quiz #3 – hip

120° of flexion

90° of flexion

115° of flexion

70

40°

• 30° of flexion
• 30° of abduction
• slight external rotation

• extension
• abduction
• internal rotation

• motion lose first
• flexion – abduction – internal rotation (order varies)
• internal rotation and extension most obviously lost function, abduction, external rotation

internal rotation and extension most, then abduction

iliopsoas, external rotators (piriformis), external rotator's( piriformis), it flexors and hamstrings

• extension
• abduction
• external rotation

medial collapse

• age of patient
• where it hurts
• how did you hurt it?
• how often
• previous treatments
• signs and symptoms

generally in front flexion crease, groin area

• getting in and out of the chair
• taking shoes on and off
• city hip impingement test
• figure 4
• leg length
• palpation

hip up to 90/90, internal rotation, -will generally produce pain if you have hip problems

SI joint, pain at iliac crest, greater trochanter bursitis

• Harris hip for THA
• Woomac or HOOS = inbetween scales

• IT band and anterior glut max slides over greater trochanter
• lie posterior with extension and slides anterior with flexion

• history
• physical exam
• dynamic US to see the snapping

IT band friction syndome leads to bursitis

• pain
• catching
• snapping
• activity related pain

• history of trauma
• idiopathic
• hyper mobile
• femoral acetabular impingement

positive hip impingement sign

• MRI
• Arthrogram

hip arthroscopic or surgical hip dislocation

• nonweightbearing with crutches for five days
• cardiovascular exercise with arm bike
• proprioceptive training of lower extremity after five days
• full Pass the range of motion with in two weeks
• after five weeks gentle running
• full training after 10 weeks

• predisposes to labral micro trauma, degeneration or separation
• could be secondary to underlying soft tissue disorder – Marfans Sydrome, or Ehlers-Danlos syndrome
• ballet or gymnastics could could induce

• femoral head abnormally shaped
• acetabulum covers too much
• both femoral head misshape and excessive acetabulum coverage

• caused by shear forces of the neck portion of FH against acetabulum
• anterior superior cartilage loss over the femoral head and dome

• repetitive contact stresses of normal femoral head against abnormal acetabular rim
• results and degeneration, ossification, and caring of the anterior superior portion of the labrum and posterior inferior contre-coup pattern of cartilage loss
• Acetabular labrum fails first causing degeneration and eventual ossification – worsening over coverage

• acetabular protrusion
• acetabular retroversion
• malunion of acetabular fx

muscle tendon junction of abductor longus and gracilis, most common cause of groin pain

• sports hernia
• osteoarthritis of the hip
• labral tears

must have full pain-free range of motion and 70% of straight to return to activity – 4 to 6 weeks

active functional exercise> Modalities

repetitive shearing forces on pubic synthesis causing pain could be from decreased internal rotation or SI joint mobility causing forces across pubic synthesis

• usually in soccer players
• ARF
• rugby

self-limiting... 9 months to a year to resolve

pain over and superior to greater trochanter that may radiate laterally to knee

• trauma
• overuse
• often contralateral of bad knee

• side lying
• positive Ober's test
• most have tight abductors and TFL
• pseudo-Trendelenburg
• want to evaluate in three planes

• NSAIDs
• exercise
• stretching
• corticosteroid injections
• rarely surgery

• iliopectineal bursitis
• iliopsoas
• anterior hip difficult to treat, often after THA
• Ischiogluteal bursitis: Tailor or Weaver bottom..US/Phono/ionto, padding

after injury patient flexes forward and toward sided pain

• low to the top of iliac crest
• TLF is usually impacted and hematoma results

• ice
• NSAIDs
• light stretching into directions opposite pain position
• preventative padding

• return to activity one week if mild
• return to activity six weeks is severe

pain in the butt, posterior leg,can radiate to calf

L5/S1 radiculopathy

entrapment of sciatic nerve in piriformis – difficult to diagnose

• stretch piriformis
• exercise internal rotator, flexors, abductors
• light stretching of extension, abduction, external rotation
• neutral tension techniques

• pelvic fracture
• hernia to obturator formen
• medial groin pain
• adductor weakness

