Hip Presentation

8/8/2019 Hip Presentation

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THE HIPTHE HIPKaren Friel, PT, DHSKaren Friel, PT, DHS

Associate ProfessorAssociate ProfessorDept of Physical TherapyDept of Physical Therapy


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KINESIOLOGYKINESIOLOGY

Composed of:Composed of:

IliumIlium

IschiumIschiumPubisPubis

Head of femurHead of femur


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NORMAL AP PELVISNORMAL AP PELVIS


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15 degree angle by neck of femur and15 degree angle by neck of femur and

transversely thru femoral condylestransversely thru femoral condyles

Increased is anteversionIncreased is anteversionDecreased is retroversionDecreased is retroversion


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Femoral Torsion

Anteversion

Retroversion


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Angle between neck and shaft is:Angle between neck and shaft is:

150 in children150 in children

125 in adults125 in adultsIncreased= coxa valgaIncreased= coxa valga

Decreased=coxa varaDecreased=coxa vara


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Coxa ValgaG. Medius

G. Medius

G. Medius


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NONCONTRACTILENONCONTRACTILE

CapsuleCapsule

LigamentsLigaments

IliofemoralIliofemoral

PubofemoralPubofemoral

IschiofemoralIschiofemoral

BursaeBursae

Greater trochanterGreater trochanter Ischial tuberosityIschial tuberosity


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CONTRACTILECONTRACTILE

MusclesMuscles


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NERVESNERVES

Sciatic: L4Sciatic: L4--S3S3

Obturator: L3,L4Obturator: L3,L4

Femoral: L2,3,4Femoral: L2,3,4


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BLOOD SUPPLYBLOOD SUPPLY

Medial and lateral circumflex arteriesMedial and lateral circumflex arteries

Implications during injury and increasedImplications during injury and increased

capsular pressurecapsular pressure OsteochondrosisOsteochondrosis

Avascular necrosisAvascular necrosis


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ExaminationExamination

L2L2--S1S1

Perceived in L3 distributionPerceived in L3 distribution

Pain midinguinal region initially progressing toPain midinguinal region initially progressing to

anterior thigh and kneeanterior thigh and knee

Pain trochanteric region/lateral thigh:Pain trochanteric region/lateral thigh:bursitisbursitis

Pain in buttocks spreading toPain in buttocks spreading tolateral/posterior thigh: lower spinal originlateral/posterior thigh: lower spinal origin

Lumbopelvic screenLumbopelvic screen


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ExaminationExamination

ObservationObservation

Inspection: bony landmarksInspection: bony landmarks

Movement AssessmentMovement Assessment

PROM (mobility testing in textbook)PROM (mobility testing in textbook) Capsular endfeelCapsular endfeel

Capsular pattern: IR and abd most limitedCapsular pattern: IR and abd most limited

CPP: Max ext and IRCPP: Max ext and IR

ResistiveResistive

FlexibilityFlexibility

Palpation: Where is tenderness?Palpation: Where is tenderness?

Special TestsSpecial Tests


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AVASCULAR NECROSISAVASCULAR NECROSIS

Ages 3Ages 3--1111

Boys>girlsBoys>girls

Etiology unknownEtiology unknown

Result of chronicResult of chronic

effusion andeffusion and

inflammationinflammation

Collapse of femoralCollapse of femoralheadhead


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AVASCULAR NECROSISAVASCULAR NECROSIS

Attempt atAttempt at

RemodelingRemodeling

DemineralizationDemineralization


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SOFT TISSUE INJURIESSOFT TISSUE INJURIES

Muscle strainsMuscle strains

Hip adductorsHip adductors

H/S strainH/S strain

Gluteus Medius strainGluteus Medius strain

Muscle compromise, imbalances,Muscle compromise, imbalances,

decreased flexibility,poor conditioning,decreased flexibility,poor conditioning,deceleration injuriesdeceleration injuries


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Extensor Weakness in EliteExtensor Weakness in Elite

SprintersSprinters((SugiuraSugiura, Saito et al, 2008), Saito et al, 2008)

30 male elite sprinters30 male elite sprinters

IsokineticIsokinetic strength tested hip extensors, quads,strength tested hip extensors, quads,

hamstringshamstrings

6 subjects sustained hamstring injury during one6 subjects sustained hamstring injury during one

year post measurementsyear post measurements

Hamstring injury ALWAYS occurred on weakerHamstring injury ALWAYS occurred on weaker

sidesideWeakness noted during eccentric hams andWeakness noted during eccentric hams and

concentric hip extensors at slower speed testingconcentric hip extensors at slower speed testing


