Ortho 2: Hip

common diagnoses in birth-2

developmental dysplasia, septic arthritis

common diagnoses in 2-12yrs

transient synovitis, coxa vara, legg-calve-perthese

common diagnoses in 8-17yrs

Slipped Capital Femoral Epiphysis (SCFE)

18-young adult

Osteochondritis dessicans, strains, stress fractures, femoroacetabular impingement and labral pathology, osteitis pubis, apophyseal injuries

20-40 years

RA

30-50 years

Osteonecrosis/ avascular necrosis

>50 years

DJD, trochanteric bursitis, hip fracture

Common Areas of Referral

lumbar spine, TL junction, SIJ, knee, Viscera

Factors Related to Fall Risk

Berg Balance Scale, Dynamic gait (DGI), Falls efficacy scale (self perception tests), History of imbalance, Type of AD used

Harris Hip Score

4 sections: Pain, Function, Deformity, ROM

Max score=100 (indicates no pain/dysfunction) (higher score the better)

MCID= 7-9 pts

Lower Extremity Function Scale (LEFS)

Rates difficulty performing 20 activities

Max score= 80 (no difficulties)

MDC & MCID= 9 pts

Developmental Dysplasia

Normal bone development of acetabulum and/or femoral head is disrupted by subluxation or dislocation

Causes: genetic, hormonal, mechanical

If improperly treated, can result in degenerative arthritis as an adult

Treatment for Developmental Dysplasia

Maintain favorable position until acetabulum and femoral head develop enough to decrease chance of further involvement

Transient Synovitis

Non-specific inflammation of synovium which is self limiting

Presents with flexion/abduction/lateral rotation posture, low grade fever

Treatment for Transient Synovitis

Bed-rest with limited weight bearing, heat, massage, NSAIDs

If pain persists: Check for Legg-Calve-Perthes

Septic Arthritis

Acute and rapidly progressing infection caused by pyogenic bacteria in the hip

Can progress to femoral head necrosis within 24 hours

Treatment for Septic Arthritis

Joint aspiration, drainage, antibiotics, hip spica, surgery

Legg-Calve Perthes Disease (LCPD)

Avascular necrosis (osteonecrosis) of capital femoral epiphysis caused by compromise of blood supply to ossification centers

2-12 years (most common 6-7 years)

Treatment for LCPD

Proximal varus osteotomy (6-10 y/o), decrease stress on hip, joint mobs & ROM, strengthening exercises, gait training

Slipped Capital Femoral Epiphyses (SCFE)

10-17 y/o for boys & 12-14 y/o for girls. Typically after a growth spurt

Growth plate is strained and epiphyses “slips” off.

Insidious onset, Treat as an emergency

Treatment and Rehab for SCFE

Surgery is treatment of choice, or skeletal maturity

Post op: Strengthening LE, increase ROM, gait training, balance/propriception, muscular endurance

No permanent disability if treated quickly

Type 1 Salter-Harris Fracture

Through growth plate

Type 2 Salter-Harris Fracture

Through growth plate and metaphysis

Type 3 Salter-Harris Fracture

Through growth plate and epiphysis

Type 4 Salter-Harris Fracture

Through all 3 elements

Type 5 Salter-Harris Fracture

Crush injury of growth plate

Avascular necrosis (AVN)

30-50 y/o

Impairment of blood to femoral head causing tissue death after 12 hours

Occurs bilaterally if not traumatic

Treating AVN

Conservative: strengthening above and below joint, limiting stress through joint with AD and pt education, pain relief

Surgery: Core decompression, Total hip, trochanteric osteotomy, vascular fibular graft

Osteoarthritis (OA)

>50 y/o insideous onset

Progressive deterioration of articular cartilage, overgrowth of periarticular bone

Idiopathic or Traumatic

Pt has decreased acetabular and femoral neck anteversion

Treatment for OA

Rest, NSAIDS, ROM/Stretching/Strengthening, STM & Joint mobs, activity modification/AD/aquatics (unload joint)

Femoroacetabular Impingement (FAI)

