MSK IV Unit 1 & 2: Hip

what occurs of the hip abductors are active with the femur fixated

contralateral pelvis elevation

what occurs if the adductors are active with the femur fixed

contralateral pelvic depression

what occurs if the hip flexors are active with the femur fixed

anterior pelvic tilt

what occurs if the hip extensorsare active with the femur fixed

posterior pelvic tilt

what occurs if the hip ER are active with the femur fixed

contralateral posterior rotation

what occurs if the hip IR are active with the femur fixed

contralateral anterior rotation

what occurs of the angle of application of a force is 90 degrees

there are large torques creating a small translational forces

what occurs of the angle of application of a force is 0 degrees

there is smaller torque but larger translational forces

what can create hip pain with osteoarthritis

large compressive forces on the joint due to the small angles of force created by the muscles creating large translational forces

what system should be closely considered with hip pain

the urogenital system

where can the kidneys refer pain

to the lateral hip

what test may be used to screen the urogenital system

kidney percussion test

what vascular conditions should be considered for the hip (3)

peripheral vascular disease

avascular necrosis

osteonecrosis

what is calve perthes disease

a pediatric disorder of the femoral head where it temporarily loses blood supply common in overweight adolescents with a recent growth spurt

what is seen in the objective exam with legg calve perthes disease (3)

antalgic gait

limited ROM

pain in the hip, groin, thigh, or knee

what is a slipped capital femoral epiphysis (SCFE)

anterior displacement of the femoral neck with posterior displacement of the femoral head occurring in preadolescent males

what is seen in the objective exam with a SCFE (5)

limited ROM especially in IR

antalgic gait

pain in the hip, groin, knee, or thigh

difficulty wt bearing

holding hip in loose pack

what is seen on radiographs with a SCFE

a line (kline's line) is drawn from the superior boarder of the femoral neck to the greater trochanter, the line should partially cross the epiphysis

if it doesn't it may indicate displacement of the femoral neck

what is congenital hip dysplasia

when there is an unstable, malformed, subluxed, or dislocated hip seen in females more than males

what tests are used to diagnose hip dysplasia (3)

galeazzi

ortolani

barlow

when should infections be considered with the hip

pts who have has an acute trauma or pot-op

what infections should be screened for in the hip (2)

septic arthritis

osteomyelitis

what cancers can refer to the hip (2)

osteoid osteoma

colon cancer

what neurological conditions should be considered with hip pain (4)

cauda equina

guillain barre syndrome

multiple sclerosis

ALS

where can the hip joint refer pain

most commonly the buttock but can refer to the groin and thigh

less commonly the lower leg and dorsum of foot

what facets can refer to the posterior hip

L2-S1

what does hip-spine syndrome indicate

a pt who comes in with posterior hip pain should be screened for hip and low back pathology

where can the gluteus maximus refer (5)

sacrum

inferior buttock/gluteal fold

coccyx

sacrococcygeal region

lateral and inferior to iliac crest

where can the gluteus Medius, gluteus minimus, TFL, and deep hip rotators refer

down the LE

where can the gluteus medius refer pain (8)

buttock

low back

sacrum

posterior iliac crest

lateral to SI joint

lateral thigh over the greater trochanter

knee

leg

where can the gluteus minimus refer pain (3)

posterior thigh

calf

may mimic L5 or S1 radicular symptoms

where can the TFL refer pain (2)

hip joint

inferior along anterolateral aspect of the thigh

where can the piriformis refer pain (4)

SI region

buttock

posterior hip

proximal 2/3 of posterior thigh

where can the obturator internus refer pain (5)

coccyx

posterior middle thigh

urogenital structures

rectum

groin and hip with spillover pattern down thigh

where can the quads refer pain (2)

thigh and knee

anterior and medial knee deep to the joint

where can the adductor longus and brevis refer pain (3)

deep and proximal to the groin

anteromedial upper thigh

upper medial knee

where can the adductor magnus refer (3)

superior in the groin below inguinal ligament

inferior to anteromedial aspect of thigh to knee

groin and pelvis

where can the pectineus refer pain (2)

deep seated ache in the groin just distal to inguinal ligament

upper anteromedial thigh

where can the semitendinosus and semimembranosus refer (4)

projecting superior to the ischial tuberosity and gluteal fold

inferior to medial posterior thigh

posterior knee

medial calf

where can the biceps femoris refer pain

posterior lateral knee

where can the gastrocnemius refer pain (2)

posterior knee

calf/plantar heel

where can the soleus refer pain (3)

posterior calf

plantar heel

SI joint

where can the tibialis posterior refer (2)

achilles

posterior calf into the plantar surface of foot and toes

what is pain onset is reported with hip pain with radiating pain

insidious onset in most cases

there may be an MOI such as a fall on the buttock

what aggs are seen with hip pain with radiating pain

prolonged static positions

what symptoms are primarily reported with hip pain with radiating pain

neuropathic symptoms such as burning, tingling, and/or sharp/shooting pain

what is likely seen in joint mobility with hip pain with radiating pain

hypomobility of the hip or lumbar spine

what factors lead to poor prognosis with hip pain with radiating pain (3)

concurrent low back pathology

older adults

higher severity

what is done in the acute phase with hip pain with radiating pain

symptom modulation with activity modification

what is done in the subacute phase with hip pain with radiating pain

movement control

what is done in the chronic phase with hip pain with radiating pain

functional optimization and education to avoid recurrence

what treatments can be used for symptom modulation with hip pain with radiating pain (4)

