The Hip.

Presentation on theme: "The Hip."— Presentation transcript:

1 The Hip

2 Lateral Femoral Triangle

3 Anatomy Ball & Socket joint
Convex femoral head: 2/3 covered with cartilage Head of femur points in anterior, medial, superior direction

4 Anatomy Acetabulum faces lateral, inferior and anterior direction
Ring of cartilage covers periphery Labrum Triangular fibrocartilaginous ring attached to the bony rim of the acetabulum Serves to deepen the socket & increase surface area; thereby increasing stability Improves mobility by providing an elastic alternative to a bony rim The acetabulum faces lateral, inferior and anterior. A ring of cartilage, which, on the caudal part is interrupted by the acetabular notch, covers the peripheral part. The acetabular notch opens to the capsule. It is covered by the transverse ligament and it forms a passage for the ligamentum teres and the obturator artery branch. The middle, deeper part of the acetabulum (acetabular fossa) is not in contact with the femur head.

5 Anatomy Collum (neck) of Femur 3-5 cm long
degree angle of inclination 10-15 degree angle with the frontal plane axis of the femoral condyles (anteversion) The collum of the femur is 3-5 cm long. The collum angle is degrees. In a tall slim person, the angle is 128 degrees with a long collum. In a short stocky person the angle will be 115 degrees with a short collum. The collum angle influences ROM, speed and strength of the bony structure. The anteversion angle of the collum is degrees with the frontal plane axis of the femoral condyles. It also forms a degree angle with the transverse axis and the mechanical axis of the acetabulum.

6

7 How do we check the anteversion angle?
Craig’s Test – patient prone knee flexed 90o Palpate posterior aspect of greater trochanter. Passive internal rotation the hip > greater trochanter in its most lateral position. If the angle is > 15 degrees in IR, the femur is considered to be in anteversion.

8 Anatomy Pulvinar acetabuli, fat pad located in the acetabular fossa
Lubrication Shock absorber Protects ligamentum teres In the acetabular fossa lays a fat pad, called the pulvinar acetabuli. It is covered with a synovial membrane. Function: Lubrication Shock absorber Protects ligamentum teres The hip is like a hydraulic system. During the swing phase, a decrease in atmospheric pressure will suck fluid from the iliac bursa into the pulvinar acetabuli. During the stance phase, the fluid gets squeezed out. The acetabular fossa is a shallow depression in the floor of the acetabulum, above the acetabular notch. The fossa is lined with a fibroelastic fat pad, which in turn is covered with synovial membrane. The membrane is attached to the medial aspect of the transverse ligament and the margins of the acetabular fossa, enveloping the ligament of the head of the femur, where it extends up to the edge of the pit (fovea) on the femoral head. © 2003 Primal Pictures Ltd.

9 Anatomy Joint capsule shaped like a
cylindrical sleeve – 4 sets of fibers: Longitudinal Oblique Arcuate Circular Deep fibers of rectus femoris strengthen capsule anteriorly The joint capsule is shaped like a cylindrical sleeve. It runs from the iliac bone to the upper end of the femur. It has 4 sets of fibers: Longitudinal fibers, which keep the joint surfaces together. Oblique fibers, with a similar function as the longitudinal fibers/ Arcuate fibers, which only attach to the acetabular rim Circular fibers, which have no bony attachment, and are thickest in the center of the sleeve. The capsule inserts medially into the acetabular ring, the transverse ligament and the base of the peripheral surface of the labrum. Laterally the capsule inserts into the base of the neck. Deep fibers of the rectus femoris strengthen the capsule anteriorly. Synovial folds (frenulae) are found superior and inferior, to accommodate for ab/adduction.