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BursitisBursitis

Grtr trochanterGrtr trochanter

Insidious onsetInsidious onset

Related to ITB tightness, poor posture, IncRelated to ITB tightness, poor posture, Inc

Q angle, LLDQ angle, LLD


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BursitisBursitis

Presents as:Presents as:

Pain laterallyPain laterally L5 L5

Pain ascending stairsPain ascending stairs

Lying on involved sideLying on involved side

Deep qualityDeep quality

ROM WNLROM WNL

Pain with resisted abductionPain with resisted abduction + Obers+ Obers

+ Piriformis at trochanter+ Piriformis at trochanter


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PIRIFORMIS SYNDROMEPIRIFORMIS SYNDROME

Selective tissue tension testing findingsSelective tissue tension testing findings

Females> malesFemales> males

Tight piriformis compresses sciatic nerveTight piriformis compresses sciatic nerve

or stretched piriformis from chronic addor stretched piriformis from chronic addand IRand IR


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Dezawa, Kusano, MikiDezawa, Kusano, Miki

Arthroscopic release of the piriformis muscle under local anesthesia forArthroscopic release of the piriformis muscle under local anesthesia for

piriformis syndromepiriformis syndrome

J Arthroscopic and Rel Surg 2003;19:554J Arthroscopic and Rel Surg 2003;19:554--557557

Subjects did not respond to conservativeSubjects did not respond to conservative

therapy for 6 monthstherapy for 6 months

Minimally invasiveMinimally invasiveAllows early return to activityAllows early return to activity

Release at ventral side of ischiatic notchRelease at ventral side of ischiatic notch

Immediate reliefImmediate relief


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OSSEUS DEFORMITIESOSSEUS DEFORMITIES

Coxa vara: angle between neck and shaftCoxa vara: angle between neck and shaft

is


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SCFESCFE

Male> female 2:1Male> female 2:1

1010--16 yo16 yo

Antalgia, hip pain,Antalgia, hip pain,

medial knee pain,medial knee pain,

limited IR, abd, flexlimited IR, abd, flex


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Coxa valgaCoxa valga

Angle between shaft and neck is>125Angle between shaft and neck is>125

Changes in WB patternsChanges in WB patterns


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ANTEVERSIONANTEVERSION

Angle between neck and condyles is >12Angle between neck and condyles is >12

Leads to IRLeads to IR

Presents as : toedPresents as : toed--in gait, increased Qin gait, increased Qangle, increased IRangle, increased IR

May lead to: chondromalacia, pronation,May lead to: chondromalacia, pronation,

lateral tracking, anterior headlateral tracking, anterior headdegenerationdegeneration


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RETROVERSIONRETROVERSION

Decreased angle between neck andDecreased angle between neck and

condylescondyles

Presents as: increased ERPresents as: increased ER


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CibulkaCibulkaDetermination and Significance of Femoral NeckDetermination and Significance of Femoral Neck

AnteversionAnteversionPhys Ther 2004;84(6):550Phys Ther 2004;84(6):550--575575

Diminished angle led to SCFE by redistributingDiminished angle led to SCFE by redistributing

forces across the femoral epiphysisforces across the femoral epiphysis

Increased or decreased angle leads toIncreased or decreased angle leads to

degenerative hip diseasedegenerative hip disease

Altered congruence leads to OA (discrepancy inAltered congruence leads to OA (discrepancy in

congruity b/w femur and acetabulum)congruity b/w femur and acetabulum)

Decreased angle may lead to torn labrumDecreased angle may lead to torn labrumbecause of repetitive impingement. Changes inbecause of repetitive impingement. Changes in

force distribution increase labral stressforce distribution increase labral stress


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FRACTURESFRACTURES

Acetabular: association with posterior hipAcetabular: association with posterior hip

dislocationdislocation

ORIFORIF

Subcapital Femoral neck fx: elderlySubcapital Femoral neck fx: elderly

Twisting during WBTwisting during WB

IntracapsularIntracapsular

ORIFORIF


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HIP FRACTURESHIP FRACTURES


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INTERTROCHANTERICINTERTROCHANTERIC

ORIFORIF


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SUBTROCHANTERICSUBTROCHANTERIC

Younger populationYounger population

ORIFORIF


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ORIFORIF


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DISLOCATIONSDISLOCATIONS

Anterior: 10Anterior: 10--15%15%

Superior: from ext, abd, ER.Superior: from ext, abd, ER.

