Exam II Week 7: Common Hip Disorders

Match the sxs to the condition:

• Antalgic gait

• Decreased ROM of hip and/or knee

  • Pain with active motion

  • Pain with passive stretch

• Edema– Variable ecchymosis (24-48 hours)

• Focal tenderness to palpation

  • Severe cases: palpable defect

Muscle Strain

What muscle strain GRADE is this referring to?

• Min tissue disruption

• Low-grade inflammation

• Strength: good w/ pain

• No loss of ROM

Grade I

What muscle strain GRADE is this referring to?

• Some disruption of tissue

• ↓ strength & ROM

• Significant Pain

Grade II

What muscle strain GRADE is this referring to?

• Complete disruption

• Complete loss strength

• Palpable defect

Grade III

What is the most frequently strained muscle?

Hamstrings! → specifically biceps femoris

What two conditions can be confused for a gluteus medius strain?

***GTPS*** and GT bursitis

GTPS is believed to the a tendinopathy of the…

gluteal tendinopathy → usually gluteus medius

At what stage of healing of a muscle strain is it ESSENTIAL to avoid streching the injured tissue (esp HS)?

Stage II (~48-72 hrs)

What is an ESSENTIAL part of the acute treatment of a quadriceps contusion?

Knee brace positioned of maximally tolerated flexion

• 24 hrs in 120 degrees flexion

  • Better if initiated within 10 minutes of injury**

• Avoid massages and NSAIDs

“Development of heterotopic bone formation in the muscle belly, possible complication of a contusion injury”

Myositis Ossificans

When will radiographs show myositis ossificans signs?

• 7-10 days signs of early ossification

• Heterotopic bone formation 2-3 wks

What are some important treatment considerations for Myositis Ossificans?

• POLICE acute injuries

• Protected weightbearing (Crutches)

• Start with gentle ROM exercises → Isometrics after swelling resolves

• NSAIDS/corticosteroids for persistent swelling

  • Avoid: heat, massage, premature return to aggressive stretching, strengthening, or return to sport

• Return to activity does not occur until after bony growth subsides

Match the sxs to the condition:

• Trunk flexed/toward injured side

• Ecchymosis/swelling

• Pain w/ use of muscles attached to iliac crest

• Focal TTP

Iliac Crest Contusion: Hip Pointer

What is the most common bursa affected by hip bursitis? What is the most common cause?

• Trochanteric bursa

  • Often d/t inflammatory arthritis, it can also be d/t trauma and repetitive activity

Match the sxs to the condition:

• TTP femoral triangle

• Pain with active hip flexion, passive extension

• MMT: pain with hip flex

• (+) Thomas test, FABER

Iliopectineal Bursitis

Match the sxs to the condition:

• Prolonged sitting or direct blow to tuberosity

• Agg: Sitting, direct palpation, HS stretch

Ischiogluteal Bursitis “Weaver’s Bottom”

What are some important treatment considerations for Myositis Ossificans?

Remove source of irritation to bursa

• Activity Modification

  • Avoid lying on affected side (trochanteric bursitis)

  • Pillow between knees

• Treat relevant impairment (Strengthening, mobility, etc.)

• Modalities for inflammation

  • NSAIDS, local injections

Match the sxs to the condition:

• “Snapping” or clicking w/ repetitive movement

• Clicking is the primary complaint

  • Evaluate the structure involved

Snapping Hip Syndrome

Match the sxs to the condition:

• Buttock pain can radiate to the posterior thigh, calf

• Sharp, burning, unilateral pain and paresthesia of LE

• AGG: Walking (swing to heel strike)

  • Ascend stairs

  • Hip IR & ADD

  • Sitting on a firm surface

  • TTP at sciatic notch/piriformis

Piriformis Syndrome (sciatic nerve) - rritation of sciatic nerve between piriformis/ischial tuberosity

Match the sxs to the condition:

• Irritation of lateral femoral cutaneous nerve next to ASIS

• Paresthesia in antero-lateral thigh

• Cutaneous distribution anterolateral thigh (no motor innervation)

