB avoids inferior shear forces across labrum  Eccentric IR, concentric ER with a moving Pilates reformer box set-up  The ball is used to maintain hip spacing 41  Clinical Examination for Athletes with Groin Pain – Thorborg et al, 2018 5 p.itFEen raoio ma ciy Classification System of Groin Pain in Athletes Griffen et al, 2016; Weir et al, 2015 coughingsneeze Abs Abs adductors FADIR MostlimitedIR 42  Key Palpation Areas and Defined Clinical Entities for Groin Pain Hernia O Een 43  FRACTURES AVULSION FRACTURES  Open growth plates o Apophyseal injuries / apophysitis Inflammation resulting from repeated stress over musculotendinous junction attached to growth plate  MOI o Rapid, violent contraction  ASIS Sartorius  AIIS RecFem  Inferior pubic ramus Adductormagnus  Ischial tuberosity Hamstrings  Acute vs chronic  Treatment o 6-8 weeks o Pain control, rest, gradual return to activity HIP FRACTURES  Leading cause of profound morbidity in individuals aged 65 or older, ranking in the top 10 causes of loss of disability-adjusted life years for older adults.  Worldwide, the number of individuals with hip fracture is expected to rise due to the aging population, higher quality of life, and more active lifestyle older in life.  In 2016, more than 228,00 females and 109,000 male Medicare beneficiaries were hospitalized with hip fracture.Female male OP  Medicare care for these individuals continues to be a major health expenditure in the US with 316,000 admissions annually and a cost of 4.9 billion dollars to treat femoral neck fractures alone.  Evidence indicates that those with hip fracture have a substantial higher risk of death up to 1 year after fracture.  90% of all hip fractures in people 65 years or older result from a ground level fall, which are low-energy fractures and therefore called fragility fractures (osteopenia/osteoporosis). Craik et al, 1994; Guccione et al, 1996; Burgos et al, 2008; Semel et al, 2010; Cheng et al 2011, Buurman et al, 2012; MacKinley et al 2014; Dyer et al, 2016 44 Pathoanatomical Features Femurfracture  Hip fractures are fractures of the proximal femur. o Intracapsular including the femoral neck Hipfracture o Extracapsular including the trochanteric area (intertrochanteric fractures) and just distal to it (subtrochanteric fractures)  Surgical treatment is highly location specific, with specialized implant devices for different fracture patterns.  Fractures of the femoral head are usually the result of high-energy fracture dislocations and 50 therefore not considered fragility fractures. Ex car accident highlytraumatic  50% of all hip fractures in the US are intertrochanteric, 37% femoral neck, and 14% Elyolo are subtrochanteric.  Intertrochanteric fractures are associated with fracture poorer health status compared with femoral neck fractures, and their relative incidence increases with age.  Hip fractures can be nondisplaced, displaced, stable, unstable, or mixed patterns. Kannus et al, 1996; Fox et al, 2000; Parker et al, 2006; Butler et al, 2009; Al Snih et al 2012 Risk Factors  Reduced bone mineral density (BMD)  Older age  Female sex  Low body mass index (BMI)  Ethnicity  Postmenopausal without estrogen replacement  Previous hip fracture  Smoking  Vitamin D deficiency  Low dietary calcium intake Samelson et al, 2002; De Laet et al, 2005; Nymark et al, 2006; Brauer et al, 2009; Robbins et al, 2014; Crandall et al, 2015 45 FEMORAL SHAFT FRACTURE  Young adults Rod  Conservative in children putincast  External fixation for open fracture compound  Intramedullary rod in adults TRAUMA SUBTROCHANTERIC FRACTURE  Young or middle aged  Treatment o ORIF (screw and plate) Screw  PWB for 12 weeks  plate If ORIF fails (non-union), then it is repeated with bone grafting FRACTURE OF THE FEMORAL NECK  Post-menopausal women  Caused by or result of a fall  Femoral head blood supply o Profunda femoral, femoral circumflex vessels, and ligamentum teres  lr necrosisispossible Limb in ER, appears shorter  Treatment o Closed reduction with NWB 12 weeks o ORIF o Other options  Total joint replacement (elderly and frail patient) o Complications  Avascular necrosis  Non-union  DJD 46  50 of fractures INTERTROCHANTERIC FRACTURE  Between lesser and greater trochanter  Extracapsular, better prognosis than femoral neck fracture  Women > 60 years old  Union 12-16 weeks  Treatment o ORIF to avoid complications Getpatientsup to overloadboneincreasestrength etc WB DISLOCATION (80%) POSTERIOR Notcommon  MOI: high-energy impact at position of