MSK 2 Compiled Notes Wks 1-6 PDF

5.1 Structure and Fxn Kinesiology assumption structure governs fxn, NOT pain but fxn This is an incorrect assumption… human fxn is multifactorial - structural biomechanics is one but not only that we adapt/compensate Hip Jt osteology 3 DOF ball and socket acetabulum is ant, inf, and lateral in fibro...

5.1 Structure and Fxn Kinesiology assumption structure governs fxn, NOT pain but fxn This is an incorrect assumption… human fxn is multifactorial - structural biomechanics is one but not only that we adapt/compensate Hip Jt osteology 3 DOF ball and socket acetabulum is ant, inf, and lateral in fibrocartilaginous labrum Landmarks Insertions hip flexors @ lesser trochanter hip abd @ greater trochanter HS originates from ischial tuberosity obturator foramen (part of ischium & pubis) = allow for neurovaculator to pass through pubic rami = 1 of 3 parts of pelvis femoral head covered by articular cartilage pubic symphysis where 2 rami from each hemi pelvis join pelvis articulates w/ lumbosacral portion of spine 5.2 femoroacetabular orientation acetabular orientation & pelvic anatomical landmarks AP Pelvic Landmarks ↳ ↓ PSA he refers a lot to the pics - ↳ ja 1 = iliopectineal line 2 = ilioischial line 3 = acetabular roof line 4 = acetabular teardrop 5 = post rim of acetabulum 6 = ant rim of acetabulum use walls to determine if pelvis is in a retroverted or antroverted position crossover sign acetabular over coverage 2ndary to retroversion -covers femoral head AP x-ray- bilat acetabular retroversion by cross over of ant and post acetabular walls (dotted lines) acetabular version angle transverse plane angle from post rim of acetabulum. on line is vertical & other extends to ant rim of acetabulum * normal is 15-20 degrees acetabular angles >20 degrees decrease femoral head containment (retroversion) 15-25 mild dysplasia LCEA 5-15 mod dysplasia LCEA 40 pincer impingement pincer deformity on center edge angle (LCEA) > 39° is abnormal and an indication of a pincer deformity * too much coverage on pelvic side * labrum subject to damage AP-front to back view acetabular inclination normal: 33-38 degrees dysplastic: >47 acetabular index- assessed on. an anterior posterior radiograph greater angle=more dysplastic acetabular index acetabular roof angle acetabluar inclination- evaluated degree of upward slope of hip socket normal: 3-13 degrees -he said 10 in his lecture so idk which to go by.. 10 or 13? under coverage: >13 (DDH) over coverage 25 degrees slightly abnormal 20-25 severely abnormal 35) fossa acetabuli is medial to kohler’s line (deep socket) acetabular protrusion -femoral head is medial to kohler’s (ilioischial) line protrusio acetabuli: shallow socket alpha angle transverse plane angle formed by a line parallel to femoral neck axis and line from center of femoral head to transition of femoral head into femoral neck (neck radius exceeds head radius) femoral neck deformity cam impingement femoral head/neck profile exceeds the radius curvature of acetabulum alpha angle >60 indicator of size of bony anomaly no absolute cut-off value high alpha angle in an asymptomatic pt should be considered an incidental finding head neck offset ration 60° 6. Arthritic grading scales range from 0-3 (Tonnis) or 1-4 (Kellgren-Lawrence) 7. Hip flexors and internal rotator muscles pass anterior to the hip axis 8. Hip extensors and external rotator muscles pass posterior to the hip axis 9. Adductors pass medial and Abductors pass lateral to the hip axis 10. Hip joint is very congruent with strong ligamentous support and the arthokinematic motion is primarily spin 11. Active insufficiency is too much slack across two joints; Passive insufficiency is too much tension across two joints all had hip surgeries hehe 5.6 History HE Gather subjective history through interview chief complaint fxnal disabilities/participation restrictions pt goals-expectations age and sex - hip injuries tend to be age specific Hip Injuries Differential Diagnosis based on age 0-2 developmental dysplasia 4-8 Legg-calves-perthes 9-15 SCFE (slipped capital femoral epiphysis), apophysitis 14-25: overuse injuries - strains, sports hernia (core injury, stress fractures) 20-40 chondrolabral pathology 35-55 GTP, snapping hips 55+ DID and Hip fractures (degenerative disease) Level A recommendation using age for diagnosis of hip pathology! Like the spine… want to know onset prior management aggravating/easing