Ortho Hip Exam Breakdown PDF

Ortho - Hip Exam Breakdown casestudies Pathology/Presentation - 6 How to assess for certain pathologies - 7 makingconnections...

Ortho - Hip Exam Breakdown casestudies Pathology/Presentation - 6 How to assess for certain pathologies - 7 makingconnections Intervention for particular pathologies - 9 Finishlabreview Movement and compensations that could occur - 2 CPG - 2 Case study similar to study in slides - 4 Hip dysplasia Pathology Dysplasia - shallow acetabulum/decreased coverageof femoral head Instability - increased stress on anterior capsul More common in women DDH - Developmental Dysplasia of Hip → Intervention - DHH Genetic pre-disposition Pavlik harness: birth to 6m Ligament laxity Avoid swaddling legs together Intrauterine crowding/breech position Avoid sling carriers that don’t support Postnatal positioning femurs Hip spica cast: 3-6m Presentation - Adult Insidious onset of symptoms Moderate to severe groin pain/lateral hip pain Activity restriction = decreased pain Limp Positive impingement sign (secondary to instability) May have catching or popping sensation Intervention - Adult Goal: reduce risk of early onset OA (dx related to joint instability) PT ○ Progress from isometric → concentric → eccentric ○ Activity modification education: avoid high impact sports and painful activities ○ Lumbopelvic and LE neuromuscular control - double to single leg ○ Periacitbular ostemotomy (PAO) for severe case ○ Derotational osteotomy of femur  Slipped Capital Femoral Epiphysis Pathology Displacement of femoral head in relation to femoral neck Occurs in adolescents 1215yrsold Weaknesss of epiphyseal plate Femoral head slips inferiorly and posteriorly More frequently in boys Categorized as stable or unstable Presentation Muscle guarding +/ trendelenburg Intermittent groin pain, hip, knee, &/or thigh pain Pain worse with activity Antalgic gait Limited IR ROM Compensatory ER w hip flexion - Drehmann sign Presentation - Unstable SCFE Sudden onse tof hip/thigh pain (often after fall/injury) Inability to WB Position of ER of affected leg LLD - affected leg may appear shorter Legg-Calve'-Perthes Pathology Idiopathic loss of blood supply to femoral head ischemia Osteonectrosis/collapse of femoral head/neck More common in boys ages 4-10 Resultant deformity of femoral head and OA Presentation Growin, thigh, medial knee pain Antalgic gait &/or + trendelenburg Decreased hip abductor function Muscle spasms Limited ROM Thigh atrophy and sometimes limb shortening Intervention Intervention goal - prevent collapse of femoral head Containment: bracing, NWB, bed rest, casting with hips abducted Surgical: osteotomy PT post surgery  Osteoarthritis Pathology Primary aging/genetic predisposition (age >50) Secondary ○ Previous injury ○ Metabolic abnormalities ○ SCFE, LCP, femoral anteversion, dysplasia, FAI CAM lesion Degredation of articular cartilage Narrowing joint space Osteophytes Sclerosis of bone “Loose bodies” or debris Presentation - Clinical Prediction Rule Must have all 5 1. Squatting as aggravating factor 2. Positive scour test for groin or lateral hip pain 3. Active hip flexion causing lateral hip pain 4. Passive IR less than 24 deg 5. Active hip extension causing hip pain Intervention Flexibilty, strengthening, and endurance exercises - A Manual therapy (soft tissue and joint mob) - A Functional gait and balance training - B Patient education combined with exercise - B Modalities - B Weight loss - C MWM shown to be beneficial to immediately decrease hip pain to increase hip function during PT  Rheumatoid Arthritis Pathology Systemic - autoimmune Involves synovial lining, cartilage, and bone Begins age 15-50 Presentation Groin pain Concurrent swelling, redness, increased temp in other joints General feeling of fatigue, weight loss, fever, cardiac, and respiratory symptoms Morning stiffness > 1 hour + rheumatoid factor Symptoms bilateral may occur suddenly or slowly Intervention Pain management Assistive device Education ROM/strengthening to prevent further joint damage Synovectomy (cartilage still intact) THA (more difficult secondary to bone