adduction/flexion  PE: short leg, add/IR  Associated fracture (CT scan)  Treatment o Closed reduction o Traction for 1-6 weeks depending on stability  Complications o Avascular necrosis increases with time ACETABULAR FRACTURE  MOI: femoral head is driven into pelvis  Intra-articular: ORIF  Neurological examination (sciatic nerve)  Treatment o Displaced vs. undisplaced  Complication o DJD 47  INTERVENTIONS FOR THE TREATMENT OF HIP FRACTURE CPG – JOSPT McDonough et al, 2021 Structured Exercise – level of evidence A Early Post-operative Period: Inpatient Setting  Interprofessional rehabilitation programs – level of evidence A   Frequency of physical therapy – level of evidence B 90min 2x a day Early assisted transfers and ambulation – level of evidence A  Aerobic exercise added to structured exercise – level of evidence C  Electrical stimulation for quadriceps strengthening – level of evidence C  Electrical stimulation for pain management – level of evidence C Post-acute Period: Home Care and Community Settings  Extended exercise – level of evidence A  Physical activity interventions – level of evidence A  Aerobic training – level of evidence C 48  EXTRA-ARTICULAR HIP PATHOLOGIES Gluteal Tendinopathy (Bewyer et al, 2003; Kong et al, 2007; Grumet et al, 2010; Magnusson et al, 2010; Docking et al, 2013; Grimaldi et al, 2015; Mulligan et al, 2015, Kinsella et al, 2024)  Females between 40-60 years of age; females 4x more likely gluteus medius tears  Non-specific aching hip and buttock pain (may radiate to the posterior / lateral thigh) aggravated by prolonged standing, sitting, long bouts of walking, stair negotiation, and lying on the involved side butto o May present with a limp and complain of fatigue with walking Aching  Pain near the lateral hip can be referred from intra or extra-articular structures so differential dx is IMPORTANT  Pain near the greater trochanter was previously called trochanteric bursitis  New term preferred is greater trochanteric pain syndrome (GTPS) o Gluteal tendinopathy / tear o External coxa saltans o Proximal ITB syndrome snappinghip  Injuries begin as acute tendonitis and progress to degenerative tendinosis with repetitive loading both tensile and ALSO compressive o Gluteal tendons exposed to high levels of compression between the ITB and greater trochanter, especially in positions of hip ADD o The structure of tendons are well suited to handle tensile loads, BUT not combined tensile and compressive loads o Abnormal movement patterns such as excessive ADD and IR of the LE place excess compressive loads on the gluteal tendons, which will be further increased by weakness in the AB and ER Test Item Cluster for GTPS  Pain localized to the greater trochanter and at least 1 of the following: o Pain at end-range ADD, AB, IR, ER Frontal transverse pain o Positive FABER test o Pain with resisted abduction o Non-radicular pain extending down the lateral thigh greatertrochanter pain 49 Glutemed TTP posterior greatertroch Key Examination findings R glutemed   Presence of a Trendelenburg sign or gait R SLS left pelvisdrops SLS on affected side with positive test being lateral hip pain within 30s  Hip ROM typically normal in gluteal tendinopathy  Passive FABER or FADER are typically the only provocative movements  Resisted AB / IR may reproduce pain, but these tests have low sensitivity  Palpation may distinguish between gluteus medius (TTP posterior aspect greater trochanter) and gluteus minimus (TTP anterior aspect greater trochanter) pathology Conservative Management  Stage of tendinopathy very important for proper treatment management o Early or reactive stage the emphasis should be on reducing the amount and types of load to the tendons  Activity modification – decrease compressive loads  Stand with equal WB  Avoid sitting with the legs crossed  No prolonged sitting on soft surfaces with > 90 degrees hip flexion couch  Possible assistive device in opposite LE loadglutemed  Carrying external loads on the ipsilateral side 50   Sleeping modification – decreased compressive loads  Pillow between the legs when sleeping side lying  NSAIDS?  