Hip Region - Musculoskeletal Physiotherapy 1

Functional Anatomy Review

• Brief review of functional anatomy of the hip (see FAB notes for further information).
• Examination of the hip.
• Brief review of relevant aspects of the Ax.
• Common clinical disorders of the hip.
• Potential treatment options.

Lecture Objectives

• Identify and describe the functional anatomy of the hip (see FAB notes for further detailed information).
• Describe the considerations associated with the examination of the hip.
• Describe the common clinical presentations of the hip, including pathology, diagnosis, and treatment options.

Acetabulum Articulations

• Rounded head of the femur.
• Acetabular labrum (deepens the ball and socket).

Hip Joint Function

• Primary weight-bearing synovial joint.
• Multi-axial ball and socket joint, promoting mobility.
• Movements:
  • Sagittal: Flexion and extension.
  • Frontal: Abduction and adduction.
  • Transverse: Internal and external rotation.
• Stability from congruency, ligaments, and musculature.

Ligaments of the Hip

• Surrounded by a strong fibrous capsule.
• Reinforced by strong ligaments, promoting stability.
• Positioned wrapping around the NOF (Neck of Femur).

Blood Supply of the Hip

• Femoral artery.
• Deep femoral artery.
• Medial circumflex femoral artery.
• Ligamentum teres artery.
• NOF - distal to proximal blood supply.

Musculature of the Hip

• Gluteus maximus, medius, and minimus.
• Piriformis.
• Obturator internus (Obtint).
• Gemellus superior (GemSup) and inferior (Geminf).
• Quadratus femoris.
• Vastus lateralis.
• Conjoint tendon.

Biomechanical Variations of the Hip

• Orientation of the NOF and articulation between the femoral head and acetabulum influence:
  • Joint congruency.
  • Mobility (ROM).
  • Weight-bearing forces.
• See FAB notes for more information.

Considerations for Hip Examination

• ROM normative values and limiting structures.
• Patient-reported outcome measures.
• Open-packed and closed-packed positions.
• Predisposing factors for hip pain.

Factors for ROM

• Clarkson, H. (2013). Musculoskeletal assessment: Joint motion and muscle testing (3rd ed). Lippincott Williams & Wiklins, Philadelphia, PA, p262

Patient Reported Outcome Measures (PROMs)

• Copenhagen Hip and Groin Outcome Score
  • Self-administered questionnaire for patients with hip and groin pain.
  • Six subscales: symptoms, pain, activities of daily living, sport and recreation, physical activities, and quality of life.
  • Raw scores converted to a scale from 0 to 100 (100 = best).
  • Test-retest reliability: ICC 0.82-0.91
  • MDC95%: 8-19 points.
  • MCID: 6-10 points.
  • Available online: www.koos.nu
• Hip Dysfunction and Osteoarthritis Outcome Score
  • Self-administered questionnaire for hip arthroscopy, hip osteoarthritis, and intra-articular hip pain.
  • Five subscales: pain, other symptoms, daily living, sport and recreation, and quality of life.
  • Raw scores converted to a scale from 0 to 100 (100 = best).
  • Test-retest reliability: ICC 0.93-0.96
  • MDC95%: 9-17 points.
  • MCID: 6-11 points.
  • Available online: www.koos.nu
• The International Hip Outcome Tool-33
  • Self-administered questionnaire for younger, active patients with hip pathologies.
  • Thirty-three items, each scored out of 100, summed, and divided by the number of items for an overall score out of 100 (100 = best).
  • Test-retest reliability: ICC 0.78
  • MDC95%: 16 points.
  • MCID: 6 points.
  • Available as appendix to Mohtadi et al. 201254

Open and Close-Packed Positions

• Open-packed:
  • 30° flexion.
  • 30° abduction.
  • Slight external rotation (\sim5°).
• Close-packed:
  • Full extension.
  • Full internal rotation.
  • Full abduction.