10 Anatomy Ligaments Ligamentum Teres Iliofemoral ligament
Pubofemoral ligament Ischiofemoral ligament Ligamentum teres From the acetabular notch to the head of the femur. Although very strong, it plays a trivial mechanical role. Contributes to the vascular supply of the femoral head via the artery of the ligamentum teres, a posterior branch of the obturator artery (runs underneath the transverse ligament before entering the ligament) Iliofemoral ligament From the ventral edge of the ilium (caudal of the AIIS) to the intertrochanteric line. The central part is relatively thin, while the superior and inferior part are very strong (8-10mm thick). Pubofemoral ligament The iliofemoral and pubofemoral ligament resemble a Z shape. Between the 2 ligaments, the capsule is thinner. Between the capsule and the iliopsoas tendon is a bursa. Ischiofemoral ligament Located posteriorly. From the dorsal edge of the acetabulum to the medial greater trochanter. The anterior and posterior hip ligaments wind around the collum in a clock wise direction. Extension “winds” or tightens these ligaments, while flexion “unwinds’ or relaxes them. In erect posture, the ligaments are under moderate tension. In external rotation, the anterior fibers are taut, the posterior fibers are slack. In internal rotation, the anterior fibers are slack, the posterior fibers are taut.

11 Arthrokinematics & ROM
Flexion/Extension:120°/20° Spin movement of the head of the femur Adbuction: 45° Head of the femur glides inferior Adduction: 30° Head of the femur glides superior Internal Rotation: 30° Head of the femur glides posterior External Rotation: 45° Head of the femur glides anterior

12 Clinical Presentation
Resting position 30° flexion, 30° abduction, 20° ER Close packed position Extension, abduction, internal rotation Capsular pattern Flexion, abduction, IR Sometimes IR is most limited. Order may vary, but will always include these 3 movements Position of reference: position denoting a “balanced pelvis” for assessment of hip abduction/adduction ROM – generally in a supine position A line between the 2 ASIS is perpendicular to the line from ASIS through patella

13 Examination

14 Hip Examination Hypothesis? Medical Screening Outcome Measure
Subjective Examination Objective Examination Intervention HEP Hypothesis?

15 Red Flags for Hip, Pelvis & Thigh
Colon CA Pathologic Fractures of Femoral Neck Avascular Necrosis Legg-Calve-Perthes Disease Slipped Capital Femoral Epiphysis Boissonault WG. Primary Care for the Physical Therapist – Examination and Triage. Elsevier Saunders 2nd ed

16 Colon CA History Exam Finding >50yoa bowel disturbances
unexplained weight loss Hx colon CA in immediate family pain unchanged by change in position Later Stages – hypo- or hyperactive bowel sounds TTP abdomen in area of CA Possible Ascites First sign may be mets to: liver, lung, brain Boissonault WG. Primary Care for the Physical Therapist – Examination and Triage. Elsevier Saunders 2nd ed Can go undetected for years before colon s/s occur

17 Pathologic Fracture of Femoral Neck
History Exam Findings Older women >70yoa with hip, groin, or thigh pain Hx fall from a standing position Severe constant pain, worse with movement Shortened LE LE in ER position Boissonault WG. Primary Care for the Physical Therapist – Examination and Triage. Elsevier Saunders 2nd ed

18 Osteonecrosis History Exam Findings Long term corticosteroid use
Osteonecrosis in the contralateral hip Traume Gradual onset of pain worse with weight bearing Stiff hip joint – most limited with IR & flexion Boissonault WG. Primary Care for the Physical Therapist – Examination and Triage. Elsevier Saunders 2nd ed

19 Legg-Calve-Perthes History Exam Findings 5-8yo males
Presenting with hip/groin pain Antalgic gait Aggravated with movement – hip abduction & IR Boissonault WG. Primary Care for the Physical Therapist – Examination and Triage. Elsevier Saunders 2nd ed

20 Slipped Capital Femoral Epiphysis
History Exam Findings Overweight Adolescent Hx of recent growth spurt or trauma Aching in groin increased by weight bearing LE held in ER Limited IR of hip Boissonault WG. Primary Care for the Physical Therapist – Examination and Triage. Elsevier Saunders 2nd ed

21 Hip Examination Hypothesis? Medical Screening Outcome Measure
Subjective Examination Objective Examination Intervention HEP Hypothesis?