manual therapy

dry needling

modalities

static stretching

what treatments can be done for movement control with hip pain with radiating pain (3)

core and lumbar stability

hip musculature strength

neurodynamics

what treatments can be done for functional optimization with hip pain with radiating pain

focus on strength and stability

what are the causes of piriformis syndrome (3)

hypertrophic piriformis

anatomical variance

overuse

what population is most impacted by piriformis syndrome

middle ages females due to difference in pelvis width

what symptoms are seen in piriformis syndroe

buttock tenderness without or with radiating pain

what may be seen in ROM with piriformis syndrome

there may be limited adduction and IR ROM with lumbosacral muscle tightness

what special test may be positive in piriformis syndrome

faber

where is weakness seen in piriformis syndrome

hip abductors

hat is the initial treatment for piriformis syndrome

decreasing the irritation of the sciatic nerve through conservative treatment and activity modification

what long term treatments are done for piriformis syndrome

strength and stabilize the hip, core, and back

what are stress fractures

microfractures that occur within the bone due to repetitive loading

where are common sites for stress fractures in the hip (2)

the femoral neck

pubic rami

what population is at increased risk for stress fractures

individuals performing sports with repetitive loading such as long distance runners, marathon runners, and military personnel

females experience stress fractures more commonly

what occurs in the bones with stress fractures

with repetitive loading the bone undergoes osteoclast activity to free up calcium in the body and without rest there is not enough osteoblast activity to rebuild that bone

where in the bone do most stress fractures occur

in the outer cortical bone due to slower remodeling

where can stress fractures occur of the pt has low bone mineral density

in the cancellous bone

where in the femoral neck do stress fractures occur (2)

the superolateral neck known as a tension stress fracture

inferomedial neck which is a compression fracture

why are tension fractures considered a higher risk situation

there is increased likelihood of the fracture displacing the femoral head from the test of the femur due to the vertical nature of the fracture

what provides counterbalance to the tension on the superior lateral femoral neck

the pull of the glute med and min so strengthening them can help reduce risk of a stress fracture

how are the compression fractures oriented on the inferomedial femoral neck

they run more obliquely which reduce the risk of displacement

what treatments can be done for a pubic rami stress fracture

with weight bearing reduction and activity modifications

what are fatigue fractures

fractures in the bone where there is normal bone mineral density

what is an example of a fatigue fracture

a compression femoral neck stress fracture in a long distance runner that recently increased their training intensity and volume

what are insufficiency fractures

stress fractures in pt when there is normal load in the bone with a lower bine density

what is an example of an insufficiency fracture

a stress fracture in a pt with low bone mineral density

what is recommended for long distance runner shoes

they should cycle new shows every 6 months or with every 300-500 miles of running

wear shock absorbent orthotics

what risk factors in females increase the risk for stress fractures (6)

BMI <19

late menarche (older than 15)

participation in leanness sports such as gymnastics, ballet, or running

female athletic triad

coxa vara

femoroacetabular impingement

what is the female athletic triad

low energy availability without disordered eating

menstrual cycle dysfunction due to deceased estrogen levels

osteoporosis or reduced bone mineral density

what is the impact of reduced estrogen in the female athletic triad

increased osteoclast activity relative to osteoblast activity

what is coxa vara

angulation of less than 120 degrees between the femoral neck and femoral shaft which can cause an alteration in hip and pelvic alignment leading to reduced efficiency of glut med and min leading to fatigue and risk for fatigue fractures

what is femoroacetabular impingement

malformation of the spherical shape of the femur or acetabulum

how can femoroacetabular impingement lead to stress fractures

it can alter the force and loading placed through the femoral neck with these deformities

what ages are often affected by hip stress fractures

between 16-58 years old

what is seen in the history with a stress fracture

a history of prior stress fractures and repetitive impact activities

what symptom onset is seen with stress fractures

a gradual onset of pain that is worse when weight bearing and doing loading activities

where is pain reported with a hip stress fracture

in the anterior hip, groin, or proximal thigh but it may be hard to localize due to the depth

what conditions may be associated with stress fractures (3)

thyroid dysfunction

gluten sensitivity

celiac disease

what is seen in ROM with stress fractures

altered active and passive ROM with pain at end range IR

what may be seen in a SLR with a stress fracture

there may be pain and the PT should be careful due to increased tensile forces across the femoral neck potentially creating a displaced fracture

where may there be pain with palpation with a hip stress fracture

over the anterior hip and inguinal area

what special tests are used for stress fractures (2)

patellar pubic percussion test

tuning fork over bony prominence

what imaging should be done for stress fractures

an x-ray first followed by an MRI due to high prevalence of X-rays missing stress fractures

what is the prognosis for uncomplicated compression sided femoral neck and pubic rami stress fractures

good as pts are expected to return to activity around 12 weeks

what can occur if stress fractures are untreated

it can lead to fracture propagation and potentially avascular necrosis of the femoral head

what should be done first if a stress fracture is suspected

immediate NWB and contact the referring provider for imaging to determine the fracture type

what is commonly needed for tension sided femoral neck stress fractures

surgery due to high risk of displacement

how long are pts NWB for a compression sided or pubic rami stress fracture

4-6 weeks

how often should imaging be done for stress fractures

weekly for 4 weeks then progress to every 2 weeks for the next 4 weeks then every 4 weeks for the next 8 weeks to ensure proper healing