Predisposing Factors for Hip Pain

• Potentially modifiable factors:
  • Hip range of motion.
  • Hip muscle strength.
  • Patient-reported outcomes.
  • Symptoms.
  • Pain.
  • Function.
  • ADL (Activities of Daily Living).
  • Sport.
  • QoL (Quality of Life).
  • Previous interventions performed.
  • Type, level, volume of sport/activity.
• Non-modifiable factors:
  • Age.
  • Sex.
  • BMI (Body Mass Index).
  • Hip OA (Osteoarthritis).
  • Hip morphology (only modifiable by surgery).
• Identify factors associated with the outcome in people with hip pain to guide targeted interventions.

Clinical Disorders of the Hip Region

• Anterior Hip Pain
  • Labral Tear
  • Stress # of the neck of femur
  • Avascular necrosis - head of femur
  • Chondropathy
  • Traction apophysitis (AIIS – Rec Fem, ASIS – Sartorius, lesser trochanter - iliopsoas)
  • Synovial chondromatosis
  • Osteoarthritis
  • Slipped capital femoral epiphysis
  • Synovitis
  • Perthes’ disease
  • Ligament teres tear
  • Tumour
  • Hip instability (hypermobility)
  • Femeroacetabular impingement
  • Groin-related hip pain

Acetabular Labrum Tear

• 22% of athletes with groin pain have labral pathology.
• 55% of patients with mechanical symptoms have labral pathology.
• Females > Males
• Growing prevalence in the asymptomatic population.
• Prevalence is greatest anteriorly but can occur posteriorly.
• Insidious onset in 61% of patients.
• 40-73% of individuals with labral tears also have chondropathy.
• Types:
  • Type 1: Detachment of labrum from hyaline cartilage.
  • Type 2: Cleavage tears within the substance of the labrum.
• Risk factors:
  • Impingement of the labrum +/- cam-type FAI.
  • Developmental dysplasia of the hip (DDH).

Labral Tear – Signs and Symptoms

• Pain:
  • Groin (92%).
  • Anterior hip (52%).
  • Lateral hip pain (59%).
  • Buttock pain (39%).
• Clicking (most consistently reported), locking, catching, and giving way.
• Constant dull ache.
• Intermittent episodes of sharp pain worsening with activity.
• 71% of patients describe night pain.
• Limitations in ROM – rotation, flexion, adduction, and abduction.
• Functional limitations:
  • Limping (89%).
  • Banister to climb stairs (67%).
  • Limitation of walking distance (46%).
  • Sitting limited to 30 mins (25%).

Labral Tear – Diagnosis

• FADDIR – Quadrant test (High Sn, low Sp).
• FABER (Patrick’s test) (High Sn, low Sp).
• Thomas test (89% Sn, 92% Sp).
• Imaging:
  • X-ray – used to determine degenerative changes of the hip.
  • MRA (90% Sn, 91% accuracy).
  • MRI (30% Sn, 36% accuracy).
  • Arthroscopy (gold standard).

Labral Tear – Treatment

• Conservative management > surgical intervention.
  • Unload labrum: Avoiding rep flexion, add/abd, rot at end range.
  • Improve neuromuscular – activation of deep stabilizing muscles.
  • Gait retraining: ↓ excessive hip extension = ↑ anterior load.
  • Address biomechanical factors.
  • Manual therapy = increase nutrition to labrum.
• Surgical intervention.
• Post-operative management:
  • Improve ROM (passive  active).
  • Increase strength (isometric  isotonic).
  • Improve function/control of movement (simple  complex).
  • Example: hip stabilizing exercise.

Chondropathy

• Pathology to the articular cartilage.
• Early sign of OA.
• Up to 88% of lesions at the anterior/superior rim of the acetabulum.
• Often co-exists with other pathologies – Labral tear, synovitis, DDH, FAI.
• Signs and symptoms:
  • Intermittent anterior hip and groin pain.
  • Stiffness (morning or after rest).
  • May limit ROM – capsular pattern.
  • Clicking, locking, catching (depending on severity).
  • Functional limitations.
  • Antalgic gait (limping).

