Hip Joint Pathology and Treatment W4 PDF

**Hip Joint Pathology and Treatment -- Physio Theory Week 4** ============================================================= **[Learning outcomes:]** - Relate the anatomy and kinesiology of the hip joint in a functional context - Recognise bony variations and how these can lead to developm...

**Hip Joint Pathology and Treatment -- Physio Theory Week 4** ============================================================= **[Learning outcomes:]** - Relate the anatomy and kinesiology of the hip joint in a functional context - Recognise bony variations and how these can lead to development of pathology - Understand common developmental hip joint conditions - Recognise acute and overuse injuries to the hip **Anatomy and kinesiology: Overview** - Hip joint: very deep and stable joint (deep socket) - Diarthrodial 'ball and socket' joint - Three degrees of freedom (flexion and extension, abduction and adduction, internal and external rotation) - Support wight of head, arms and trunk (HAT) -- weight bearing (force coming down -- gravity and force coming up -- ground reaction force) - Open and closed chain function (end of the chain -- foot is fixed to the floor (closed chain), foot is swinging in space (open chain)) - Role in lumbopelvic chain (hip joint rarely works in isolation) e.g. if there is weakness in hip, there may be overcompensation from spine Passive stabilisation: - Bony architecture (congruent), Labrum; strong ligamentous system (particularly anteriorly) -- fibrocartilaginous layer around the edge of the socket that gives depth to the socket -- gives extra in built passive stability - As physios, cannot do much for passive structures Active stabilisation: - External rotator muscles (joint compression) - Hip abductor muscles: role in stance phase of gait: "Trendelenburg" gait phenomenon - Gluteal muscles are the largest and strongest in the body **The hip joint:** - Hip = a component of the lumbo-pelvic-hip complex (move together to give us function and movement) - Interrelationship between joints in the body - When assessing joints, always look at the joints above and below e.g. Lumbar spine and knee and always check the other side **The hip region: an introduction to pain referral patterns --** - Pain may arise from a local structure, but may also be referred to that site from a structure some distance away e.g. someone has tooth infection, get pain in ear - Lumbar spine can refer pain to hip region usually in a lateral and diagonal (dermatomal) pattern - Pain straight in front, deep in or behind the joint is usually arising from the joint itself - Hip joint will also refer pain straight down to the knee, and the 'grasp sign' may be acetabular pain **Bony variations: femur** - Angle of inclination = 125^o^ (normal) - Coxa Valga = \>125^o^ (increase in angle) - Coxa Vara = \ - Can just be born with a different angle **Bony alignment: femur** - Angle of torsion  Person with excessive anteversion may walk with their toes slightly internally rotated (allows femoral neck to line up properly in socket) - Have more flexion of hip joint than extension and this is due to forward facing acetabulum **Impact of coxa vara/valga:** The greater moment arm we have the easier the job of the hip abductors to work and hold us up on one leg This is why angle of inclination is at 125^o^ (gives us a good enough moment arm for hip abductors to work nicely but also balancing the shearing forces that are coming down from our HAT -- minimising risk of hip joint fracture) **Acetabular alignment:** - Centre edge angle (Wibergs angle) -- the amount of inferior tilt - The degree of femoral head coverage - Smaller angle -- decreased coverage of head femur -- increased chance of superior dislocation -- acetabular dysplasia - Larger angle -- too much coverage -- pincer FAI - Impingement  - Acetabular anteversion - Represents magnitude of anterior orientation - Increase is associated with decreased joint stability ***Common hip conditions in a younger population:*** **[HIP DYSPLASIA:]** Potential causes: - Coxa valga - Femoral anteversion (forward facing of femur) - Shallow acetabulum Can result in: - Reduced congruence of the hip joint - Prone to dislocation, labral tears, impingement syndromes (i.e. FAI)  **Development dysplasia of the hip:** Management in babies -- - Braces -- pelvic harness - "frog leg position" - Maintain hip joint flexion, abduction and external rotation to improve articular contact Long-term management: osteoarthritis due to stress distribution concentrated in a smaller area - Arthroscopy, hip resurfacing, replacement - Estimate: 25% OA related to residual effects of developmental hip dysplasia **[PERTHES' DISEASE:]** - Osteochondrosis (avascular necrosis -- death of bone cartilage surface due to poor circulation) affecting epiphysis and therefore the femoral head - Unilateral (20% bilateral) - Children 3-10 years - Males \ females  **History:** - Insidious onset (just came on -- no specific incident/precursor) - Hip/groin/knee