Hip Notes PDF - Exam 1

Hip Thursday, September 5, 2024 9:01 AM - Key takeaways from these sections that will be assessed on the exam ○ The functional anatomy of the hip and knee to include musculature, ligaments, and bony landmarks ○ The biomechanics of the hip and knee ○ The evaluations of the...

Hip Thursday, September 5, 2024 9:01 AM - Key takeaways from these sections that will be assessed on the exam ○ The functional anatomy of the hip and knee to include musculature, ligaments, and bony landmarks ○ The biomechanics of the hip and knee ○ The evaluations of the hip and knee ○ Biomechanics and evaluations are the most important parts - Functional anatomy ○ Osseous structures ▪ Innominate □ Ilium (superior), ischium (posteroinferior), pubic (anteroinferior) □ ▪ Acetabulum □ Faces anterior, lateral, and inferior □ Center of acetabulum has fatty tissue covered by synovial membrane ▪ Dislocation □ MC direction of hip dislocation is posterior & superior Unlike shoulder, where MC dislocation is anterior & inferior Although both femoral and humeral head face the same direction, dislocation differences occur due to musculature, ligaments, and open/ closed-packed positions ▪ Femoral head □ Covered by hyaline cartilage except for fovea capitis □ Faces posterior, medial, and superior ▪ Trabecular patterns □ Tension trabeculae More superior Run from femoral head trochanteric area □ Compression trabeculae More inferior Run from trochanteric area femoral head Exam 1 Page 1  Run from trochanteric area femoral head □ As we age, likelihood of trochanteric - femoral neck fractures increases ○ Capsular ligaments ▪ Ligaments wrap around and extend from the peripheral surface of the acetabular labrum to the intertrochanteric line ▪ Capsule is thicker on the anterosuperior portion of the capsule ▪ ▪ Iliofemoral lig. □ Location Lies anterior & superior Extends from the AIIS to the trochanteric line of femur ◊ Forms an inverted Y □ Purpose Prevents posterior tilt of pelvis when standing erect □ Limits extension of hip joint ▪ Ischiofemoral lig. □ Location Lies posterior & inferior Extends from the ischium posteriorly to inner surface of greater trochanter □ Purpose Reinforces posterior portion of the capsule □ Limits excessive internal rotation, abduction, extension ▪ Pubofemoral lig. □ Location Extends from obturator crest & superior ramus of pubis to the deep vertical bands of the iliofemoral lig. □ Purpose Reinforces medioinferior joint capsule Exam 1 Page 2  Reinforces medioinferior joint capsule □ Limits excessive external rotation, abduction, extension ▪ Ligamentum teres □ Location Extends from the fovea capitis femoris to each side of the acetabular notch □ Purpose Some protection of the nutrient artery that supplies the femoral head Becomes taut when thigh is semiflexed and adducted or externally rotated Lined with synovium and can assist with lubrication of femoral head, acting like a meniscus ▪ Transverse lig. □ Location Crosses acetabular notch □ Purpose Converts the notch into a foramen, which the nutrient artery that supplies the femoral head crosses ○ Musculature ▪ Actions □ ▪ Stabilities □ Posterior stability Gluteus maximus, posterior fibers of Gluteus medius, Hamstrings, Piriformis □ Anterior stability Iliopsoas, Sartorius, Quadriceps/ rectus femoris muscles □ Lateral stability TFL, Gluteus medius, Gluteus minimus □ Medial stability Pectineus, Adductor muscles, Gracilis ▪ Bursae □ Iliopectineal bursa Location ◊ Between iliopsoas and hip joint capsule Pathology ◊ Trauma can cause excess fluid to spill into it ◊ Hip flexion & adduction, or excessive extension can compress the inflamed bursa □ Trochanteric bursa Location ◊ Separates the gluteus maximus tendon & IT band from the greater trochanter Pathology ◊ Direct trauma or overuse of this area can inflame the bursa Exam 1 Page 3  ◊ Direct trauma or overuse of this area can inflame the bursa □ Ischiogluteal bursa Location ◊ Superficial over the ischial tuberosity Pathology ◊ Sitting for prolonged periods of time can inflame the bursa - Biomechanics ○ Closed-packed position ▪ Full extension, internal rotation, and abduction ○ Loose-packed position ▪ 30 degrees of flexion, 30 degrees of abduction, and slight external rotation ○ Degree of movements ▪ □ ***Know these numbers*** ○ Femoral neck ▪ Angle of inclination of neck-shaft □ ~125o; 90-135o □ Coxa valga Angle > 125o Greater pressure on the femoral head Longer leg with toes in DDx ◊ Immobilizing disorders, cerebral palsy □ Coxa vara Angle < 125o Greater pressure on the femoral neck Shorter leg with toes out DDx ◊ Skeletal dysplasia, fractures, AVN, SCFE, Rickets, Paget's disease □ Note* this is different than genu valgum