Chondropathy – Diagnosis and Treatment

• Diagnosis:
  • FADDIR, FABER (high Sn, low Sp).
  • MRI.
  • Confirmed with arthroscopy (gold standard).
• Treatment:
  • Conservative options should be trialed first.
  • Similar to labral pathology.
  • Combined with OA treatment.
  • Weight management/reduction.
  • ↑ physical activity (e.g., aquatic exercise, walking).
  • Strengthening exercise.
  • Manual therapy.
  • Neuromuscular control (glute max and medius).
  • Minimize synovitis – synovium inc. cartilage nutrition.
• Surgical repair.
• Post-op management (as per labral tear).

Osteoarthritis

• Chronic and progressive degeneration of the joint.
• Breakdown of cartilage.
• Development of bone spurs.
• Narrowed joint space.
• Epidemiology:
  • 9.3% of Australians (~2.2 million people).
  • 21% of Australians over 45 years.
  • 36% over 75 years.
  • 1 in 11 people.
  • 3 in 5 are female.
• No known cause but possible contributing factors:
  • Female.
  • Genetic factors.
  • Excess weight.
  • Joint misalignment.
  • Joint injury/trauma.
  • Repetitive loading (kneeling, squatting, heavy lifting).

Osteoarthritis – Signs & Symptoms and Diagnosis

• Signs and Symptoms:
  • Chronic pain+ (groin, thigh, buttock).
  • Antalgic gait.
  • Stiffness.
  • Crepitus.
  • Locking, catching, clicking.
  • Symptoms worse in the morning, or after resting.
• Diagnosis:
  • Subjective information.
  • Intra-articular tests: FADDIR, FABER (high Sn, low Sp).
  • Imaging: Radiograph (KL Grading system), MRI.

Kellgren-Lawrence Score

• Grade 0 – Normal.
• Grade 1 – Doubtful narrowing of joint space, possible osteophytic lipping.
• Grade 2 – Definite osteophytes and narrowing of joint space.
• Grade 3 – Moderate multiple osteophytes, definite joint space narrowing, sclerosis, and contour deformity.
• Grade 4 – Large osteophytes, marked narrowing of joint space, severe sclerosis, definite contour deformity

Osteoarthritis – Conservative Treatment

• Conservative management is preferred for as long as possible, including education and exercise.
• Education is critical for encouraging self-management, although the effects of isolated education are limited.
• Exercise is a critical component of conservative non-pharmacological management of hip OA, irrespective of disease severity, patient age, comorbidity factors, pain severity, or disability level.
• Manual therapy is also commonly used in clinical practice, but only a few studies are available with mixed results.
• Weight loss is strongly recommended for overweight/obese individuals (BMI > 25kg/m^2).
• Promotion of general physical activity (e.g., walking, aquatic exercise).
• Additional interventions are used to reduce load (e.g., gait aids).

Osteoarthritis – Surgical Treatment

• Many surgical procedures to improve symptoms of hip OA.
• Total Hip Replacement (arthroplasty).
• Half hip replacement (hemiarthroplasty).
• Depending on the location of pathology.
• Usually try to save as much tissue as possible if undamaged.
• Physiotherapy Perspective:
  • Post-op management.
  • Orthopedics component (Third Year).

Osteoarthritis – Treatment Evidence

• Exercise therapy (including strengthening) significantly decreased pain and increased function in individuals with hip OA.
• Exercise therapy in addition to patient education can reduce the need for THR by 44% in patients with hip OA.
• 81% of patients do not get adequate exposure to conservative management before being referred to secondary care (Orthopedic Specialists).

Ligament Teres Tear

• Thought to play a proprioceptive and stabilizing role.
• MOI: Forced flexion and adduction, and internal or external rotation; hyperabduction can also cause injury.
• Unknown prevalence: ~70% of athletes undergoing hip arthroscopy for FAI have a tear.
• Three types:
  • Type 1: Partial tear.
  • Type 2: Complete rupture.
  • Type 3: Degenerate ligament.
• Signs and Symptoms
  • Anterior hip and groin pain.
  • May limit ROM – capsular pattern.
  • Clicking, locking, catching.
  • Functional limitations.
  • Antalgic gait (limping).