factors S.I.N.S - symptom descriptors Hip Specific interview insights 1. Lumbogenic - symptoms change w/ spinal position/motion - line of radiating pain dismally - complaint of parethesia 2. Labral/Intraarticular - unresolved groin pain, “mechanical symptoms” - arthritis in older, labral in younger 3. overuse injuries (tendinopathies, stress fx - significant changes in increase/duration of sports or ADLs 4. avascular necrosis/osteonecrosis - history of alcoholism, prolonged steroid use, blood disorders Subjective history date and mechanism of injury gradual or traumatic onset recent falls, twists, or strains occupational and.or athletic ADLs - frequency, duration, intensity, recent changes Previous tx what where when by whom current-past medications/injections (related to hip/ prescribe/OTC) orthotics, braces, belts, spicas all tells us how successful or not the tx was Present status - better, worse, same 1. symptom (pain) complaint - location, nature, severity, duration, time - aggravated or alleviated by - impact of sitting, rising, walking, climbing stairs, squatting 2. neurological complaints - lumbar & SIJ symptoms can be referred to hip, thigh, iliac fossa, buttock, groin 3. work/activity status/impact History pain location intra articular = anterior or medial groin area lateral pain = trochanteric (tendon or bursa) or L4 referred) posterior = SIJ, piriformis, or L5-S1 referred hip pain can extend into thigh toward knee in acute stage Past medical history previous related injuries general medical or family history pregnancy-menstrual status diagnostic studies - X-rays, CT scan, MRI, EMG/NCV (nerve conduction velocity) Psychosocial influences psychological distress has correlation w/ self report scores pt factors like mental health, activity level, sex, smoking more predictive of baseline hip pain than actual intra articular hip findings tx of insomnia and anxiety improves hip pt outcomes Functional Outcome tools harris hip score (or mHHS): surgeon based outcome measurement tool assessing pain & fxn after hip surgery iHOT-12: mulligan likes this w/ 12 slider VAS scale questions WOMAC (hip & knee) - disease specific (OA) scale LE functional scale (LEFS): most common region specific scale, hip, knee, ankle Hip outcome score (HOS): jt specific, self report w/ highest levels of internal reliability, validity, & responsiveness HAGOS: region specific, self report for younger more active individuals w/ established clinimetric values add all up divide by 12 5.7 Hip Impairments Screening the Lumbopelvic Spine ROM in cardinal planes with OVERPRESSURE PA Spring (Posterior or Anterior springs on the spinous process Lumbopelvic Rhythm Is lumbar motion and hip motion both occuring in equal/proportional amounts? Quadrant test EXT and Sidebending and Rotating to the same side (Kemp Test) Special tests SLR Slump test for sciatic tension Fermoral nerve tension in prone SIJ cluster Positions for evaluation Standing Supine Check femur and tibia lengths with knees flexed at 90 and hips at 45 Prone Supine to sitting leg lengthening or shortening can also be indicative of SIJ dysfunctions Direct measuring ASIS or umbilicus down to Malleolus can have errors for palpation, iliac asymmetries, frontal plane deviations (var valgus) Joint contractures, asymmetrical thigh girth Indirect measure Palpation of bony landmark symmetry Leg length discrepancy considerations Is Subtalar joint neutral ? What is considered significant? 5-6mm Prevalance varies in literature from 5-90% but very common in adolescence Probably about 50% if using bench mark of 5mm HIP JOINT ROM Normal values AAOS What is needed for normal gait Thomas Test Check flexibility for 1 joint and 2 joint flexors 1 joint- iliopsoas 2 joint- rectus femoris, tensor fascia, and sartorius Supine position Contralateral single knee to chest to maintain lumbar spin in flexion Opposite hip drops into EXT with knee at 90degree should be flush with resting surface Monitor for substitution if hip abduction, TFL may be restricting motion if knee extension, indictment of rectus femoris length ‘ if tibia abduction or ER, sartorius is probably limited Hamstring flexibility combine hip flexion with knee ext in supine Ideal 80-90 of hip flexion while maintaining full knee ext with hip at 90, what is popliteal angle at ? (The slight knee bending during hip FLX at 90) Note influencers of tight hip flexors Medial vs Lateral hamstring? Medial- have