Stretching or flexibility exercises should be AVOIDED during the early phase of recovery as it will further compress the tissues  Strengthening exercises emphasizing core and gluteal muscles should be included in the early stages o Exercises should be chosen at the appropriate level and in positions that do not compress the tendons further o Isometric exercises should be considered first in shortened ranges followed by more end-range isometric holds o Monitor for substitution of the TFL and QL o Clam shells at this point will aggravate the condition as it places rotatory forces through the tendons WB NWB o WB exercises MAY be better tolerated than NWB as these will NOT place compressive loads through the tendons o Strengthening program should be performed 2-3 times a week with adequate recovery periods for adaptation of tissues o In later phases moderate to heavy eccentric training MAY help reorganize the collagen in tendons and strengthen the overall structural integrity ECCENTRI follows uninvolved eccentric byinvolved 51 Rock involvedside concentril Runners Sprinters jumpers Hamstring syndrome (Sizer et al, 2016); Podschun et al, 2013)  Presents as gluteal / buttock pain secondary to the sciatic nerve being irritated as it wraps around the ischial tuberosity (IT) and long head biceps femoris  History of repetitive hamstring injury or LBP / surgery Paresthesia  Runners, sprinters, and jumping athletes  Pain around the IT that is exacerbated with activity and palpation  Resisted knee flexion with the hip extended (prone) is pain free  Treatment o No hamstring stretching o Sit on a wedge with the thicker part dorsally o Flossing sciatic nerve Sidelying o Modalities in sidelying to the lateral IT o Surgery if conservative management fails Hamstring tendinopathy (Sizer et al, 2016; Afonso et al, 2024, )  Caused by microtrauma and repetitive loading of the hamstring origin at the IT  Similar pain as hamstring syndrome  No pain with sitting Isn't for HS syndrome  Negative SLR and slump  Resisted knee flexion painful with the hip extended Isn't for HS Syndro  Less severe situations may require eccentric loading to reproduce pain  Treatment o Rest o CFM o Gentle stretching second Season o Gradual eccentric strengthening/loading – need more research, Nordic hamstring exercise, loading and dosage may be more important than actual exercise chosen 52 Snapping Hip Syndrome / Coxa Saltans (Flanum et al, 2007 Winston et al 2007; Little et al, 2008; Deslandes et al, 2008; Meira et al, 2010; Tylet et al, 2014)  Can be intra-articular or extra-articular in nature SnappingHip I o Intra-articular causes can include  Labral tears / FAI  Chondral defects  Loose bodies I o Extra-articular causes – classified as being internal or external  Internal cause involves the iliopsoas muscle / tendon  External cause involves the ITB Internal Snapping Hip Syndrome  Snapping and / or pain located anteriorly on the hip with active movements overgroin  Common in sports during repetitive movements of flexion combined with IR / ER o Soccer, football, gymnastics, dance, and martial arts o Prevalence can be as high as 90% in elite ballet dancers with symptoms usually being bilateral  Pain / symptoms also brought on during transitional movements forth o Sit to stand Iliopsoas snappingback o Car transfers femoralhead overeminence iliopestiney  Symptoms occur as the iliopsoas tendon subluxes or rolls over the Iliopectineal eminence, femoral head / anterior joint capsule, or the lesser trochanter  Perceived snapping occurs with movements of the hip from a flexed, AB and ER position into a position of extension, ADD, and IR  Secondary theory is the iliopsoas flips around the iliacus muscle as the hip moves to a more neutral position from a flexed, AB, and ER position 53  Key Examination Findings  Symptoms can be reproduced by the examiner PASSIVELY moving the hip from the flexed, AB, ER position to extension and IR  Can be confirmed with pressure to the iliopsoas tendon, which should cause the snapping to disappear as the tendon will NOT move medially  Thomas test for iliopsoas shortness should be assessed  Strength of the iliopsoas can be assessed supine with the leg in an ER position to potentially isolate the muscle Conservative Management  Rest, avoidance of aggravating factors, iliopsoas stretching, and hip strengthening  Consider use of modalities if highly irritable  Rates of successful management have varied from 36-63%  Begin with core stabilization training to find neutral spine and then progress hip flexor strengthening from there as symptoms permit  Consider muscle imbalances of hip flexor shortness with weakness in the hip rotator muscles tent canadd Rto 3 sets of 10 15 Fk n proprioceptive 54  External Snapping Hip Syndrome (Fredericson et al, 2002; Wahl et al, 2004; Baker et al, 2007; Strauss et al, 2010; Stubbs et al, 2013)  Mechanical snapping as the ITB and