MSK II Exam 2 review: Hip pt.1

what is the traditional definition of hip OA?

• Wear and tear due to increased load

• Caused by cartilage loss

what is the contemporary definition of hip OA?

• Whole joint disease 

• Affects labral, cartilage, and subchondral bone, synovial inflammation, and muscles

• Many risk factors, including physical inactivity

  • The runners' knees are actually healthier compared to those who don't run

what are the extrinsic factors that causes hip OA?

• the type and amount of activity

• body mass

what are examples of extrinsic factors for type and amount of activity that causes hip OA?

• High impact sports

• At elite levels

• Physically demanding work

• Sedentary lifestyle

what are examples of extrinsic factors for body mass that causes hip OA?

obestiy

what does obesity do to cause hip OA?

• Increased joint load

• Systemic inflammation

  • Metabolic changes are prone to systemic inflammation

what are intrinsic factors that cause hip OA?

• they start from age 

• hip morphology 

• strength 

• ROM 

• gait biomechanics

what is hip morphology?

• FAI

• Labral tears

• Chondropathy 

• Dysplasia

what are the different types of FAI?

CAM or pincer

what is hip dysplasia?

The hip joint does not develop properly, causing the ball of the femur to fit loosely or incompletely into the acetabulum of the pelvis.

what is typically weak for patients with hip OA?

• Weak hip extension/abduction/ER

• Weak knee extension

• Weak posterior compartment of the leg

what ROM is reduced with hip OA?

• Reduced hip flexion and IR ROM

• Reduced hip extension ROM

what is effected with gait biomechanics in hip OA?

• Midstand → increased external flexion/adduction/IR movement

• Terminal stance → decreased hip extension

what is effected during midstance in gait for hip OA?

increased external flexion/adduction/IR movement

what is effected during terminal stance in gait for hip OA?

decreased hip extension

what is the subjective for hip OA?

• Age (50+)

• Athletic history 

• Type of work

• Previous Hx of hip pain

• Pain increases with increased sitting time

• Morning stiffness <1hr

• Pain at rest and night (synovitis)

• Difficulty donning socks/shoes

• Difficulty getting out of a low chair

• Pain location

what specific previous diagnosis can lead to hip OA?

1. SCFE (slipped capital femoral epiphysis)

2. DDH (developmental dysplasia of the hip

3. FAI (femoroacetabular impingement)

what are red flags for a patient with hip OA?

• Hx of cancer (prostate, breast, gynecological mets to hip)

• Female sex → gynecological issues refer to hip

• Alcohol abuse (AVN)

• UTI

• Unexplained weight loss (CA)

• Change in bowel habits (CA or other lower GI)

• Corticosteroid use (AVN, stress fractures)

• Acute pain with fever (infection)

what are signs and symptoms for hip OA that compare to the lumbar spine orpelvis?

• Walking with a limp (7x more likely hip)

• Pain in groin/anterior hip (7x more likely hip)

• Reduced hip IR (14x more likely hip)

• No change in symptoms with repeated movements lumbar spine (SN = 92% to rule out lumbar spine)

• Negative lumbar quadrant test (SN = 100% to rule out lumbar spine)

• Negative thigh thrust (SN = 82% to rule out SIJ)

• No pain over SIJ → rule out SIJ

what do you exam for a patient with hip OA?

• movement analysis 

• tests and measures 

what is within movement analysis?

• gait 

• squat 

• full body rotation 

• single leg stance 

what should you see during gait for a patient with hip OA?

• Pain

• Decreased stride length (lack hip extension)

• Early heel off

• Trendelenburg (glute med problem), compensated trendelenburg

• Increased knee/hip flexion mid stance

what should you see during a squat for a patient with hip OA?

• Pain

• Decreased hip flexion ROM

• Increased hip adduction/IR

what should you see during full body rotation for a patient with hip OA?

• Pain

• Decreased ipsilateral pelvic rotation 

  1. Stabilize the hip to check lumbar rotation → if no symptoms, it is the hip

what should you do during full body rotation when you discover decreased ipsilateral pelvic rotation ?