Implications for neurovascular bundleImplications for neurovascular bundle

Inferior: from flex, abd, ERInferior: from flex, abd, ER

Posterior: 80%Posterior: 80%

Sciatic nerve damageSciatic nerve damage

Present with add, IR, unable to WBPresent with add, IR, unable to WB

Beware of associated fxBeware of associated fx


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HIP DISLOCATIONHIP DISLOCATION


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Hillyard, FoxHillyard, Fox

Sciatic nerve injuries associated with traumatic posterior hipSciatic nerve injuries associated with traumatic posterior hip

dislocationsdislocations

Am J Emer Med 2003;21:545Am J Emer Med 2003;21:545--548548

Higher incidence of major sciatic nerveHigher incidence of major sciatic nerveinjury in patients transferred from facilityinjury in patients transferred from facilitywith hip still dislocatedwith hip still dislocated

Up to complete sciatic or peroneal nerveUp to complete sciatic or peroneal nervedeficitdeficit

Major nerve injury greater with longer timeMajor nerve injury greater with longer time

to relocationto relocationNerve injury becomes more severe asNerve injury becomes more severe astime to relocation increasestime to relocation increases


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OSTEOARTHRITISOSTEOARTHRITIS

Exam:Exam:

Anterior pelvic tiltAnterior pelvic tilt

Hip flex, ERHip flex, ER

+ Trendelenburg+ Trendelenburg

Hypomobile in capsular patternHypomobile in capsular pattern

Weakness in glutealsWeakness in gluteals


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SURGICAL MANAGEMENTSURGICAL MANAGEMENT

THRTHR

Femoral head: chrome cobaltFemoral head: chrome cobalt

Stem: titanium alloyStem: titanium alloy

Acetabulum: Metal shell with polyethylene cupAcetabulum: Metal shell with polyethylene cup


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SURGICAL APPROACHESSURGICAL APPROACHES

PosterolateralPosterolateral

Most commonMost common

Leaves abductor intact, but unstable jtLeaves abductor intact, but unstable jt

Hip precautions: Avoid flex> 90, IR andHip precautions: Avoid flex> 90, IR andadduction past neutraladduction past neutral

AnterolateralAnterolateral

Dissect glut mediusDissect glut medius Restricted WB, stable jtRestricted WB, stable jt

Avoid ext, add, ERAvoid ext, add, ER


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SURGICAL APPROACHESSURGICAL APPROACHES

Transtrochanteric approachTranstrochanteric approach

AKA: trochanteric osteotomyAKA: trochanteric osteotomy

Restricted WB 6Restricted WB 6--8 weeks8 weeks

Can tighten glut medius to increase stabilityCan tighten glut medius to increase stability

Avoid ext, add, ERAvoid ext, add, ER

Beware of abductionBeware of abduction


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FIXATIONFIXATION

Cemented: early WBCemented: early WB

Porous coated: NonPorous coated: Non--WBWB

Hybrid: Cemented femoral andHybrid: Cemented femoral anduncemented acetabularuncemented acetabular

Immediate WBImmediate WB

ComplicationsComplications


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TOTAL HIP REPLACEMENTTOTAL HIP REPLACEMENT


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Jackson, Emerson, SmithJackson, Emerson, SmithJOSPT; 2002;32:260JOSPT; 2002;32:260--267267

To compare outcomes one year post THR fromTo compare outcomes one year post THR frominvolved to uninvolved sideinvolved to uninvolved side

All subjects had 1All subjects had 1--6 weeks of home PT6 weeks of home PT

ROM, Postural stability, MMT, selfROM, Postural stability, MMT, self--assessmentassessmentof fxnof fxn

Decreased postural stabilityDecreased postural stability---- significantlysignificantlydifferentdifferent

No sig diff in MMTNo sig diff in MMTPositive correlation b/w function and hipPositive correlation b/w function and hipabductor strengthabductor strength


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ConclusionsConclusions

Brief postsurg rehab may not be sufficientBrief postsurg rehab may not be sufficient

Emphasize postural stability and WBEmphasize postural stability and WB

activities further postop. Advance exerciseactivities further postop. Advance exerciseprogramprogram

Increased strength and postural stabilityIncreased strength and postural stability

may prevent subsequent fallsmay prevent subsequent falls

FreburgerFreburger


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FreburgerFreburger

An analysis of the relationship between the utilization ofAn analysis of the relationship between the utilization of

physical therapy services and outcomes of care for patientsphysical therapy services and outcomes of care for patients

after total hip arthoplastyafter total hip arthoplasty

Phys Ther 2000:80:448Phys Ther 2000:80:448--458458

Almost 8,000 subjects in acute careAlmost 8,000 subjects in acute care

Outcomes measured by total cost of careOutcomes measured by total cost of careand discharge destinationand discharge destination

More PT intervention directly related toMore PT intervention directly related to

lower total cost and higher likelihood oflower total cost and higher likelihood of

discharge homedischarge home


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ACETABULAR PROTRUSIOACETABULAR PROTRUSIO

Hip Presentation

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