Ligament teres tear – Diagnosis and Treatment

• Diagnosis:
  • Subjective interview (?).
  • Intra-articular tests (high Sn, Low Sp).
  • Imaging – MRI.
  • Arthroscopy (gold standard).
• Conservative:
  • Similar to labral tear.
  • Particular focus on neuromuscular control and proprioception (e.g., stabilizing muscles).
• Surgical intervention.
• Post-operative management.
  • Example: hip stabilizing exercise

Synovitis

• Inflammation of the synovium.
• Co-exists with labral tear, FAI, ligamentum teres tear, rarely seen in isolation.
• Signs and symptoms:
  • Constant pain++ (anterior hip, groin).
  • Night pain.
  • Limited and painful ROM.
  • ↓ muscle activity – atrophy.
  • Functional limitations (e.g., limping).
• Concern to clinicians:
  • Synovium/synovial fluid = nutrition to the cartilage.
  • Increase risk of chondropathy/OA.

Synovitis – Diagnosis and Treatment

• Diagnosis:
  • No good clinical tests or imaging (patient history and clinical reasoning).
  • Arthroscopy (gold standard).
• Treatment:
  • GP involvement – NSAIDs or intra-articular injections.
  • Peak synovial fluid pressure is reduced in-open packed position = reduces nutrition to the joint  avoid these positions.
  • Promote movement = ↑ synovial fluid movement = ↑ joint nutrition.
  • Treat the deficits you identify:
    • ROM deficits.
    • Neuromuscular control deficits.
    • Balance.
    • Weakness.

Hip Instability or Hypermobility

• Gross instability – excessive ROM, poor balance, proprioception, and coordination of the hip.
• Signs and symptoms:
  • Clinically difficult to detect.
  • Athletes with excessive ROM: Dancers, gymnasts, yoga.
  • Poor balance/neuromuscular control, lack of proprioception, poor coordination, extreme ROM, poor strength.
  • +/- Pain. Observable translation of the Head of Femur.
• Diagnosis: DDH: X-ray.
• Treatment – Treat the deficits you identify (neuromuscular control, balance, strength, etc.).

Femoroacetabular Impingement (FAI)

• Mechanical problem where morphological abnormalities occur to the femoral neck or acetabulum or both – clinical diagnosis must be symptomatic.
• Three types:
  • Cam deformity – abnormality of the neck of the femur (10-25% in asymptomatic populations, up to 89% in male athletes, males > females).
  • Pincer deformity – abnormality of the acetabulum (~20% of the population, females > males).
  • Combined/mixed – both abnormalities.
• Cam impingement associated with intra-articular pathology.
• Hip loading during maturation  risk factor for the development of Cam deformity.
• Deformity and signs and symptoms do not always match.

FAI – Signs & Symptoms and Diagnosis

• Signs and Symptoms:
  • Pain (but may be asymptomatic).
  • Catching, grinding, grating.
  • Reduced ROM (internal rotation).
  • Impacting on function (e.g., running, jumping, kicking).
• Diagnosis:
  • FADIR, FABER (high Sn, low Sp).
  • Radiographs.
  • MRI.
  • Confirmed with arthroscopy.
• Treatment:
  • Conservative for cases not wanting to return to sport but generally surgical intervention to remove the lesion.
  • Post-operative management.

FAI – Treatment

• Conservative/pre-surgery:
  • Avoid impingement positions (i.e., FADDIR).
  • Modify activity/sport.
  • Neuromuscular control (stabilizing muscles).
  • Strengthening.
  • Stretching.
  • Manual therapy (small improvements  ↑ training).
• Surgical intervention: Shave off the deformity.
• Post-operative management.