Stabilize the hip to check lumbar rotation → if no symptoms, it is the hip

what should be observed during single leg stance in a patient with hip OA?

• Pain

• Decreased hip extension

• Trendelenburg, compensated trendelenburg

what falls under test and measures for hip OA?

• ROM 

• strength 

• muscle length 

what specific ROM can be decreased in a patient with hip OA?

• Hip flexion is 15 degrees less than the other side or <115 degrees if bilateral

• Hip IR < 25 degrees

  1. Underline → diagnostic of hip OA

• May also see decreased ankle DF

what is an underlined diagnostic of hip OA?

Hip IR < 25 degrees

what are some strength deficits that can be found in a patient with hip OA

• Weak glute max, glute med

• May also see weak quads and posterior compartment of leg

what muscle length can be examined in a patient with Hip OA?

Tight TFL, rect fem, deep posterior hip

what are recommended interventions for patients with hip OA ?

• Education combined with exercise and/or manual therapy (activity modification, weight reduction, methods of unloading the joints)

• Provide impairment-based functional, gait, and balance training

• Manual therapy (joint mobilization, HVLAT, soft tissue)

  1. As hip motion improves, add exercises, including stretching and strengthening, to augment improvement 

• Individualized flexibility, strengthening, and endurance exercises

• Use ultrasound to the anterior, lateral, and posterior hip (1MHz, 1W/cm for 5 mins each)

how should you move forward with manual therapy in a patient with hip OA?

As hip motion improves, add exercises, including stretching and strengthening, to augment improvement

which interventions is not recommended for hip OA?

Use bracing as a first line treatment

what should you educate a patient who has hip OA?

• dispersion of forces 

• living at the end range 

• capcity vs load 

• weight loss 

• multiple levers we can pull 

• facts 

what is dispersion of forces of hip OA?

Deceased mobility = decreased surface area being utilized = increased stress on a specific part of the joint

what is living at the end range for hip OA?

Decreased mobility = stress on tissues around the joint

what is capacity vs load in hip OA?

Tissue capacity is only as high as the load that is regularly placed on it. Cartilage and bone need load too

what is education for weight loss in hip OA?

10 lbs reduction in bone weight = 60lbs reduction in joint load

for education what is multiple levers we can pull, in hip OA?

Activity, weight, muscle strength, ROM, gait

FOr education what is facts we can give about hip OA?

• Imaging correlates poorly with pain and disability

• Pain does not equal damage

• Exercise is safe and helpful

• Rest and avoidance make pain worse

what is exercsies for hip OA?

• Good Living with osteoArthritis: Denmark (GLA:D)

  1. General exercises for knee and hip OA

  2. It helps

     1. wellness 

     2. self efficacy 

which body parts do we generally give exercises for a patient who has hip OA?

General exercises for knee and hip OA

what is wellness exercise?

• Pain reduction and management

• Improved mobility

• Improved strength

what is self-efficacy for exercise ?

• Confidence

• Awareness

• Motivation

what test is used for ROM in hip OA?

Using Craig’s test (looks for the total arc of 90-100 degrees and bony end feel, but don't force IR with retroversion)

what is normal for femoral neck degrees?

8-15 degrees of the angle between the posterior condyles and the femoral neck → normal 

what is anteversion?

• increased hip IR and decreased hip ER (the angle >15 degrees)

  1. Toes in walking as compensation

what is retroversion?

• increase hip ER and decreased hip IR (the angle <8 degrees)

  1. Toes out walking as compensation

what is surgical management for hip OA?

• THA

  1. Mainstay for the treatment of 

     1. End stage hip OA

     2. End stage hip RA

     3. Younger individuals with severe hip dysplasia

what is THA?

• The resection of the femoral head acetabulum and replacement with metal or polyethylene components

• Hemiarthroplasty where only the femoral component is replaced

  • May be performed after certain types of proximal femur fractures

• Allow immediate full weight bearing

  • May be partial weight bearing of the femoral fracture occurs after THA

• 10 year survival rate for a THA implant is 95%

• 25 year survival rate is 78% → need revision later on in life

• The most common reason for the failure of THA is aseptic loosening of the components

• __ where only the femoral component is replaced

  • May be performed after certain types of proximal femur fractures

Hemiarthroplasty

what is the 10 year survival rate for a THA?