loss/density) Gluteal Tendinopathy Pathology “Failed-healing” response w disorganziaed collagen bundles More often in females Insidious onset Middle aged Presentation Pain w resisted IR, ER, and abd Pain w palpation around greater trochanter Pain w passive adduction Stretchtotissues Pain w 30 SLS test ○ Positive trendelenburg sign w increased pain as test progressed) ○ Greater hip adduction and pelvic obliquity with movement PT - Intervention Load management ○ Reduction of compressive forces ○ Strengthening of the gluteal muscles Improve pelvic core control Change faulty movement patterns (excessive adduction) Eccentric exercise (to normalize tendon structure) Education (avoid excessive SLS, crossing legs, sleeping on side)  Femoral Acetabular Impingement Syndrome Pathology FAI - abnormal acetabular and femoral head/neck morphology FAIS - a movement related disorder with symptoms and clinical findings Leading cause of labral tears Casues chondral damage and leads to OA 3 types ○ CAM ○ Pincer ○ Combined (CAM and pincer) CAM deformity Femoral irregularity/aspherical 2x prevalent in males Exotosis on femoral head and neck Abnormal contact of femoral head and acetabulum Damge to acetabular cartilage then subsequent damage to labrum Pistol grip deformity Pincer deformity Refers to acetbular irregularity - over coverage Premature abutment of femoral neck on anterior acetabular rim Pinching of labrum Radiographic finding CAM morphology - increased femoral neck diameter Pincer morphology - increased acetabular depth, decreased acetabular inclination, acetubular retroversion A presence of a CAM or Pincer deformity does not equal a clinical dx of FAIS Presentation Active young adults Slow-onset, persistent, intermittent groin pain + FADIR (positive impingement sign) Decrease in ROM (flexion and IR primarily) Symptoms - clicking, catching, locking, stiffness Aggravated with cutting, lateral movements, starting/stopping, long periods of ambulating Aggravated with squatting, driving, sitting extended time PT Intervention - FAIS Greater Trochanteric Pain Syndrome (GTPS) Pathology Umbrella term for a cluster of symptoms May include ○ Trochanteric bursitis ○ Abductor tendinopahty abnormal mechanical loads with altered cellular response (primary cause) ○ External coxa saltans (external snapping hip) Presentation Indisidous, chronic, intermittent or constant, proximal lateral hip pain (may radiate to the distal thigh) Pain with palpation of greater trochanter Inability to lay on affected side Limping Difficulty with sit to stand transfer and stair climbing Sitting with affected leg crossed Positive 30 second single leg stand test (due to pain not necessarily weakness)  Labral Lesions Pathology Associated with OA ○ Risk of chondral damage doubles with presence of labral lesion Labrum functions as: ○ Shock absorber ○ Pressure distributor ○ Joint stabilizer ○ Contributes to joint proprioception Presentation Anterior hip/groin pain Catching, locking, clicking, or giving away sensation Limitations in ROM, particular in rotation Dull pain, episodic sharp pain, worsens with activity or prolonged sitting Provocation tests ○ + FADIR = anterior tear ○ + EABER = posterior pain/posterior tear Conservative Treatment Anti-inflammatory meds Limit pivoting motions/modify ADL’s Trial 10-12 weeks of PT ○ Limit anteriorly directed forces on hip ○ Strengthen inhibited muscles ○ Joint mobilization Surgical Intervention mostoftenneeded Debridement/resection vs repair Goal = to preserve seal effect of labrum Lateral labral tear (has vascular supply to heal) Larbal repair (grafts) ○ Can use ITB, gracilis, semitendinosis  Iliotibial Band Syndrome Pathology Lateral hip or knee pain Weaker hip abd strength hiplog trendelenking or Related to increased peak hip adduction and knee IR (during stance)medialcollapse Relationship of hip abductor weakness, side-to-side imbalances in strength Intervention = activate glute med while minimizing activation of TFL Wouldwanttoperformmotorcontrolexercises forabduction IR Avulsion Fractures Pathology Location: Most seen in boys ages 14-17 Presentation Sudden pain