NOF Stress

• 3% of all sport-related stress #s.
• Three main types – Compression – Tension – Displaced.
• 16 to 56 years.
• Females (4.1% prevalence) > males (1.8% prevalence).
• Most commonly reported causative sports:
  • Marathon running.
  • Long-distance running.
  • Basketball.
  • Gymnastics.
  • Ballet dancing
• Signs and symptoms:
  • Anterior groin pain (87% of patients).
  • Thigh or glute pain.
  • Pain can radiate to the knee.
  • Pain late in the activity.
  • Antalgic gait.
  • Eventually pain at rest and at night.
  • “Crack” or “Pop” if displaced.

NOF Stress # - Diagnosis and Treatment

• Diagnosis:
  • Compressive testing (Drop Test).
  • Fulcrum Test – femoral shaft (88-93% Sn, 13-75% Sp).
  • Imaging: X-Ray, MRI, Bone Scan, CT scan.
• Treatment:
  • Superior aspect – strict rest following surgical intervention.
  • Inferior aspect – conservative 6-12 weeks of rest followed by a strict reloading program.
• Major concern  complete fracture.

Traction Apophysitis and/or Avulsion

• Apophysitis – painful inflammation of a bony outgrowth in the area of active bone growth and muscle attachment (younger population).
• Avulsion fracture – the forcible tearing/fracture of bone while maintaining contact with the muscle (older population).
• Common sites: AIIS – Rec Fem, ASIS – Sartorius, lesser trochanter - iliopsoas
• Signs & Symptoms:
  • Pop or snap for avulsion #
  • Hip/groin pain (dull ache – apophysitis, severe/constant pain – avulsion).
  • Reduced ROM (location dependent).
  • Weakness.
  • Functional limitations (e.g., limp).

Traction Apophysitis and/or Avulsion

• Diagnosis:
  • Apophysitis:
    • Clinical reasoning, palpation, AROM/PROM, MMT
  • Avulsion:
    • Trauma-related, pain+, weakness/inability to contract, deformity
• Treatment:
  • Apophysitis:
    • Rest/activity modification (period of healing).
    • Progressive strengthening (isometric  isotonic).
    • Progressive stretching  improve pain-free ROM.
  • Avulsion #:
    • Surgery

NOF

• Fracture to the Neck of Femur (NOF).
• ~19,000 people over 50 years of age have a NOF # each year.
• Usually older population (osteopenia, osteoporosis).
• Associated with trauma (e.g., fall or MVA).
• Different types .
• Secondary complications – Avascular necrosis.

NOF # - Signs & Symptoms and Diagnosis

• Signs & Symptoms:
  • Constant anterior/lateral hip pain+ and/or groin pain+.
  • Swelling+.
  • Inability to move the limb – loss of ROM.
  • Weakness?.
  • Deformity?.
  • Inability to WB.
• Diagnosis:
  • Patient history and clinical reasoning as most tests are contraindicated with a #.
  • Imaging – X-ray (first line), MRI, CT Scan.
  • Referral to orthopedics.

NOF # - Treatment

• Surgical intervention – Many techniques depending on severity and patient characteristics.
• Post-operative management.
• Secondary complications – Avascular necrosis.

Avascular Necrosis of the NOF

• Avascular – no vascular supply.
• Necrosis – death of cells.
• Fracture or dislocation to the NOF can disrupt the distal to proximal blood supply.
• May also be related to fatty deposits.

Avascular Necrosis of the NOF

• Signs and Symptoms:
  • Trauma – NOF # or dislocation.
  • ? No pain in early stages if other causes.
  • Gait disturbances.
  • Constant pain – suggests more than mechanical pain.
  • Hx: IVDU, smoking +++
• Diagnosis:
  • Refer for imaging (MRI, X-ray, Bone Scan).
• Treatment (depends on severity):
  • Surgery to correct blood supply.
  • Pharmacology (blood thinners, pain relief).
  • Post-operative rehabilitation:
    • ROM, strengthening, gait retraining, function.