22 Hip Specific Historical Examination
Questions: Do your symptoms change (better or worse) with any movements of the low back? Do you have any pain in your low back, even if you feel it is unrelated to your hip pain? Does your hip pain extend down into your thigh or leg? Do you ever experience numbness or tingling into the hip, thigh, leg ankle or foot? Have you recently increased your physical activity, especially running (distance, terrain, speed) or other weight bearing activities? Do you have pain or stiffness in the hip or groin region? Do you have a family history of osteoarthritis? Morning stiffness <60 minutes? Pain with prolonged walking? Do you experience clicking, catching, or giving way of the hip? Do your symptoms worsen with full flexion or extension? Ref: Flynn TW, Cleland JA, Whitman JM. Users’ Guide to the Musculoskeletal Examination. Evidence in Motion. ISBN

23 Hypothesis? Physical Examination serves to support/refute your working hypothesis/hypotheses

24 Seated Examination Neuro exam if indicated ROM MMT (as indicated)
Myotomes Dermatomes MSR Note alteration in areas of peripheral nerve sensation ROM Hip IR/ER MMT (as indicated) Hip flexors Knee extensors Ankle dorsiflexors

25 Standing Examination Lumbar Observation Palpation
A/P/OP ROM Observation Standing: observe anterior, posterior and lateral for asymmetry of: Soft tissues or bony landmarks of hip, gluteal region, low back, lower extremities Gait: abnormal gait mechanics and/or reproduction of symptoms Palpation Iliac crest ASIS PSIS Greater trochanter Special Tests (as indicated) Standing flexion (SIJ)

26 Supine Examination ROM (A/P/OP) Flexibility Observation/Palpation
Flexion IR/ER Abduction Flexibility HS Piriformis (>90/<90° flexion) Iliopsoas, RF, ITB (Thomas test) Observation/Palpation Iliac crest, ASIS Malleoli (after leveling) Inguinal ligament Joint Mobility Anterior glide Posterior glide Inferior glide Long axis distraction Special Tests (as indicated) Scour FABER SLR Sign of the buttock Leg length Compression/Distraction (SIJ) Supine to sit (SIJ)

27 Side-lying Examination
Flexibility ITB (Ober’s Test) MMT Hip Abductors

28 Prone Examination Palpation ROM (A/P/OP) Flexibility Joint Mobility
Iliac crest/PSIS Sacral sulcus ILA Ischial tuberosity ROM (A/P/OP) Hip extension Flexibility Rectus Femoris (Ely’s test) Joint Mobility Anterior glide Posterior glide MMT Hip extensors Knee flexors Special Tests (as indicated) Flick test (SIJ) Deerfield (SIJ)

29 DIFFERENTIAL DIAGNOSIS
What is common?

30 Hip Osteoarthritis Moderate to severe OA affects more than 22 million American adults between ages yrs (Mikesky et al 2006) Incidence study showed rates of 0.5/1000 per year of people with hip OA (Felson et al, 1987)

31 Pathology of Hip Osteoarthritis
Loss of hyaline cartilage Sub-chondral bone sclerosis Joint space loss Osteophyte formation

32 Diagnosis Many patients often have symptoms of hip and knee OA early in its course without radiographic changes and 40% of patients with typical radiographic changes may be asymptomatic. Therefore, subject matter experts recommend the diagnosis of hip & knee OA not be based on radiographs alone (Altman et, 1986; Balint et al, 1996)

33 Test Item Cluster for Hip Osteoarthritis
Test Cluster 1: Self reported squatting as an aggravating factor Passive hip IR ROM <25° Active hip flexion causing lateral hip pain Active hip extension increases pain Scour’s + for pain Diagnostic Accuracy: If 4/5 components of the test cluster are present: + LR=24.3 This increases the probability of having hip OA to 91% Ref: Sutlive et al. JOSPT 2008

34

35 PT for Hip OA – Hoeksma 2004 RCT, n = 109, 29 week follow-up
9 treatments Manual PT + Exercise vs Exercise alone Clinically meaningful improvements (pain, ROM, function) at 6 mos Manual therapy treatment: Long axis manipulation + stretching

36 Manual Therapy and Exercise Group
Traction of hip joint Traction Traction manipulations Stretch: Quadriceps Tensor fascia lata Adductors Sartorius Gracilis

37 Exercise Group Stretches Exercises to increase motion
Muscle strengthening exercises Balance activities Home exercise program

38 Results of the Harris Hip Score
Results on range of joint motion from flexion to extension

39 Both strengthening and aerobic exercise can reduce pain and improve function.
2. Prescription of exercise is essential core aspect of management of hip OA 3. Exercise should be individualized 4. Exercise adherence is important 5. Effectiveness of exercise is independent of radiographic severity

40 Evidence for Exercise is Strong

41 Let’s back up the truck…
Where is all this OA coming from? Possibility of undiagnosed and untreated underlying movement dysfunctions, FAI, or hip labral tears?