Limited active motion Weakness Conservative Treatment = limit motion and stress at site Ischemic Necrosis of Femoral Head (AVN) Pathology Avascular necrosis bone tissue death Femoral head blood supply interrupted Presentation Groin pain (exacerbated by WB and relieved by rest) ○ Worsens over time and with use Limitation in ROM in non-capsular pattern Crepitius/antalgic gait Seen on imaging Treatment = NWB/Surgery  Coxa Saltans/Snapping Hip Pathology Intra-articular (any derangement of inferior hip joint) ○ Labral tear ○ Ligamentum teres tear ○ Loose body Extra-articular → ○ Internal ○ External Presentation Catching, clicking, “stuck” sensation May or may not have pain Maybe lateral with visible snap - ITB or gMax May be deep anterior with audible snap - iliopsoas Glute med weakness often associated with internal coxa saltans Conservative Treatment Asymptomatic - most “snapping” is benign Symptomatic ○ Treat iliopsoas tightness ○ Neuromuscular eccentric control of iliopsoas ○ Modify movement patterns (ex: imbalance between gMax and TFL) ○ Strengthen ER and abductors Muscular Lesions Hamstring Injury Increased risk = previous hamstring injury, imbalance, poor flexiblity, limited ankle ROM Assessment: taking shoes off test (100%) Prevention - exercise ○ In lengthening positions ○ Eccentric ○ Hip extension/glute strengthening Hamstring Tendinopathy/Tendinosis Overuse injury → fails to heal → chronic Pain in lower gluteal region (at times radiating into hamstrings) Increased running speed and sitting = increased pain Stretching of hamstrings = worsening Palpable pain and tenderness of ischial tuberosity w resisted knee flexion Assessment Treatment = progressive eccentric hamstring strengthening at higher hip angles Adductors Adductor role ○ Adduct thigh in open chain ○ Stabilize LE in all planes in closed chain ○ Decelerates hip extension into toe off, concentrically assists w hip flexion during swing (particularly during running)  Reep Gluteal Syndrome Pathology Cluster of complex pain generators in posterior hip buttock region - possible referral of leg and foot pain Commonly attributed to piriformis - close relationship between piriformis and sciatic nerve Non-disconegenic extrapelvic entrapment of sciatic nerve Structures that can cause entrapment: ○ Piriformis (piriformis syndrome) ○ Fibrous bands of tissues with blood vessels ○ Hamstring (hamstring syndrome) Presentation Buttock pain - worse w prolonged sitting or activity Referred pain to knee - numbness and paresthesia Glute max atrophy Positive SLR and slump test (exacerbated by hip flexion/rotation) Isometric piriformis contraction may exacerbate symptoms Assessment FAIR test - piriformis stretch or piriformis contraction Straight leg raise Neural mobilizations of sciatic nerve (slump test) Piriformis/ischial palpation positive for reproduction of pain I hamstringorigin Intervention Relative rest, activity modification Glute med and glute max strengthening ○ Need to offload piriformis Alteration of sitting position Avoid stretching hamstrings Nerve flossing  Athletic Pubalgia/Core Muscle Injury (CMI) Pathology Chronic abdominal and groin pain sometimes radiating into perineum/proximal adductors Acute or insidious onset Exacerbated by kicking, cutting, and sprinting Muscle imbalance - chronic overload of musculature outside hip joint Shearing force across pubic symphysis from repetitive motion against a fixed extremity = avulsion of fascia/musculature of posterior inguinal wall Rectus abdominus and adductor longus intimately involved in most core muscle injuries Risk Factors Adductor to abductor strength ratio Delay of abdominal muscle recruitment Decreased levels of pre-season sport specific train ing More common in males/active population Structural associations: FAI and dysplasia → Repetitive turning and twisting sports - core rotation on planted foot Presenation Pubic, medial thigh/groin pain Exertional adductor/inguinal pain Pain with: ○ Palpation of → ○ Resisted sit up ○ Resisted hip adduction &/or SLR ○ Pain w coughing Decreased hip IR Increased lumbar extension / decreased hip extension Intervention