Legg-Calve-Perthes’ Disease (aka Perthes’ Disease)

• Osteochondritis of the head of the femur.
• Flattening of the femoral head.
• Affects children 4 – 10 years old (boys > girls).
• Associated with delayed skeletal maturation.
• Signs and Symptoms:
  • Pain (dull ache hip, groin).
  • Limp (altered gait).
  • Limited abduction and internal rotation.
• Diagnosis:
  • Imaging – x-ray, MRI.

Legg-Calve-Perthes’ Disease (aka Perthes’ Disease)

• Management:
  • Rest – activity modification.
  • ROM exercise to maintain/improve internal rotation, abduction.
  • Age and severity will determine the management.
  • Children under 6:
    • Avoid jumping, running.
    • Pain killers.
• Children over 6:
  • Surgical intervention is often required.
  • Potential use of orthoses/bracing may be warranted.

Slipped Capital Femoral Epiphysis

• Widening and irregularity of the growth plate resulting in a posteroinferior slip of the head of the femur.
• Children 12 – 15 years of age.
• Affects boys > girls.
• Bilateral in 20% of cases.
• Risk:
  • Overweight or high BMI.
  • Delayed maturation.
  • Increasing childhood obesity.
• Slipping process usually gradual but may occur suddenly.
• Signs and Symptoms:
  • insidious groin/hip/thigh/knee pain.
  • painful limitation of hip ROM.
  • psoas spasm.
  • antalgic/Trandelenburg gait.

Slipped Capital Femoral Epiphysis

• Diagnosis:
  • Clinical reasoning.
  • Shortening of the affected leg.
  • Resting in external rotation.
  • Limited hip abduction and internal rotation.
  • During flexion the hip moves into abduction and external rotation.
  • Imaging – X-ray (Frog view).
• Treatment:
  • Surgical intervention to prevent further slip.
  • Secondary complication:
    • Avascular necrosis

Lateral Hip Pain

• Including:
  • Gluteus medius tears/tendinopathy
  • Referred lumbar pain
  • Fracture of the neck of femur
  • Pain from trochanteric bursa
  • Nerve root compression
  • Tumour

Greater trochanteric pain

• (predominantly glute med/min tendinopathy).
• Include pathology of the localized bursa.
• 10-20% of individuals with hip pain.
• Long-distance runners and women > 40 years old.
• ?MOI Compression (between ITB and greater trochanter).
• Biomechanical factors:
  • Hip abduction.
  • Q-angle (FAB).

Compressive forces in tendinopathy

• Gluteus medius tendinopathy and bursitis are related to compression between the iliotibial band (ITB) and the greater trochanter. This excessive compression can lead to ITB thickening, bursa distension, and structural changes within the tendon, ultimately reducing tensile loading capacity.

Greater trochanteric pain syndrome

• Signs and Symptoms
  • Dull ache located on the greater trochanter
  • Refer down the lateral thigh
  • Stiffness (particularly morning)
  • Difficulty to get moving… once warm may not feel as painful
  • Weakness of hip abductors (plus pain)?
  • Trendelenburg sign?
• Diagnosis
  • Direct palpation over the trochanteric region (High Sn, Low Sp)
  • Single leg stance for 30 seconds (Low Sn, High Sp)
  • De-rotation test (See practical notes)
  • Resisted abduction (not overly sensitive)

Greater trochanteric pain - Treatment

• Managing pain
  • Activity modification
  • Reduce compressive loads (pt positioning)
• Managing load
  • Progressive strengthening
    • Isometric abduction (neutral)
    • Neuromuscular control
    • Isotonic (concentric/eccentric)
    • Functional exercises

Posterior Hip Pain

• Including:
  • Posterior Labral tear
  • Referred pain lumbar spine and pelvic joints
  • Nerve root compression
  • Posterior chondral lesion
  • Proximal hamstring related pain
  • Tumour
  • Ligamentum teres tear
  • Sciatic nerve entrapment in short posterior rotators