42 FAI Abnormal abutment between the acetabulum and femoral head causing progressive cartilage erosion: “Cam” – femoral head “Pincer” – acetabular Cam lesions: younger male patients predominantly at the lateral and anterior aspects of the femoral neck Older female patients cam lesion is seen more commonly at the anterior aspect of the head–neck junction.

43 Clinical Findings with FAI
Flexion and IR painful that is intermittent with repeated hip activities May c/o: Clicking Snapping Popping Radiographic findings of the bony anomaly Macfarlane RJ, Haddad FS. The diagnosis and management of femoro-acetabular impingement. Ann R Coll Surg Engl 2010; 92:363–367.

44 FAI Precursor for labral tears (responsible for large proportion) and hip OA Predisposers for FAI: Genetic morphological anatomy Slipped femoral epiphysis Legg-Calve-Perthes Hip dysplasias Malunited fractures Macfarlane RJ, Haddad FS. The diagnosis and management of femoro-acetabular impingement. Ann R Coll Surg Engl 2010; 92:363–367.

45 Surgical Intervention for FAI
Early recognition with possible surgical repair to avoid the degenerative changes in the hip and labral damage Philippon et al in a prospective analysis of 112 patients undergoing primary hip arthroscopy for symptomatic FAI, demonstrated a significant improvement in pre-operative Harris hip scores (HHS) from a mean of 58 to a postoperative mean of 84, at a mean follow-up of 2.3 years. Macfarlane RJ, Haddad FS. The diagnosis and management of femoro-acetabular impingement. Ann R Coll Surg Engl 2010; 92:363–367.

46 Labral Tears Labral Function: Etiology of Labral Tears: Stability
Shock absorption Pressure distribution (increases the surface area by 28%) and lubrication Etiology of Labral Tears: Trauma femoroacetabular impingement (FAI) capsular laxity/hip hypermobility Dysplasia Degeneration contact stress may increase by as much 92% when the labrum is not there Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med 2009; 2:105–117 [13, 30]. Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med 2009; 2:105–117 [13, 30].

47 Labral Tears Clinical Presentation: anterior hip or groin pain
frequently with mechanical symptoms: Clicking Locking Giving way Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med 2009; 2:105–117 [13, 30].

48 Diagnosis of Labral Tears
Frequently undiagnosed for an extended period of time… Initially will perform plain radiographs to assess for dysplasia, degeneration, and other causes of pain. Magnetic resonance arthrography (MRA) is the diagnostic test of choice, with arthroscopy being the gold standard. Magnetic resonance imaging (MRI) and computed tomography scans are unreliable for diagnosis. Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med 2009; 2:105–117 [13, 30].

49 Soft Tissue Injuries Trochanteric bursitis:
Bursa becomes irritated and inflamed due to excessive compression and repeated friction as ITB snaps over bursa Psoas bursitis: Pain in groin or anterior thigh, maybe into patellar area Aggravated with activities requiring excessive hip flexion Ischiogluteal bursitis: (Tailor’s/Weaver’s Bottom) ischial tuberosities especially when sitting

50 Gluteus medius Piriformis Superior Gemellus Obturator internus Inferior Gemellus Quadratus femoris

51 JOINT MOBILIZATION

52 Distraction of the Hip Hip in resting position
Distract by leaning away from pt and gliding femoral head in lateral, inferior and posterior direction.

53 Long Axis Distraction

54 Anterior Capsule Mobilization
Stabilization pad under superopost. iliac crest. Therapist on opposite side of table. Hand over hand on trochanter, elbows extended. Pushing down on greater trochanter

55 Posterior Capsule Mobilization
Pt prone, pillow under ASIS, foot and ankle off end of table. From opposite side of table, hand over hand on greater trochanter, elbows extended. Push down on posterolateral aspect of trochanter.

56 Posterior Capsule Mobilization
Therapist stands at opposite side of table. Proximal hand is hooked under posterolateral iliac crest. Distal hand on knee. Push down on knee to glide head of femur posterior.

57 Inferior Glide Mobilize by leaning back, creating a distal glide of the head of the femur. Increases flexion, internal rotation