Examination of the Hip - Student PDF

Examination of the Hip Rebecca Pinkus, PT, DPT, NCS PT8311 Contributions by: Jolene Walsh, PT, MPT, Keith Cole, PT, DPT, PhD, MBiomedE, OCS & Joseph Signorino, PT, DPT, OCS, FAAOMPT Dhinu Jayaseel...

Examination of the Hip Rebecca Pinkus, PT, DPT, NCS PT8311 Contributions by: Jolene Walsh, PT, MPT, Keith Cole, PT, DPT, PhD, MBiomedE, OCS & Joseph Signorino, PT, DPT, OCS, FAAOMPT Dhinu Jayaseelan, DPT, OCS, FAAOMPT https://paindoctor.com/conditions/hip-pain/  Objectives 1. Discuss relevant subjective questioning specific to hip pathology 2. Discuss relevant anatomy related to physical examination of the hip 3. Describe typical goniometric and muscle testing technique for the hip region 4. Present various clinical presentations of hip dysfunction that may be more likely based on appropriate examination techniques  Subjective Subjective intake needs to include for both family and individual: – CA, HTN/CAD, cholesterol, DM Symptoms – Quality – burning, aching, stabbing, shooting, stiffness, N/T, unstable – Deep or superficial – Location SINSS including aggravating/alleviating factors – Common Complaints: Sitting? Sitting durations? Squatting? 24hr pain pattern? (AM/day/night) Joint sounds? – Clicking, crepitus  Importance of Subjective History Hip can be primary source of pain and localized, or Hip structures can often refer pain away from the joint Possible Referred Pain to the hip/buttock area Lumbar and/or Thoracic Spine Pubic symphysis, pelvic girdle pain Visceral – appendix, renal GU –ureter, bladder Hernia  Where is the pain? Lesher et al, 2008. Pain Medicine. Irritant injection  Primary Functions 1. Support the weight of the head, arms, trunk in a static, erect postures and dynamic postures 2. Pathway for transmission of forces between the pelvis and lower extremities http://www.painfreenyc.com/hip-flexor-strain- specialists-brooklyn-hip-pain-doctors/  The Hip Very (very) stable joint Acetabulum: Faces laterally, inferiorly & anteriorly Femur: longest bone in body, wide diameter http://www.childrenshospital.org/centers-and-services/child-and-adult-hip-preservation-program/your-hip-joint  The Hip “Ball and socket” Circumduction joint ROM – Flexion – Extension – Abduction – Adduction – External rotation – Internal rotation Axis of rotation: ________________ Muscle groups – Gluteal http://cephalicvein.com/2016/06/ball-and-socket-joint/ – Adductors – Iliopsoas – Lateral/external rotators  Acetabulum Combined Ilium, ischium, pubis Not a complete circle Acetabular notch (inferior): transverse ligament completes the circle Labrum “O” ring 70% of head of femur articulates with acetabulum http://medical-dictionary.thefreedictionary.com/acetabulum  Ligamentous Support Posterior: Anterior: – ischiofemoral – iliofemoral – pubofemoral http://centenoschultz.com/hip-pain-arising-from-hip-capsule/ http://danceproject.ca/advanced-hip-flexor-stretching-for-the- hypermobile/  Pelvic tilt and hip ROM / https://completegamept.com/blog/ 7s8sywyy4jmawfnczpdep9897s3res http://practicingashtanga.com/understanding-pelvic- tilt/  Posture Vladimir Janda’s (1928-2002) “Lower Crossed Syndrome” defined in 1979 http://www.jandaapproach.com/the-janda-approach/jandas-syndromes/ https://mikereinold.com/the-influence-of-anterior-pelvic-tilt-on-hip-flexion-mobility/ https://bretcontreras.com/current-position- statement-on-anterior-pelvic-tilt/ https://builtwithscience.com/anterior-pelvic-tilt  Goniometry Sagittal Motion (Flexion/Extension) – Axis- frontal Frontal Motion (Abduction/Adduction) – Axis- sagittal Transverse Motion (IR/ER or medial/lateral rotation) – Axis- longitudinal http://teamawesome34.weebly.com/functional-a  Knee flexed: why? When does