Ortho 2: Hip

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common diagnoses in birth-2

developmental dysplasia, septic arthritis

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common diagnoses in 2-12yrs

transient synovitis, coxa vara, legg-calve-perthese

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common diagnoses in 8-17yrs

Slipped Capital Femoral Epiphysis (SCFE)

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18-young adult

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

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20-40 years

RA

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30-50 years

Osteonecrosis/ avascular necrosis

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>50 years

DJD, trochanteric bursitis, hip fracture

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Common Areas of Referral

lumbar spine, TL junction, SIJ, knee, Viscera

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Factors Related to Fall Risk

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

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Harris Hip Score

4 sections: Pain, Function, Deformity, ROM

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

MCID= 7-9 pts

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Lower Extremity Function Scale (LEFS)

Rates difficulty performing 20 activities

Max score= 80 (no difficulties)

MDC & MCID= 9 pts

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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

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Treatment for Developmental Dysplasia

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

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Transient Synovitis

Non-specific inflammation of synovium which is self limiting

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

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Treatment for Transient Synovitis

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

If pain persists: Check for Legg-Calve-Perthes

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Septic Arthritis

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

Can progress to femoral head necrosis within 24 hours

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Treatment for Septic Arthritis

Joint aspiration, drainage, antibiotics, hip spica, surgery

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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)

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Treatment for LCPD

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

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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

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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

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Type 1 Salter-Harris Fracture

Through growth plate

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Type 2 Salter-Harris Fracture

Through growth plate and metaphysis

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Type 3 Salter-Harris Fracture

Through growth plate and epiphysis

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Type 4 Salter-Harris Fracture

Through all 3 elements

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Type 5 Salter-Harris Fracture

Crush injury of growth plate

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Avascular necrosis (AVN)

30-50 y/o

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

Occurs bilaterally if not traumatic

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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

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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

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Treatment for OA

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

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Femoroacetabular Impingement (FAI)

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

Young <50 y/o Insidious onset

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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

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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

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Mixed lesion

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

Most common FAI

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FAI treatment

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

Early operative prevents OA

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Hip Labral Dysfunction

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

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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

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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

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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

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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

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Muscle Strains

Caused by stresses placed on muscles especially during eccentric contractions

Commonly at musculotendinous junction of 2 joint and fast twitch muscles

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Grade 1 strain

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

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Grade 2 strain

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

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Grade 3 strain

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

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Strain Treatment

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

Late Stage: endurance and coordination activities to return to sport

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Bursitis

Secondary to direct trauma, repetitive activity, or inflammatory arthritis

Insidious onset

Most common of Hip: Trochanteric, Iliopectineal, Ischiogluteal

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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

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Treatment for bursitis

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

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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

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Grade 1 Contusion

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

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Grade 2 Contusion

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

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Grade 3 Contusion

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

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Treatment for Contusions: Phase 1

RICE, NWB with AD

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Treatment for Contusions: Phase 2

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

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Treatment for Contusions: Phase 3

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

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Myositis Ossificans

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

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Myositis Ossification Treatment

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

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Traumatic Hip Instability

Dislocation/subluxation

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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

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Piriformis Syndrome Treatment

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

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Adult Patient History Questions

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

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Cyriax Capsular Pattern

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

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Meadows Capsular Pattern

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

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Transient Synovitis: Severe Involvement

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

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Transient Synovitis: Moderate Involvement

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

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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)

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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

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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

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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

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Progressed Avascular Necrosis

Pain moves into inner thigh and eventually becomes constant

Slight limp becomes noticeable in gait

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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

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FICAT Stage 0

Xray: normal

MRI: normal

Bone scan: n/a

Clincal sx: none

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FICAT Stage 1

Xray: normal or minor osteopaenia

MRI: edema

Bone scan: increased uptake

Clinical sx: pain typically in groin

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FICAT Stage 2

Xray: mixed osteopaena &/or sclerosis

MRI: geographic defect

Bone scan: increased uptake

Clinical sx: pain and stiffness

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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

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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

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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

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Idiopathic OA

Occurs in middle age with no known cause (DJD)

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Traumatic OA

Occurs in response to injury, deformity, or disease

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OA on Xray

Osteophytes

Joint space narrowing

Subchondral sclerosis

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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

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Rehab Considerations After Arthroscopic Decompression

Excessive hip flexion, Abduction, and Medial Rotation

Initially limited, improve over time

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Causes of Labral Injuries

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

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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

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