• meralgia parasthetica
• obesity
• tight belts
• trauma
• physical therapy/injections
• no motor weakness
• just sensory

• postsurgical
• Fibular
• tibial, or both; fubular drop foot

after hernia repair, appendectomy, or by trauma and excessive ab training; numbness/pain in testicle or labia

• usually for stretching and flexibility... Sprinters, hurdlers, adolescent athletes
• eccentric muscle contraction

• ASIS = Sartorius
• AIIS = practice for Morris
• lesser trochanter = iliopsoas
• greater trochanter = gluteus medius or piriformis

• protected weight-bearing
• avoid high forces that place stresses at site of injury
• surgery is significantly displaced
• shut down and treat like fracture; six – eight weeks

bone forming within muscles

• no well-defined protocol
• aggressive stretching/exercising can accelerate, so you want to be gradual and less aggressive when stretching

surgery or radiation may be necessary if condition progresses

• pain with fabulation, rest, and night pain
• point tender

• history of tumor
• common metastasis with lung, breast, prostate cancers

X-Ray, bone scan, MRI

may be referred by PCPs as "pain, evaluate and treat"

will eventually require surgery so want to get them strong, flexible, and increase cardiovascular fitness, can't cure them

• increase range of motion and manual muscle strength >>> Especially with extension, internal rotation, and abduction
• balance and gait training
• traction at hip
• endurance and cardiovascular wellness
• address functional activities – need outcome measurements

• avascular necrosis
• greater trochanter non-union
• pain from hardware

• decrease impingement and pain
• stoppe degeneration
• preventive need of THA

• TTWB x 6-8 weeks until osteotomy heals
• <70 degrees
• anterior hip dislocation precautions

if already have arthritis then cannot be a candidate

femoral head blood supply – 90% –medial femoral circumflex; 10% ligament of head of teres

collapse of subchondral bones supporting the overlying cartilage

acute onset of severe hip pain – may be bilateral

• steroids
• renal disease
• thyroid
• alcoholics

• MRI early
• X ray in advanced stages

• pre-collapse; observation, core decompression, fibular vascularized autograft
• post-collapse; total hip, hip resurfacing

femoral neck compression (green – treated conservatively) or tension ( read – needs to be treated with pinning), pubis, ramus, sacrum

• recent changes in mileage
• intensity
• surface
• shoes and training
• disordered eating
• menstrual cycle and age of menarche

• insidious onset
• early on pain with activity
• later on pain at rest to pain with internal rotation

• MRI = gold standard
• T-1 fat is white
• T-2 water is white so can see swelling

• relative rest – cycling, deep well running, swimming, going
• surgery; femoral neck or inter-trochanter fracture
• Cross training to promote blood flow without stress

20 – 40 = high-energy trauma ( watch for AVN) >60 = low-energy trauma (falls)

• femoral neck
• inter trochanteric
• subtrochanteric

knee pain

elderly: simple fracture = 6-8 weeks, severe fracture = 3 months

• femoral neck fracture
• risk of AVN
• surgery; nondisplaced or valigus impact=screws; displaced:hemiarthroplasty, bipolar or THA

• intertrochanteric
• surgery;hip compressions screw, intramedullary hip screw

• 10 – 40% in first year
• about 1/2 of those from deep vein thrombosis

• NWB - 0% body weight – need Walker/crutches
• TDWB (touch down) -10 – 20% BW ( need Walker/crutches)
• PWB – 30% BW (need Walker/crutches)
• 50% WB – 50% BW ( need cane)
• FWB – 70 – 100% (can/no device)

• different hardware devices allow different amounts of weight bearing
• screws, plates, rods, can usually allow more weight bearing the nails
• cemented can wait there more than non-cemented

• Quad sets, hamstring sets, ankle pumps, glut sets, AAROM of flexion, abduction, abduction
• Heel slides, bed mobility transfers, upper extremity exercises
• initiate ambulation – stay away from internal/external rotation because could move fracture

• SLR in all directions, like Quad sets
• ADL devices
• sit in chair, sit stand, ambulate twice a day

• independent transfers and bedroom
• ambulate 50 feet and have home program
• if they don't fit these criteria then extended rehab facility