  • Caused by compression: tool belts, obesity, pregnancy

Lateral Femoral Cutaneous Nerve (Meralgia Paresthetica)

T/F: Hip labral pathology and FAI could be asymptomatic

True, especially in people

Match the sxs to the condition:

• Catching/clicking w/ pain in hip

• Groin pain, flexed/IR/ADD

• ROM restrictions

• Confirm with MRA and diagnostic injection

• Insidious onset or traumatic

Labral Pathology

Match the sxs to the condition:

• Anterior/groin pain (C-Sign) with prolonged sitting, walking, squat

• May have clicking/popping

• Pain with Flex, IR, ADD, may have bony endfeel

Femoroacetabular Impingement Syndrome (FAI)

What are the differences between FAI pincer and cam deformities?

Cam Deformity:

• Bony growth at the femoral head/neck junction

• Repetitive stress/contact of the head/acetabular rim

• Developmental condition

Pincer Deformity:

• Overcoverage of the acetabulum

• The acetabular rim impinges on the femoral neck

What TWO interventions are classified as “F” for nonarthitic hip pain in the 2023 CPG?

• Manual therapy

• Neuromuscular re-education

According to the 2023 CPG, what is the BEST intervention for NonArthritic Hip Pain?

Multimodal interventions

• Clinicians should utilize multimodal interventions consisting of activity modification and exercises for strengthening hip-specific muscles (iliopsoas, gluteus medius,gluteus maximus, hip internal, and external rotators), trunk musculature (abdominals and paraspinals), and general lower extremity musculature combined with additional interventions such as manual therapy, postural and movement correction, stretching, and balance exercises, when treating individuals with nonarthritic hip joint pain, particularly FAIS and labral injuries.

Match the sxs to the condition:

• Insidious onset anterior hip/groin pain, stiffness

• More common > 50 y/o

• AM stiffness < 60 minutes

• Pain with WB, end of day, cold weather

• Improves with rest

• May refer to knee (rarely below)

• Capsular pattern ROM limitation (flex < 115°, IR < 15°)

• Hypomobile accessory motion(s)

• (+) FABER, (+) Scour

Hip Osteoarthritis

What is the Altman’s criteria for hip OA diagnosis?

Test Cluster 1

• Hip pain with IR

• Hip IR < 15°

• Hip flexion < 115°

If hip IR >15°…

Test Cluster 2

• Hip pain with IR

• Age > 50

• AM stiffness < 60 min

According to the 2017 CPG for hip OA, what are the BEST interventions to use (“A”)?

• Manual therapy

• Flexibility, strengthening, and endurance exercises

  • Class B: Patient education, modalities

Match the sxs to the condition:

• Anterior hip/groin pain

• Possible referral to thigh/knee

• Vague, deep, dull, aching pain

• Intermittent progresses to constant pain

  • AGG: WB Activity

  • EASE: Rest, NWB

  • 24 Hr: Better in AM, worse with activity (WB)

• Antalgic gait

• Pain at higher ROM

• Possibly TTP deep anterior hip

Femoral Neck Bone Stress Injury (BSI)

Which type of BSI is worse? Tensile or compressive?

Tensile! High risk in anterior tibial cortex → NWB does not fully decrease the tensile forces, so they need surgery!

What is the gold stander to diagnose a femoral neck BSI? Why?

MRI = gold standard (high Sn/Sp)

• Radiographs high false negative

• Healing not visible until ~14-21 days

Match the sxs to the condition:

• Groin pain

• Same hx as Femoral Neck/other BSIs

• TTP pubic ramus

• Pain with adductor stretch & resisted ADD

Pubic ramus BSI

Match the sxs to the condition:

• Deep anterior thigh pain

• Same Hx as Femoral Neck/other BSIs

• (+) fulcrum test

Femoral Shaft BSI

Match the sxs to the condition:

• Pain in pubic symphysis region, lower abdominal/groin

• Post op, pregnancy/delivery

• Athletes, especially kicking sports, hockey

• Clicking/popping

• TTP

• Painful/weak ADDs/Abdominals

  • AGG: Running, SL pivoting, kicking, stairs, compression of pelvis

Osteitis Pubis