femur in ER Lateral- have femur in IR LUMBOGENIC/LUMBO PELVIC Piriformis Flexibility Adductor Flexibility In hip FLX and ADD, See the IR ROM or In FLX and IR, assess amount of horizontal ADD Assess hip ABD while monitoring for hip rotation, knee flexion, and hip hiking OBER test Hip Rotation ROM Check TFL Hip in EXT and allowed to ADD Pelvis must be stabilized while top extremity is about 15 below horizontal Note subtle substitution motions of trunk lateral flexion or hip flexion/rotation Modified- knee straight, typically get a few more degrees of adduction Assess amount of IR and ER rom in position of hip flexion (seated, legs hanging ) Quadriceps flexibility knee flexion ROM heel to butt stretch without hip FLX or ABD Screen also for femoral nerve tension Compare with results with patient in prone and in hip extension Prone knees in 90 FLX, compare results in hip FLX IF equal, then most likely no soft tissue limitations Normal Values 30-40 IR 40-45 ER Assess Hip Strength in cardinal planes MMT for Hip Muscles Percentages are compared to boyweight measured with dynamometer 5.8 Special Tests HE Log Roll Test - Test done in supine - Differentiate intra from extra-articular movement - Test - Gently rolling femur into IR/ER ROM (Femoral head rolls on stationary acetabulum) - Moving femoral head in relation to acetabulum does not significantly challenge myotendinous or nervous structures - Results - If you can recreate patients symptoms, indication of intra-articular problem - Test not sensitive to rule out an intra-articular problem > Scouring/ Quadrant Test - Test in supine - Test - Circumduction, rotation and/or ab-adduction of hip joint while in 90-140 of FLEX concurrent w/ long axis compression along femur - Evaluates hip OA & may aggravate labral pathology in involved quadrants - Possible exacerbation of arthritic type symptoms - Results - Single study evaluated diagnostic accuracy for IA hip pin found - No good studies to back it up - Poor sensitivity, bad specificity > - Femoroacetabular/Labral Pathology Tests - Anterior Hip Impingement Maneuvers (Anterolateral, more common) - Movement combinations - FLEX/ADD/IR - FLEX/IR - FLEX/IR w/ Axial Compression - F/ADD w/ Axial Compression - FADIR Test - Combination of FLEX/ADD/IR - Very sensitive tests (90%), low specificity - Can not use for rule in, can use for rule out - FABER - Combination of FLEX/ABD/ER - Also called Patrick Sign, place distal lateral leg on opposite anterior distal thigh (stabilize contralateral pelvis) - Normal response is limb falls parallel to table w/o pain at SI joint - Good reliability, highly sensitive - Rule out but not for ruling in - FABER Modification - If limb stays up in horizontal ADD, have them activate core - Have them push arms into yours, creates posterior tilt - More clearance for patient w/ FAI - More FABER - Pay attention to where patient reports pain - Anterior complaint - FAI w/ lateral hip pain to conduct pain syndrome - Lateral Complaint - GTPS - Posterior Complaint - SIJ ↳ Posterior Inferior Impingement Test - ER in supine w/ hips at edge of table to allow maximal EXT - Positive test is the reproduction of familiar deep groin/buttock pain - Unknown diagnostic accuracy - Not prevalent enough, hard to evaluate accuracy > Ischiofemoral Impingement - Posterior Hip Pain - Hip, groin, & post. Thigh pain due to narrowing of ischiofemoral space resulting in compression or impingement of quad femoris - Longer the stride, more hip pain - Non-ambulatory test - If they are having pain during impingement test - Extend hip close to ischiofemoral space, in both ADD/ABD position - If painful when ADD, positive test > Hip Stability Assessment - Anterior Femoral Head Displacement - Put inn combination of hip ABD/EXT/ER - Tests - AB-HEER (Mullys favorite) - Sidelying position - EXT/ABD hip, let it drop - Evaluate for apprehension or symptom reproduction - Prone Instability Test - ER in EXT pushing femoral head ANT - HEER - Hip EXT/ER - Symptomatic response is instability sensation - Positive test in 2/3 signifies origin of complaint is instability > / Fulcrum Test for Femoral Stress Fractures - Place forearm proximal to suspected fracture, bend femur - Positive result would be reproduction of sharp pain - Very sensitive test - Negative response would rule out need for MRI > Femoral Stress Fracture Test - Patellar-Pubic Percussion tEst - Patella tapped while osculating the suspected fracture