motion end? End-feels: – Soft due to ______________ – Firm due to ______________ http://www.scranton.edu/faculty/kosmahl/courses/gonio/lower/index.shtml  Knee position? When does motion end? End-feel: Firm due to ______________ ______________ ______________ ______ Alternative testing position- http://www.scranton.edu/faculty/kosmahl/courses/gonio/lower/index.shtml  End-feel: firm due to… ?? http://www.scranton.edu/faculty/kosmahl/courses/gonio/lower/index.shtml End-feel: firm due to…. End-feel: firm due to…. http://www.scranton.edu/faculty/kosmahl/courses/gonio/lower/index.shtml  Capsular Pattern Internal rotation > Flexion/abduction > extension  Functional ROM Walking 30 flex to 10 ext Stair ascent 65 flex Stair descent 40 flex Sitting in chair 90-112 flex Putting on socks 120 flex Squatting 115 flex Sitting on floor cross- 90-100 flex, 35-60 ER, legged 40-45 abduction Muscular Considerations Hip flexors: Iliacus and Psoas Major(Primary), sartorius, TFL*, rectus femoris, adductor longus, pectineus (Secondary) – Iliopsoas can produce anterior tilt force across lumbosacral region – *TFL can be a primary hip flexor in anatomic position – Rectus femoris responsible for ~1/3 of  Hip extensors: Glute max and hamstrings(Primary), Adductor Magnus(Secondary) – Glute Max is most effective in near full extension and is a mix of both slow and fast twitch fibers – Adductor magnus- powerful extensor when femur is flexed Hip Abductors- glute med, glute min, TFL (Primary), piriformis, sartorius, obturator int, Gemelli (Secondary) Single leg stance with level pelvis should equal Grade 4 or 5 TFL often compensates for weakness of glute med – TFL blends in with fibrous tissue (ITB), potentially creating increased friction at lateral knee – Common compensation with hip abd testing is hip flexion Glute Med has anterior, middle, and posterior fibers: ant=IR, Post=ER https://www.precisionmovement.coach/gluteus-medius-exercises/ Hip Adductors: Adductor magnus, brevis, and longus; pectineus and gracilis (Primary), biceps femoris (long head), lower fibers of glute max, and quad fem. (Secondary) Adductor longus can both flex and extend the femur Adductor longus may be more active during open chain activities than the adductor magnus Hip Internal Rotators: Glute med and min (anterior fibers) , TFL (Primary), Glute max, Semiten, Semimem, Adductor magus and longus (position-dependent), piriformis (position-dependent) (Secondary) No primary internal rotators in the anatomical position At 90 degrees of hip flexion, IR torque dramatically increases Muscles that switch action from ER to IR beyond 90 degrees of hip flexion: Piriformis Ant. Fibers of glute max Posterior fibers of glute min. https://www.paulasbodyshop.com/blog/the-ultimate- https://www.verywellhealth.com/intermediate- piriformis-stretch piriformis-syndrome-stretching-routine-4022709  Hip External Rotators: Glute max and the “Deep 6” (Primary), Glute med posterior fibers, sartorius, long head of biceps fem. (Secondary) Obturator externus- line of force too close to axis of rotation. Based on location and innervation it’s more like the adductor group  Proximal Contribution to Distal Pathology Hip dysfunction often linked biomechanically to knee and/or foot problems o Treatment approach = regional interdependence Clinical Example: Anterior knee pain Weakness/impaired coordination or timing of hip abductors/external rotators Increased dynamic genu valgum (femoral adduction + Internal rotation) Increased lateral compression, medial tension Powers, 2010 JOSPT  Clinical Case: Hip Osteoarthritis History: – Older patient – >60 years – Groin pain, lateral hip pain, knee pain – High frequency with associated L-spine DJD – Morning hip stiffness (