10 year survival rate for a THA implant is 95%

what is the 25 year survival rate for a THA?

25 year survival rate is 78% → need revision later on in life

what is the most common reason for THA failure?

aseptic loosening of the components

what is the procedure (approaches) for THA?

• Traditional approach: posterolateral or lateral approach

• anterior approach 

• mini open technique 

• joint resurfacing 

what is Traditional approach: posterolateral or lateral approach?

• Having a risk of dislocating the hip posteriorly

  1. Precautions are important to limit motion that would stress the posterior capsule to prevent dislocation

what is anterior approach for THA?

• More technically demanding approach 

• Spares direct trauma to the glute med

• The femur is dislocated anteriorly, so the anterior capsule must be protected by limited hip extension and external rotation

what is mini open technique for THA?

Uses a small incision to create less tissue damage, presumably resulting in decreased pain and decreased strength deficits

what is joint resurfacing in THA?

• Carefully cuts around the femoral head and places an artificial cap on to create a new joint surface

  1. Used on younger patients to allow easier revision surgery to convert to a traditional THA

     1. Younger and have few or no comorbidities patients are able to go home the same day as the procedure

who is joint resurfacing used on?

• Used on younger patients to allow easier revision surgery to convert to a traditional THA

  1. Younger and have few or no comorbidities patients are able to go home the same day as the procedure

what are precautions for THA?

• Usually in place between 4 and 12 weeks after surgery to allow the joint capsule to heal

  1. The research found similar rates of dislocation (~2%) between patients whose postop protocol included these restrictions and those patients whose motions were unrestricted

  2. But clinicians should clearly communicate with the patient’s surgeon to best understand the precautions for a given patient

what is the precautions for posteriolateal approach THA?

• No hip flexion over 90 degrees

• No hip adduction

• No hip IR

what is the precautions for anterior approach THA?

Limited hip extension

what are preoperative treatments for THA?

• education 

• expected outcomes

• recovery process

• exercises to help prevent DVT and pneumonia

what should be educated for preoperative treatments of THA?

• Post-op precautions

• Use of assistive device

• Expected functional recovery and time frame

• Beginning post-op exercises

what treatment can be given to help prevent DVT and pneumonia preoperative of THA?

• Wainwright et al (2020) concluded that pre-op PT may be effective in specific patient groups but it is not an essential intervention

• NICE guidelines were unable to make recommendations for practice in this area

• Widner et al (2022) concluded that there are no negative effects of prehabilitation on the outcomes

what are postperative treatments for THA?

• PT begins the day of surgery

• Restore ROM is seldom a problem, unlike TKA

• Strengthening of hip and entire LE should be emphasized throughout rehab

• NMES to the quads may be beneficial 

• Heavy strength training, working up to loads of 85-90% of 1RM, sets of 4-6 reps, is well tolerated and does improve LE strength deficits

• Balance training should be included

• Gait training

what occurs when the PT begins the day of surgery postoperative for THA?

• Most of the time, PT is the first one to get the patient out of bed → remember to check orthostatic hypotension 

• Early mobilization with an assistive device

what occurs Restore ROM is seldom a problem, unlike TKA postoperative for THA?

The patient with THA appears to have less problems with pain but more difficulty with regaining hip strength

what is Strengthening of hip and entire LE should be emphasized throughout rehab for postoperative?

• Should include weight bearing and nonweight bearing exercises

  1. Heel raises

  2. Squats

  3. Sit to stands

  4. Steps up

     1. Should be progress to the use of resistance bands, weights, and machines

are we missing the mark for THA?

• Sekita et al (2024) discovered that the hip and knee muscle strength on both surgical and nonsurgical knees in female patients may not recover to the same level

• Winther et al (2018) study showed that maximal strength training (MST) was stronger in leg press and abduction than the conventional PT group and 6 months postoperatively

• It takes approximately 1 year to achieve their prior functional activities

what is hip fracture?