gluteus maximus snaps over the gr. trochanter flex and extension  Most common cause of perceived snapping at the hip  Pain experienced with lying on the involved side, transitional movements like sit to stand, walking up inclines, ascending stairs, and running  More common in women and athletes (cyclists and runners) and may be bilateral in nature Key Examination Findings was  Reproducible during the examination  It is usually observable with the naked eye to see the ITB snap back and forth  Ober test for ITB / TFL shortness should be assessed  Passive IR / ER with the hip in a position of extension and ADD Conservative Management  Rest, activity modification, modalities, NSAIDS, and corticosteroid injections  Flexibility emphasis on the TFL / ITB cannotstretchITB  Any weakness especially in the hip AB and ER should be addressed StrengthenAdb  Movement retraining addressing excessive LE valgus is important ER Left side stretch 55  Athletic Pubalgia OR Sports Hernia (Swann et al, 2007; Kachingwe et al, 2008; Campanelli et al, 2010; Preskitt et al, 2011; Minnich et al, 2011; Sedaghati et al, 2013; Ellsworth et al, 2014; Munegato et al, 2015)  Activity limiting lower abdominal and / or groin pain with an inconclusive physical exam and the absence of a true hernia  Incidence 0.5 – 6.2%  Usually from a weakening of the posterior wall of the inguinal canal, but can also be from dysfunction of the transversalis fascia, rectus abdominis insertion, or external oblique aponeurosis  MOI can be an acute injury, BUT usually from repetitive eccentric loading of the lower abdominal wall  Imbalance between the upward oblique pull of the abdominal muscles and the downward and lateral pull of the adductor muscles at the inferior pubis  Diagnosis is one of exclusion as there is NO definitive diagnostic test  Individuals present with NO palpable hernia and often a normal physical exam  Differential should include: osteitis pubis, labral tears, ADD / psoas tendinopathy, stress fractures pubic ramus  Need to rule out urogynecological pathology Clamshells in 45 hip flexion but mainly 56 fibers of glutemed min Target post of eccentriccontrol to avoid ADDAR k Key Examination Findings  Palpation can rule out a true inguinal hernia  Should assess for TTP at the pubic ramus, conjoint tendon, adductor longus origin, and / or rectus abdominis insertion Verymedial  ROM and muscle length testing are important to rule out intra-articular pathologies and possibly identify muscle imbalances or risk factors that may be associated with groin pain  FAI has been reported in 12 – 94% of cases of sports hernia or adductor related groin pain o CAM type FAI creates increase symphyseal motion due to limited ROM  Strength testing can help identify or rule out the presence of muscle strains or tendinopathy o Resisted bilateral adduction knees bent and straight o Resisted crunch or curl up Clinical Cluster of Symptoms Consistent with Athletic Pubalgia / Sports Hernia  Subjective report of deep groin and / or lower abdominal pain  Pain worse with activity especially sport, but decreases with rest  TTP at pubic ramus, conjoint tendon, rectus abdominis  Pain provocation with resisted curl  Pain provocation with resisted bilateral ADD with the hip in 0, 45, or 90 degrees of flexion 57  Conservative Management vs Surgical Intervention  Initial management is modalities such as NSAIDS, ice and avoidance of aggravating factors  Literature favors surgical intervention over conservative management, BUT an initial trial of PT is recommended for 4-6 weeks  Emphasis should be on core muscle re-training and strengthening, as well as correction of any muscle imbalances o Progress core and strengthening exercises from NWB to more upright postures o Consider intermediate positions such as quadruped or half-kneeling o Eccentric loading in later phases of rehabilitation Piriformis Syndrome (Miller et al, 2012; Martin et al, 2013; Michel et al, 2013; Parlak et al, 2014)  Posterior lateral hip pain can be challenging as it is a common site for referred pain  The piriformis can be associated with non-discogenic extrapelvic nerve compression producing local and radicular type pain, as well as paresthesias in the region  Current theory is that piriformis syndrome is caused by entrapment of the sciatic nerve by other structures in the region therefore a new term “deep gluteal syndrome” is being recommended o Gluteal and hamstring muscles o Gemelli-obturator internus complex Piriformis Deepgluteal structures