Hip Slides 2.pdf

The Hip  Introduc0on Di2eren0al diagnosis is di7cult – Referred from GI or urogenital systems – Lumbar spine, knee, and foot dysfunc0on can cause hip pain – Radiologic Andings do not always correlate with symptoms  Introduc0on Prognosis of...

The Hip  Introduc0on Di2eren0al diagnosis is di7cult – Referred from GI or urogenital systems – Lumbar spine, knee, and foot dysfunc0on can cause hip pain – Radiologic Andings do not always correlate with symptoms  Introduc0on Prognosis of recovery – Risk factors for worsening pathology Increased age, higher BMI, propriocep0ve deAcits, increased pain intensity – Factors associated with improved outcomes Gluteal strength, mental health, self-e7ciency, social support, anaerobic exercise  Typical hip pain Felt as groin pain Can be anterior hip, lateral hip, or posterior hip – Most commonly groin pain though – Dis0nguish from upper & lateral thigh pain and buLock pain Can refer to ankle, knee, LS, & SIJ Pain/dysfunc0on in gluteus minimus/medius – “pseudo-scia0ca” Glut min/med trigger point can look like scia0ca  Time of pain & symptom paLern Pain paLern can be similar to SI joint Pain with sleeping – Nocturnal pain is also an indicator of visceral pathology and cancer Pain with movement: DJD, hip impingement, labral tear, muscle strain Pain in sta0c posi0on: contusions, trochanteric or ischiogluteal bursi0s  How do we diagnose hip pathology? AGE & SEX: 18 years  young adults Birth  2 years Osteochondri0s dessicans Developmental dysplagia (F) Strains Sep0c Arthri0s Stress fractures 2 years  12 years Transient synovi0s Femoroacetabular Coxa vara impingement Legg-Calves-Perthes (M) Labral pathology (F) 8 years  17 years Ostei0s pubis (M) SCFE (M) 20 years  40 years RA >50 years DJD Trochanteric bursi0s Hip fracture  HISTORY For an adult, ask about… – Developmental dysplasias or childhood hip condi0ons – Familial history of connec0ve 0ssue disease  History Mechanism of injury – Acute: fx, disloca0ons, muscle strains, compartment syndromes, contusions, labral tears Muscle strains usually occur from eccentric decelera0on – Gradual onset (microtrauma): tendinopathy, bursi0s, hernias, stress fractures, ostei0s pubis, FAI Stress fracture pain begins with pain at the end of ac0vity, progressing to pain with ac0vity, to pain with ADLs, then pain at rest – Insidious onset: DJD & referred pain  Occupa0on & Ac0vity Considera0ons SigniAcant associa0on between occupa0onal lieing & hip OA – Repe00ve mo0on and body mechanics – Hip fx risk is ↓ in post-menopausal women who have been in a job with heavy ac0vity for > 20 yrs Prolonged signg is not tolerated by individuals with labral dysfunc0on &/or femoroacetabular impingement Compe00ve athletes are at risk for soe 0ssue injuries, hernias, impingement, & labral tears SigniAcant ac0vity & overuse can worsen symptoms – Muscle strains, tendinopathy, stress fractures, compartment syndromes  What can refer pain to the hip? Lumbar spine SIJ Knee  What can refer pain to the hip? Visceral involvement/serious diseases – Chronic liver disease  femoral head osteonecrosis  trochanteric & lateral thigh pain – Pancrea00s  femoral head osteonecrosis  inguinal & anteromedial thigh pain – Kidney/bladder  pain in medial thigh – Bone tumors or spinal metastases to femur/lower pelvis – Hernia, AAA, appendici0s, Crohn’s disease – Pelvic inlammatory disease  Mobility Three degrees of freedom Mo0ons – Flexion/extension – Abduc0on/adduc0on – Medial/lateral rota0on  Func0onal Range of Mo0on Flexion 120 degrees – With compensa0on (including posterior innominate rota0on and lumbar lexion) Lateral rota0on 20 degrees Abduc0on 20 degrees  Range of Mo0on How much is necessary for certain ac0vi0es? Shoe tying: 120 degrees lexion Signg (average seat height): 112 degrees lexion Stooping: 125 degrees lexion Squagng: 115 degrees lexion, 20 abd, 20 IR Ascending stairs (average stair height): 67 degrees lexion Descending stairs (average stair height): 36 degrees lexion Pugng foot on opposite thigh: 120 degrees lexion, 20 abd, 20 ER Pugng on pants: 90 degrees lexion  Pelvic Mo0ons Rela0vity – Anterior/posterior 0lts – Drop/hike – Lateral shies Double limb stance – right shie = lee hip abduc0on and right hip adduc0on – Forward/backward rota0on Transverse plane – forward rota0on = internal rota0on of stance hip – Compensatory spine mo0ons – “closed chain” This is rela0ve mo0on explaining what happens to the hip when the pelvis moves. Note that with an anterior pelvic 0lt, the hip goes into rela0ve lexion. Hip lexion does not cause an anterior pelvic 0lt though!  Musculature Flexion – Primary Iliopsoas – main Rectus femoris Sartorius TFL  Musculature Flexion – Secondary Pec0neus Adductor magnus (inferior) Adductor longus Gracilis  Musculature Flexion – Ter0ary Adductor brevis Gluteus medius (anterior) Gluteus minimus (anterior)  Musculature Extension – Primary Gluteus maximus – main Hamstrings – Secondary Gluteus medius (posterior) Piriformis Adductor magnus (superior)  Musculature Abduc0on – Primary Gluteus medius – main Gluteus minimus – Secondary Sartorius Gluteus maximus (superior) TFL  Musculature Adduc0on – Primary Adductor magnus – main Adductor longus Adductor brevis – Secondary Pec0neus Gracilis  Musculature Medial rota0on – Equal par0cipa0on Gluteus medius (anterior) TFL Adductor longus Adductor brevis Adductor magnus (upper)  Musculature Lateral rota0on – Primary Six short rotators – main – Obterator internus (Gemelli aLach) – Obterator externus – Gemellus superior – Gemellus inferior – Quadratus femoris – Piriformis  Musculature Lateral rota0on – Secondary Gluteus medius (posterior) Gluteus maximus Adductor magnus (inferior) Anatomy  Anatomy Three pelvic bones make up the acetabulum – Pubis 1/5 – Ischium 2/5 – Ilium 2/5  Ar