site - Looking for duller response - Can use fork in lieu of tapping on patella - Trendelenburg Sign - Weakness is hip ABD/Glute Med - Drop of contralateral pelvis - Glute Med Tendinopathy - Reliable test w/ SN of 73% using MRI evidence of torn tendon as reference standard - Osteoarthritis - Lower sensitivity for detecting OA Provacative Tests for Gluteal Tendinopathy - Symptom reproduction of pain complaint is positive sign - Tests - Unilateral stance for 30 sec - Don’t let trunk side bend to ipsilateral side - High SN & SP - External De-Rotation Test (Non-WB position) - Resistance to IR from position of hip FLEX/ER back to neutral’ - Lower SN, High SP - Hip Lag Sign - Hip at end ROM of ABD, little IR - Patient holds against gravity - Positive test is drops more than 3-4 inches - Can Rule Out w/ palpation - Can run in w/ Abduction challenge or De-rotation MMTS Simple Impairment-Based Decision Making Tool - Absence of pain to palpation followed by negative resisted hp abduction test decreased probability of condition from 59-13% - Presence of pain to palpation followed by positive resisted hip abduction test increased probability of condition from 59-96% Hip Lag - Hamstring Diagnostic Tests & Provocative Maneuvers - 2 Choices - ADL motions - Reproduce symptoms w/ passive stretch, & active contraction - Loading hamstring - Low-moderate-high load, assess pain tolerance - Low may be indicative of hamstring pathology - Systematic review found mild-moderate accuracy & high likelihood ratios using contractile lesion pathology - “Removing shoe” was almost perfect - Use of opposite foot to push down heel as FLEX knee 5.9 Gait & Function Stationary Functional Tests - Deep Squat - Ability to complete w/ symmetrical movement of hips & knees - Could help screen for hip intra-articular pathology - Cross Leg Sitting - Ability to place lateral malleolus & distal leg on opposite anterior distal thigh - Stair Ambulation - Ability to ascend & descend 8-12” steps - Stork Stand - Assessment of proprioceptive abilities, kinesthetic awareness & control, balancing abilities, reproduction of SIJ symptoms Ambulatory Functional Tests - MCD (Minimal Detectable Change) - 6 Minute Walk Test - Highly reliable indicator ability to walk long distances w/ MDC of approximately 60 meters - Self-Paced Walk Test - How fast a person can walk 4 or 40 meters - Highly reliable w/ MDC of 4 sec for 40 meter walk & 0.1m/sec for 4 meter walk - TUG Test - Highly reliable test of ADL function w/ MDC of 2.5 sec Step Down Test/Single Leg Step Down - Effective method of identifying hip muscle dysfunction - Highly reliable in differentiating b/w good, fair, or poor - “Good” performance was indicative of earlier & more intense recruitment of Glute Med Functional Movement Screen (FMS) - Consists of squat, hurdle step, in-line lunge, leg raise, push up, rotational reach, behind back reach - Each test scored on 0-3 scale - 0, too painful to complete - 1, significant deviations - 2, Limited abilities or notable movement deviations - 3, normal - Highly reliable & specific but poor sensitivity in predicting sports injury Observational Gait Analysis - Lurch/lateral trunk flexion in midstance to side of WB or dysfunction - Pelvic drop in midstance to side of WB or dysfunction - Excessive lumbar lordosis or flat back - Alterations in angle or base of gait - Altered stance limb stability & timing - Stride Length Common Abnormal Hip Gait Patterns - Antalgic Gait - Gait that develops to avoid pain while walking - Ambulation pattern where stance phase of gait is abnormally shortened relative to swing phase - Non-specific indication of pain in body region w/ WB - Trendelenburg Gait - Glute Med limp secondary to weakness - Deviations - Contralateral pelvis drops - COG shifts towards side of weakness w/ lateral trunk lean - Identifies poor hip control, not specific pathology or diagnosis - Glute Max Weakness Lurch - At heel strike, trunk remains extended to keep COG posterior to hip joint - Key Points - Differential musculoskeletal hip presentations are usually age & location specific - Short-sighted to manage hip w/o considering lumbar spine - Important to baseline function with PROM - Baseline hip mobility & strength deficits - Use appropriate special tests to confirm or exclude specific pathologies - Must evaluate function, gait & common ADL’s - Use observations & findings to synthesize a customized POC pincer- congenital cam-aquired