o Ischial tuberosity entrapment syndrome syndrome o Acetabular reconstructive surgery causing 58 Key Examination Findings Piriformis Syndrome  Blunt trauma to the posterior hip and / or buttock region can be a mechanism of injury as scar tissue is laid down and entraps the sciatic nerve  Typical presentation is buttock pain, but some radiating pain into the posterior lateral thigh is also described  Paresthesias t/o the involved LE may also be reported  Symptoms can be exacerbated with prolonged sitting, and increased activity such as prolonged walking, or walking up hills  Palpation is important as TTP is common, which must be compared to the uninvolved side o TTP at the piriformis o Level of the external rotators TTP to tendor palpation o Just lateral to the ischium  Diagnosis is one of exclusion with tests designed to reproduce the patient’s symptoms (pain provocation tests) with either passive stretching or active contraction Conservative Management  No gold standard for this treatment  Early management should include rest, modalities, activity modification, NSAIDS, muscle relaxers, possible corticosteroid injections  Initial program should consider stretching of the ER (piriformis can be stretched by flexion, ADD, IR)  Strengthening should address any muscle imbalances Piriformis stretch overrated may make paresthesia worse muscle will rub more on scar tissue FADIR Piriformis stretch at anatomical neutral No primary IR of hip become good IRs in hipflexion Glute med min 59  17 24 or 10 24 24 10 SPECIAL TESTS Iliopsoas Ruling Out Serious Pathology Resisted Straight Leg Raise (Sp 95%; +LR 2.4; Sn 16%, -LR 0.90) (Wagner et al, 1996) Patient: sitting and leaning back on the hands or lying supine Clinician: standing on the side being tested Instructions  The patient actively flexes the hip app 30 degrees  The clinicians applies a downward force as the patient resists  +ve test is pain reproduced in the lower quadrant indicating peritoneal inflammation, appendicitis, or inflammation of the iliopsoas muscle Stress Fracture (Fulcrum Test) (Sp 13%, +LR 1.0; Sn 88%, -LR 0.92) (Kang et al, 2005) Stress Fracture Patient: short sitting with knees at 90 degrees of flexion Clinician: sitting on the side being tested Instructions  The clinician’s places one forearm under the thigh  The clinician pushes down on the femur assessing for pain reproduction  Clinician can move more proximally assuming the test is originally negative  +ve test is pain with this maneuver, which MAY indicate stress fracture o Refer to an MD for testing most likely MRI Listen for transmission Patellar-Pubic Percussion (Sp 86%, +LR 6.11; Sn 95%, -LR 0.07) (Reiman et al, 2013) Patient: supine, with both lower extremities straight Clinician: standing on the side being tested Instructions:  Clinician places a stethoscope over the pubic tubercle towards the side being tested  The clinicians taps the ipsilateral patella as he/she listens with the scope  +ve test is diminished percussion on the side of pain, which MAY indicate femur fracture o Refer to MD for testing 60 Ruling Out Pain from Lumbar Spine Straight Leg Raise (Sn 97%, -LR 0.05; Sp 57%, +LR 2.2) Vroomen et al, 2002) right would be tested Patient: supine, with head and neck in neutral Clinician: standing on the side being tested Instructions  Maintain trunk and hips in neutral and avoid any rotation  Examiner supports the patient’s involved leg and maintains knee extension and neutral DF  Raise to the point of symptom reproduction  Add DF to assess change in symptoms  +ve test is reproduction of patient’s symptoms Slump Test (Sn 84%, -LR 0.19; Sp 83%, +LR 1.82) Majilesi et al, 2008) Patient: sitting on the table straight up with the hands behind the back and the posterior knees against the table Clinician: sitting on the side being tested Instructions  Spinal flexion – arm across shoulders  Neck flexion  Active knee extension  Active ankle DF  Release neck flexion Look up after  +ve test is reproduction of patient’s symptoms 61 Flexibility Tests Thomas Test (Greenman 1996, Kendall 2005) Patient: standing edge of table Clinician: standing on the side being tested Instructions  Patient grabs one knee while standing  While pulling that knee to the chest have the patient lean back into the supine position with clinician assist  Make sure once the patient is lying down there is no lumbar lordosis remaining  Assess the position of the test leg as depicted in the photos to the right ASSESSMENT  Less than 10-15 degrees of hip