and varum, as that relates to the knee only Coxa valga is increased angle of inclination of the femoral neck to shaft Genu valgum/ valgus is a decreased angle of femoral shaft to tibial shaft causing knees that are bowed inward ▪ Angle of anteversion of neck (long axis)-femoral condyles (transverse axis) ~12o; 10-30o □ Aka angle of torsion □ In children, this angle is larger and gets smaller with age □ Note, the femoral head stay put because it is 'locked' in the acetabulum. The distal part, i.e. the tibia, will either compensate by externally rotating or stay in place and internally rotate If a pt has retroverted hips, i.e. toes out, and you tell them to bring their toes in for a squat, then it can cause anterior impingement of the iliofemoral lig. or anterior part of the labrum □ Anteversion Angle >12o ◊ Exam 1 Page 4  Angle >12o ◊ Produces toe-in posture □ Retroversion Angle trochanteric bursa Flexion -> iliopectineal bursa Extension -> ischiogluteal bursa □ Tenderness over bursa ▪ DDx □ OA, lumbar radiculopathy, IT band syndrome, muscle strain ▪ Treatment □ Rest is gold □ Work surrounding tissues, don’t put pressure on bursa □ Adjustments to LB and pelvis ○ Snapping hip ▪ Background □ Muscle or tendon is snapping over the bone □ External Most common IT band, glutes, TFL □ Internal Iliopsoas □ Intra-articular Labral tears, fracture fragments, loose bodies ▪ Presentation □ Repeatable audible/ palpable click or snap is key ▪ Provocative □ Movements with muscles Hip abduction -> psoas ◊ Pain more anterior Hip adduction -> IT band, TFL, glutes ◊ Pain more lateral/ outside of hip ▪ Exam □ Psoas Going from hip flexion to extension & external rotation □ TFL/ IT band Side lying going from hip internal rotation to external rotation ▪ DDx □ Bursitis, OA, tendinopathy, labral tear ▪ Treatment □ Muscle work - usually issues of muscle tightness/ weakness □ Adjustments ○ Piriformis syndrome ▪ Background □ Compressed/ irritated sciatic nerve from the piriformis Exam 1 Page 8  □ Compressed/ irritated sciatic nerve from the piriformis ▪ Presentation □ Buttocks pain that can radiate down the leg □ Potential antalgic gait with externally rotated hip on affected side □ Tenderness over glutes/ piriformis ▪ Provocative □ Sitting, hard surfaces □ Anything that involves them to internally rotate their hip Due to tight piriformis that is an external rotator ▪ Exam □ Deep palpation & piriformis stretch reproduces symptoms □ Lumbar ROM normal ▪ DDx □ Lumbar radiculopathy, SI joint syndrome, hamstring strain ▪ Treatment □ Heat/ stretching, manual massage □ Work on internal & external rotators ○ Acetabular labral tear ▪ Presentation □ Groin pain is most common □ Potential LB/ glute radiation □ Joint clicking & locking □ Usually normal ROM ▪ Provocative □ Activities, deep hip flexion □ "hip giving away" ▪ Exam □ Impingement test Pt in supine, hip flexion and adduct slightly -> pulse slightly into internal rotation ◊ This stresses anterior labrum □ FABER Pt in figure 4 position, hip abduction and external rotation ◊ This stresses posterior labrum □ MRI is gold standard ▪ DDx □ DJD, groin strain, hernia ▪ Treatment □ Outer labral tears (outer 1/3rd) do better with conservative treatment Heat/ stretching, manual massage, strengthen surrounding muscles □ Inner labral tears (inner 2/3rd) may require surgery ○ Strains ▪ Groin - Adductors □ Most commonly adductor longus □ Forceful abduction leads to pain in adductors as they try to restrict the abduction □ Pain worsens with abduction ▪ Hamstrings □ Stretched eccentrically at high speeds Quick stops -> changing directions □ Weak glutes, adductors, and core leads to larger activation of hamstrings □ Instruct pt that they do not return to activity until they are back to 90% strength 75% recurrent strain is there is no rehab □ Pain worsens with hip flexion ▪ Both □ Caused by overstretching or did not warm up the muscles Exam 1 Page 9  □ Caused by overstretching or did not warm up the muscles □ Sudden ripping, stabbing, popping muscle □ If acute Do not stretch, it needs to be assessed □ Grade 3 tear Full rupture, but is less painful with more muscle weakness □ Recovery involves passive ROM with eventually isometric contractions ○ Nerve entrapment ▪ Femoral nerve □ Trauma, dislocation, hematoma can cause entrapment □ Anterior thigh numbness ▪ Sciatic nerve □ Can be compressed with the piriformis muscle or due to canal stenosis □ Concurrent with motor & sensory changes of nerves ▪ Lateral femoral cutaneous nerve □ Entrapment near ASIS where nerve passes lateral part of inguinal ligament □ Creates Meralgia Paresthetica Burning pain sensation in the anterolateral thigh □ Standing up is palliative Exam 1 Page 10