• standing 4 way hip; focus on glut/hip MMT
• progress from Walker to cane
• bike, pool, treadmill

Femoral-Acetabular impingement, posttraumatic, DDH, Perthes

groin or buttock pain, decreased internal rotation

• find location
• extent and type of pain
• restricted motion

• x-ray; show joint deterioration
• lab test; rule out other diseases

• NSAIDs
• weight loss
• exercise
• activity modification
• AD
• joint replacement surgery

• control pain and symptoms
• increase function
• educate patients and families

rheumatoid, lupus, other systemic diseases

• morning stiffness
• many involved joints

• pharmacological
• AD
• exercise
• surgery

low-impact, range of motion, pacing your activities

exercise nourishes Cartledge, keeps bones strong, joints limber, strengthens muscles, prolongs joint life

3 pounds of pressure on joints for every pound of body weight, fat accelerates rate of cartilage destruction

• aspirin three pain relievers – Tylenol
• anti-inflammatory drugs – Aleve
• cortical steroids
• sleep meds
• topical creams
• supplements

• heel wedges, orthotics, and good shoes crucial for aligning legs and keeping pressure off these
• rubber shoe inserts can decrease impact loading from knees and hips

arthritis incidence higher in people with low vitamin C and D

true

• 750,000 hip arthroplasty's
• 1/3 to 1/2 are THA
• $15 billion a year
• 60% paid by Medicare

• rheumatoid arthritis
• osteoarthritis – pain
• avascular necrosis
• alcoholism
• tumor
• TB
• congenital hip deformities

cemented or on cemented

• anterior
• anterior lateral
• direct lateral
• posterior lateral

• education
• guard against dislocation
• gain functional strength
• gain hip and knee strength
• prevent deep vein thrombosis, pulmonary embolism
• teach transfers and ambulation
• obtain pain-free range of motion

nothing non-impact; bike, dancing, golf, Nordic track, swimming, walk, bowl, double tennis, low-impact aerobics

father of temporary THA with a head 22 mm, now used 36 – 44 mm (had stability so decreases dislocation of)

• for young population, less loosening long-term
• living interface between stem and bone
• TDWW ( with Walker 6 – 8 weeks post op and PWB - check with MD)

• cement will eventually microfracture and loosen
• WBAT – with Walker immediately after surgery

open the capsule dislocate the hip , saw the femoral neck and ream of acetabulum,brooch with humor and place trials, once in the right place, pressfit or flue femoral component, place ball to reduce hip

• extension, adduction, and external rotation (TFL, glut med)
• muscle sparing – so quicker recovery
• Meralgia peresthetica - anterlateral femoral cutaneous nerve gets irritated
• precautions 0 – 3 months: no long strides walking or backwards walking, don't kneel on surgical side, avoid extreme abduction or external rotation, don't. Unplanted could, don't swing surgical leg out of bed, don't crossleg

avoid hip extension, adduction, external rotation and abduction exercises

• avoid hip flexion, adduction, internal rotation ( and external rotation exercises)( TFL, Glut max, ER)
• most commonly done
• slightly higher dislocation rate
• precautions 0 –3 months – don't flex > 90, don't cross legs in chair or bed, don't adduct past midline, avoid low chairs

instruct on precautions, transfer and ambulation instructions, demo they want to exercises

• Quad sets, hamstrings sets, glut sets, ankle pumps
• 4 way isometrics
• straight leg raise, heel slide <90
• up in chair 2x's a day, transfers, upper extremity exercises, initiate appropriate ambulation ( cemented versus non-cemented

straight leg raises, abduction, adduction, supine – stand, light quad stretch

• independent transfers, bedroom, home program, and straight leg raise
• ambulate 50 feet
• if not met, need extended rehab facility

• install elevated toilet seat
• home exercise program
• no driving for six weeks

• femoral stem = titanium alloy
• acetabulum = cobalt, chrome, titanium or tantalum component
• acetabulum liner = polyurethane, ceramic or metal
• femoral head = general metal or plastic

metal on metal: durum, depuy ASR, early loosening, metallosis, pseudo-tumors, ALVAL

foot rotated in and length is shortened

foot rotated out and leg shortens

Activity restrictions after six months