Abnormal or early contact between bony prominences of the acetabulum and femur

Young <50 y/o Insidious onset

Pincer lesion

FAI classification, a deep acetabular socket with excessive coverage of femoral head

Associated pathologies: Coxa prounda, retroversion of acetabulum, anterior rotation of pelvis in the transverse plane

More common in middle aged active women

CAM lesion

FAI classification, lesion that reduce the medial proximal femoral angle

Associated pathologies: Coxa vara, developmetnal dysplasia, Legg-Calve Perthes disease, SCFE

2nd most common

Mixed lesion

FAI classification, results in an abrasion of the labrum, labral degeneration, ossification of acetabular rim and deepening acetabulum

Most common FAI

FAI treatment

If cause is overuse and no structural deformity: non operative, conservative treatment

Early operative prevents OA

Hip Labral Dysfunction

Compromised seal from tear causing higher stress across the joint, causing joint deterioration

Treatment of labral injury

Conservative: Rest and WB restrictions, NSAIDs and pain meds, manual therapy and joint distraction, movement modification

Operative: Similar to meniscal tears

Anterior hip dislocations

Forced abduction —> femoral neck or trochanter impinges against superior dome of acetabulum —> head out through tear in anterior capsule

Considered an emergency as its associated with arterial injuries or venous thrombosis, neuro status must be documented

Posterior hip dislocation

Occurs with hip/knee in flexion —> limb shortening, adduction and medial rotation

Should rule out femoral head/shaft fracture, and sciatic nerve injury

Fractures

Intracapsular: Rare in kids but if seen is serious, worst prognosis

Extracapsular: >swelling

Immediate groin pain, pain with movement, tender anterior to femoral neck, shortened limb, held in lateral rotation, ecchymosis

Muscle Strains

Caused by stresses placed on muscles especially during eccentric contractions

Commonly at musculotendinous junction of 2 joint and fast twitch muscles

Grade 1 strain

Min tissue disruption, min inflammation, strong and painful, full ROM but pain with stretch

Grade 2 strain

Some fiber disruption, decreased Strength and ROM, severe pain especially with stretching

Grade 3 strain

Complete rupture of muscle fibers, max weakness, no pain with stretching, palpable/visible defect

Strain Treatment

PRICE, NSAIDs, crutches, ROM, isometric, modalities for pain and swelling

Late Stage: endurance and coordination activities to return to sport

Bursitis

Secondary to direct trauma, repetitive activity, or inflammatory arthritis

Insidious onset

Most common of Hip: Trochanteric, Iliopectineal, Ischiogluteal

Bursitis Presentation

Achiness or tenderness over lateral posterior trochanter and thigh, snapping, pain with climbing stairs, lying on side, stretch of glute max, resisted abduction, extension and lateral rotation

Treatment for bursitis

PRICE, NSAIDs, stretching tight structures, strengthening to decrease muscle imbalances

Contusions

Direct blow to anterior or lateral thigh, dull ache over ant thigh with swelling, antalgic gait, difficulty flx/ ext knee, positive SLR and difficulty contracting quads

Grade 1 Contusion

Min discomfort, local tenderness, lack of gait disturbance, painless knee motion

Grade 2 Contusion

Swelling, tender muscle mass, antalgic gait, knee ROM <90, difficulty climbing stairs or getting up from chair

Grade 3 Contusion

Extreme pain/ swelling, knee ROM <45 ,limp, effusion into ipsilateral knee, AD needed

Treatment for Contusions: Phase 1

RICE, NWB with AD

Treatment for Contusions: Phase 2

Restore motion, progress WBAT as swelling resolves, active flexion/extension, gentle PROM

Treatment for Contusions: Phase 3

Functional rehab once ROM increases and WB has progressed, progress strengthening as pain allows

Myositis Ossificans

Complication of contusion of quadriceps causing development of heterotopic bone in muscle

Myositis Ossification Treatment

Rest and crutches, gentle ROM as pain resolves, submax isometrics once allowed, NSAIDs and steroids to decrease swelling

Traumatic Hip Instability

Dislocation/subluxation

Atraumatic Hip Instability

global laxity, idiopathic nature, groin pain with rotation on fixed foot, anterior hip pain with OP into hip extension and lateral rotation