• One of the most common fractures

• Only refers to proximal femur fractures and not to acetabular fractures or femoral head fractures

  • Femoral head fractures have an increased risk of AVN due to poor blood supply

  • Proximal femur fractures may be intracapsular or extracapsular

Femoral head fractures have an increased risk of?

AVN due to poor blood supply

Proximal femur fractures may be

intracapsular or extracapsular

what are intracapsular fractures?

• Involve the femoral neck

• Femoral neck has a more tenuous blood supply and these fractures and nonoperative treatment is seldom possible

• Operative treatments

  1. Closed or open reduction with internal fixation

  2. Hemiarthroplasty

  3. THA → when combined with preexisting hip OA

what are operative treatments for hip fractures?

• Closed or open reduction with internal fixation

• Hemiarthroplasty

• THA → when combined with preexisting hip OA

what are extracapsular fractures?

• Include intertrochanteric and subtrochanteric fractures

• The majority of proximal femur fractures are intertrochanteric

• Mostly are treated with open or closed reduction with internal fixation using implants such as compression screws and intramedullary nails with or without a plate

what is postoperative hip fracture management?

• Early rehab occurs in the acute setting

• Patient will have limited hip strength

• Progressive strength and functional training should be included

• E-stim for quads strength and pain management is indicated 

• Weight bearing and non weight bearing exercises should be included to provide adequate muscle strengthening and decrease osteoporetic bone loss

• Progressive balance exercises such as dual tasking

• Aerobic exercises should be part of the rehab to maximize outcomes

• The clinician should discuss any needed modifications for safety

what should early rehab focus on for hip fracture management?

Focus on pain management, early mobilization, and prevention of secondary impairments

where will a patient have limited strength in for hip fractures postoperative?

Decreases in hip extensors, hip abductors, and knee extensors common

what can patients do for hip fracture managment postoperative?

• Tai chi

• Chair yoga

• Aquatic exercises

• Silver sneakers

what should the clinic discuss post hip fracture?

• Rest breaks

• Performing exercises next to a secure handrail

• Seated alternatives

what did the research show for postoperative hip fractures?

The research concluded that home dwelling hip fracture patients can benefit from an extended supervised strength training. The patients are capable of high intensity strength training which should optimise gains in physical function, strength, and balance. Resistance exercise training seems to influence functional performance adaptation,

what CPG’s is recommended for post hip fracture?

• Additional therapies such as strength, balance, functional, and gait training to address existing impairments and activity limitations and fall risk

• PT must provide recommendations to patients to maximize safe physical activity

• PT must provide aerobic training to progressive resistive, balance, and mobility training in the community setting for older adults after hip fracture

what is involved for mobilization in hip?

• Monitor progress - asterisk/comparable/concordant signs

  • Used to monitor progress within and between sessions

what is 2 subjective for hip mobilization?

Monitor between sessions

what is 2 objective for hip mobilization?

• Monitor effects of manual therapy and SMPs within sessions

  • For hip flexion closely predicts outcome and is sensitive to change

  • Avoid using IR because it likely will not change with treatment

what is the goal of every treatment for hip mobilizations?

Within and between session change, associated with functional recovery

what is MWM procedure?

1. Test asterisk/comparable signs

2. Have the patient actively move the joint through the desired motion and note the patient's ROM and symptoms

3. Apply the desired glide to the joint

4. Have the patient actively move the joint through the desired motion as you maintain the glide

5. Observe for a change in ROM and ask the patient if the patient feels better, the same, or worse with the applied glide

If ROM and symptoms are not significantly better (>80% pain reduction)?

adjust the force of the glide, the direction of the glide or the patient’s movement

If MWM procedure is not working?

transition to a general mobilization or try a different mobilization technique or plan of motion

if MWM procedure is significantly better (>80% pain reduction)?

you can apply overpressure at the end range and have the patient continue to go in and out of the motion 6-10 times while maintaining the glide. Recheck the signs. If improved, repeat the procedure 1-2 more times.