extension indicates a short iliopsoas  Knee flexion less than 100-105 degrees indicates a short rectus femoris Knee  With the low back and sacrum flexion taut recfem flat on the table the posterior thigh should touch the table and the knee should flex app 80 degrees  Shortness on the TFL is indicated by AB of the thigh or IR of the hip Tests for Alignment Greatertroch disappears Craig’s Test (ICC 0.45) (Souza et al, 2009) Patient: prone with the knee flexed to 90 degrees Clinician: standing or sitting on the side being tested Instructions  Palpate the posterior aspect of the greater trochanter  Clinician passively rotates the hip internally and externally until the greater trochanter is parallel with the examining table, or it reaches its most lateral position  Measure the IR angle with a goniometer  Value should be between 8-15 degrees Legout  > 15 degrees indicates excessive anteversion 62  Weal r glutemed ShortRglutemed Tests for Muscular Dysfunction Gluteal Tendinopathy / Greater Trochanteric Pain Syndrome Trendelenburg Sign (Sp 92%, +LR 6.83; Sn 61%, -LR 0.25) (Reiman et al, 2013) Patient: standing with weight equally distributed through both LEs Clinician: standing behind the patient Instructions  Patient is asked to stand on one limb  The clinician assesses for pelvic drop on the non-stance side, which is the positive test  Can also use this test for endurance and hold for 30s checking for reproduction of pain Resisted External De-Rotation Test (Sp 97%, +LR 32.6; Sn 88%, -LR 0.12) (Lequense et al, 2008) Patient: supine with the noninvolved LE straight Clinician: standing on the side being tested Instructions  Clinician places the patient’s hip in 90 degrees of flexion and ER to the point of discomfort if pain is present o If there is NO pain the therapist can go to MAX ER  Clinician backs off slightly and then tells the patient to perform resisted IR against the therapist’s hand  If the test is negative, it is repeated with the patient prone hip extended, and the knee in 90 degrees of flexion  +ve test is spontaneous reproduction of symptoms Piriformis Syndrome FAIR Test (Sp 83%, +LR 5.2; Sn 88%, -LR 0.14) (Fishman et al, 2002) Patient: side lying on the noninvolved side with the hip and knee in slight flexion on the side to be tested for stability Clinician: standing behind the client at hip level Instructions  Clinician grasps client’s shin and bring the hip into flexion, adduction, and internal rotation (FAIR)  +ve test is reproduction of the patient’s symptoms  Consider active contraction of the piriformis following this test FADIR 63 Hamstring Injury Hamstring Provocation Test (Sizer et al, 2016) Patient: prone over the table Clinician: standing stabilizing posterior pelvis Instructions  Patient performs slight hip extension and knee flexion  Clinician exerts force to the lower leg trying to extend the knee while the patient resists the force  +ve test is reproduction of the patient’s symptoms Bent Knee Stretch Test (Sp 87%, +LR 6.5; Sn 84%, -LR 0.18) (Cacchio et al, 2012) Patient: supine with both LEs straight Clinician: standing on the side being tested Instructions  Clinician places patient’s hip and knee at max flexion  The clinician slowly extends the patient’s knee  +ve test is reproduction of the patient’s symptoms (pain)  TIP: recommend measuring the angle for inter- session changes Tests for Intra-Articular Pathology Scour Test (Sp 29%, +LR 0.70; Sn 50% -LR 1.72) (Maslowski et al, 2010) Patient: supine with both LEs straight on the table Clinician: standing on the side being tested Instructions I Enentral  Clinician flexes, adducts, and slightly IR the hip until resistance is felt or the pelvis lifts from the table (assess inner quadrant)  Maintaining the hip flexion, the clinician brings the hip into abduction and ER (outer quadrant) Holdtibia w armpit  The clinician takes the hip through TWO full arcs of motion  If the patient reports no pain, the clinician repeats the test with axial compression 64 FABER Test (Patrick’s Test) (Sp 25%, +LR 1.1; Sn 81%, -LR 0.72) (Maslowski et al, 2010) Patient: supine with both LEs straight on the table Clinician: standing on the side being tested Instructions  The clinician places the patient’s heel of the leg being tested over the opposite knee preferably above the patella  While stabilizing the opposite pelvis, the clinician guides the patient’s hip into AB and ER with his hand over the patient’s knee SLOWLY  The clinician adds overpressure to assess end-feel and symptoms  +ve test is