Piriformis Syndrome Treatment

Muscle energy techniques, PNF, lateral rotator strengthening, neuromuscular reeducation, steroids, botox, surgical release

Adult Patient History Questions

Traumatic injury, Developmental dysplasias, Childhood hip conditions, Family history of connective tissue disease

Cyriax Capsular Pattern

gross limitation in flexion/abduction/medial rotation, slight limitation of extension, little to no limitation in lateral rotation

Meadows Capsular Pattern

Early arthritis, Painful flexion/adduction/medial rotation, Limited in extension/ adduction/medial rotation

Transient Synovitis: Severe Involvement

Pain in hip; Refuses to walk; All AROM/PROM is limited

Transient Synovitis: Moderate Involvement

Pain in thigh, knee, and hip; Antalgic gait; Limited hip extension and medial rotation

Signs of Septic Arthritis

Irritability, fever and chills, shorter leg, prominent greater trochanter, swollen thigh, hip spasms

Hip in flexion/abduction/lateral rotation, decreased ROM at hip (medial rotation)

Signs of Legg-Calve Perthes Disease (LCPD)

Pain and “achiness” in hip, groin, or knee. Can refer to thigh

Pain in WB, antalgic gait, tender anterior/posterior capsule, decreased ROM, trendelenburg, ipsilateral side shorter

SCFE Presentation

Out toeing, Abduction and lateral rotation with passive hip flexion, Knee pain is initial sx for 46% of patients, tender anterior and lateral hip, adductor spasm, fatigue after walking, limited ROM in flexion/abduction/medial rotation, quad atrophy, antalgic gait, trendelenburg

Early Avascular Necrosis

Pain is mild dull ache or throbbing, intermittent in groin or hip, typically occurs with WB and decreases with rest

Normal ROM and gait

Progressed Avascular Necrosis

Pain moves into inner thigh and eventually becomes constant

Slight limp becomes noticeable in gait

Late Avascular Necrosis

Stiffening of the joint with muscle spasm (iliopsoas, rectus femoris, sartorius)

Glutes and piriformis tender to palpation

Limited abduction and medial rotation

FICAT Stage 0

Xray: normal

MRI: normal

Bone scan: n/a

Clincal sx: none

FICAT Stage 1

Xray: normal or minor osteopaenia

MRI: edema

Bone scan: increased uptake

Clinical sx: pain typically in groin

FICAT Stage 2

Xray: mixed osteopaena &/or sclerosis

MRI: geographic defect

Bone scan: increased uptake

Clinical sx: pain and stiffness

FICAT Stage 3

Xray: crescent sign & eventual cortical collapse

MRI: same as Xray

Bone scan: pain and stiffness

Clinical sx: radiation to knee and limp

FICAT Stage 4

Xray: end stage with evidence of secondary degenerative change

MRI: same as Xray

Bone scan: n/a

Clinical sx: pain and limp

OA presentation

>50 y/o insideous onset

Groin or greater trochanter pain, pain with WB, stiffness after resting and relieved with activity

Capsular pattern: decreased extension/medial rotation/extreme flexion

Idiopathic OA

Occurs in middle age with no known cause (DJD)

Traumatic OA

Occurs in response to injury, deformity, or disease

OA on Xray

Osteophytes

Joint space narrowing

Subchondral sclerosis

FAI Presentation

Presents with unilateral groin and anterolateral hip pain, clicking or locking, decreased ROM on exam, empty end feel with flexion and rotation, c sign, sharp pain with pivoting (especially internal rotation) , ant pinching with sitting

Rehab Considerations After Arthroscopic Decompression

Excessive hip flexion, Abduction, and Medial Rotation

Initially limited, improve over time

Causes of Labral Injuries

Trauma, Hyperextension, FAI, Decreased acetabular anteversion, Decreased femoral neck anteversion

Labral Injury

Females>Males

Gradual hip pain (90% anterior hip or groin pain)

Slight ROM limitations with rotation/hip flexion/adduction/abduction

Sx for >2 years

Major cause of OA in young patients