pain - Limitation of hip movement (Internal rotation and abduction) -- pain actively (when they move it) and passively (when I move it) due to passive structures in joint - Beware the painful knee Physical examination: - Antalgic gait - Restricted hip joint ROM and pain **Management:** - Specialist input -- paediatrician etc - Conservative management (non-surgical): non-weightbearing to allow revascularisation (regrowth of circulatory supply into area of femoral head that has started to die off) and healing - Often 12 months away from 'loaded' sport - Strengthening of affected and unaffected limbs - Think of low-load activities: - i.e. hydrotherapy, cycling etc (increase ROM and strength without undue load on joint) **[SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE):]** Note: Coxa vara = increased shearing force of HAT down through neck -- in immature bone, may excessively load across growth plate -- head 'slips' down with force from above  **Classification:** 1. stable (90%): ambulation is possible 2. unstable (10%): behaves like a fracture - often an acute mechanism - poorer prognosis: avascular necrosis of head of femur **'Stable' SCFE** [History:] - Intermittent limp - Hip/groin/thigh/knee pain - Reduction in hip ROM - Describe progressive external rotation of hip, shortening of leg - Decrease in function e.g. sport [Physical examination:] - Antalgic gait - **Clear lumbar spine and knee joint** - Reduced hip joint ROM hip, IR, flexion, abduction - Leg length discrepancy - Muscle atrophy (pain alteration in gait mechanics) **'Unstable' SCFE** [History:] - Late adolescent/ early teens - Extreme pain, often acute mechanism i.e. fall, or twisting injury [Physical examination:] - Unable to walk - Hip held in flexion, ER and abduction (similar to \#NOF position) - Passive Hip flexion moves into flexion, abduction and ER  **Management:** - NWB (crutches, wheelchair) - Orthopaedic surgeon - Surgery: internal fixation (pinning) with central screw or multiple pins **Post-op SCFE Rehab:** - Touch weightbearing (TWB) 4-6/52 (decrease load from hip joint) - Muscle strengthening - Gradual return to activities - Prognosis: generally good. Increased risk OA, avascular necrosis - Severe/ failed cases may require fusion, total hip replacement **[ACETABULAR LABRAL TEARS:]** Acetabular labrum may be torn by a rotation or pivoting motion when under load [History:] - Common in athletes, cyclists, truck drivers (sustained hip joint flexion) - May describe a 'giving way' sensation and acute pain - May describe an audible click on IR and adduction of hip - Common cause of chronic back pain [Common sites of symptoms in patients awaiting hip arthroscopy:] - 58% deep inside hip - 51% groin - 45% outside of hip - 42% low back pain **Extrinsic causes:** - MVA (motor vehicle accident) - Lateral impact - Lifting/twisting/squatting/ bending injuries - Passive impingement (truck drivers, horse riders etc) - Active impingement (dancers, cyclists, martial arts, water polo etc) **Intrinsic causes:** - Hip dysplasia - Low tone - Ligament teres tears - Old SCFE ('pistol grip' deformity) - Femoral bossing/ Ganz (CAM) lesions/ FAI **Labral tears -- physical examination:** [Tends to be a combination of tests:] - Painful and restricted 'hip quadrant', FADIR test (flexion, adduction and internal rotation) - Secondary muscle tightness - Secondary muscle weakness - Magnetic resonance imaging (MRI) and hip arthroscopy **Labral tears -- management:** - Trial conservative management - May require arthroscopic surgery - Repair or arthroscopic debridement - Prognosis good - Strength, functional strength, ROM - NB Chondral lesions and subchondral bone cysts can also be associated with labral damage **[FENORO-ACETABULAR IMPINGEMENT (FAI):]** - A common bone growth variant seen in approximately 20% people - Not all are symptomatic (approx. ¼) - Not a pathology -- can however result in pathologies (i.e. labral tears, early OA) - Cause -- not sure. Maybe excessive activity during periods of growth; maybe a genetic link 3 main types: - Cam (Ganz) - Pincer - Mixed FAI -- Cam lesion:  **[TROCHANTERIC BUSITIS:]** - Bursae: fluid filled sacs designed to reduce friction between bone and soft tissues - Numerous bursae described around the greater trochanter - May become inflamed with excessive friction/trauma - Overloading of Gluteus Medius can irritate both tendon and bursae - Generally co-existing pathologies **Trochanteric bursitis/ Gluteus Medius tendinopathy:** History: - Often seen in distance runner - Single leg stance -- overuse of glut med - Gradual onset of pain - Aggravator: activity and lying on affected side - 24/24: inflammatory signs Physical examination: - Pain on glut med stretch - Pain on resisted hip abduction - Pain on SLS, hip hitching, hopping - May have positive Trendelenburg sign - Pain on palpation on greater trochanter and common glut tendon Management: - Load manage e.g. pool running - Strengthen glut med and lumbo-pelvic stabilisers - Local corticosteroid injection (CSI) into bursa