True or False

If the hip is injured, the lesion will usually be immediately perceptible during gait.

True

What other areas need to be examine when the hip has been implicated?

Lumbar spine

SI joint

Knee

Where does the hip refer pain to?

Lumbar Spine

SI joint

Knee

Ankle

Groin

List 3 signs/symptoms of a femoral nerve injury

1. Loss of sensation medial aspect of thigh and leg
2. Loss of quadriceps deep tendon reflex
3. Weakness of hip flexors and knee extensors

Groin pain that increases during Valsalva that

is not relieved with rest is characteristic of

what nerve injury?

Obturator Nerve

Injury to the obturator nerve will result

in weakness where?

ADductors

Knee flexion (gracilis)

ER (obturator externus)

Rate of neural regeneration

~1" per month

What gait may patients present with if obturator nerve is injured?

Waddle

(due to pain and weak adductors)

Piriformis Syndrome

Entrapment of Sciatic Nerve by the Piriformis

High Step Gait

Cause?

Possibly a result Sciatic nerve injury

(hamstrings and all muscles below will be affected)

Patient Reports:

Burning pain in the sacral/gluteal region

Sensory alteration down the post. thigh and leg

Possible Cause?

Sciatic Nerve Injury

Is Piriformis Syndrome more common in men or women?

Women

Typical complaint with Piriformis Syndrome

Pain in the buttocks  and into the lateral calf and foot

Treatment for Piriformis Syndrome

Gentle Stretches

Ice massage

Trigger Point Release

Neural tensioning addressed

Spray and stretch

Strain-counterstain

Trochanteric Bursitis

• Pt c/o deep aching pain in lateral hip, thigh, or groin
• Pain usually made worse w/ stair climbing and sidelying on involved side
• Palpation typically reproduces pain
• Area usually warm to touch

Typical gait with Trochanteric Bursitis

Shortened WB stage or an

ABducted leg to reduce pain

Who is it common to see trochanteric bursitis in?

Runners who run on the same side of the road causing one leg to repetitively adduct

*overuse injury common in runners, bikers, and cross-country skiers

Trochanteric Bursitis Treatment

• Modalities: ultrasound/phonopheresis/ionto
• ice
• NSAIDS
• ITB/TFL stretching
• Biomechanical faults addressed
• slow integration of PRE

Snapping Hip Syndrome

External Snapping

• Caused by tight ITB or Gluteus Max riding over greater trochanter
• Snap or pop felt laterally
• occurs during hip flex/ext and may be worse if trochanteric bursa is inflamed

Snapping Hip Syndrome

Internal Snapping

Cause?

Iliopsoas tend snapping over ridge of lesser trochanter

OR

Iliofemoral ligament snapping over femoral head

OR

Stenosising tenosynovitis of iliopsoas insertion

Snapping Hip Syndrome

Internal Snapping

When does snap/click occur?

when hip is extended from a flexed position, adducted and externally rotated

Snapping Hip Syndrome

Intra-articular snapping

• Caused by labral tear or loose body which may lead to degeneration
• Worst with pivoting motions resulting in sharp groin/ant. thigh pain
• passively, clicking may be felt when extended hip is adducted and externally rotated

Snapping Hip Syndrome

Interventions/treatment during acute phase

Standard anti-inflammatory care

eliminate exacerbating activities

modalities may be used

External Snapping Hip Treatment

Conservative Management

-Rest

-NSAIDS

-Static/dynamic functional assessment

treatment (ITB stretching)

*If conservative Tx fails, surgery may be appropritae

Internal Snapping Hip Treatment

Conservative management

*If that doesn't work, surgery good option

Intra-Articular Treatment

Somewhat controversial

-Conservative management including non-WB appears to completely resolve patients symptoms;

*NWB technique shows no signs of healing even though symptoms are relieved

-Arthroscopic debridement (good short-term outcomes)

What is Femoraacetabular Impingement (FAI)?

Premature or improper collision of femoral head and acetabulum.

Causes decreased hip ROM and pain

CAM FAI

result of excess bone that has formed around head and/or neck of femur

often occurs in pts with post-traumatic deformities, SCFE, coxa vara, and AVN

Males who are heavy day laborers

Risk factors for FAI

• Athletic activities, medical/family/social hx
• Hx of trauma
• Use of glucocorticoids
• Previous surgery

FAI treatment

Conservative

• rest, activity modifications, NSAIDS
• Mobilizations, strengthening and stretching
• Gait mechanics, orthotics, improve core stability
• Lifestyle modifications
• Injection of anesthtetic
• Surgery

Structural Risk Factors for

Developing Labral Tears

Retroversion

FAI

Hip Dysplasia (leads to decreased joint SA)

In US, most common location of labral tears

Anterior

*Ant. region undergoes higher forces than other areas

PT for labral Repair

Month 1: tissue healing phase (RICE)

Month 2: early functional recovery (full AROM)

Month 3: late functional recovery (strength, balance)

Clearest indication for hip arthroscopy

Loose Body

Three phases of Hip Arthroscopic Rehab

1. tissue healing, reduce inflammation, avoid muscle atrophy, PROM
2. early strengthening and WB activities
3. full strength, endruance, ROM

Avascular Necrosis

Occurs when the blood flow to the femoral head is interrupted

the affected part of the bone begins to die

Causes of AVN

Hip Fx, dislocation

diabetes

sickle cell disease

gout

prolonge/high doses of steroids

arthritis

AVN Treatment

Rest and protected WB

Gentle exercise may help

Surgery (THA) is usually required

Legg-Calve-Perthes

Self-limiting pediatric disorder

idiopathic

usually occurs in boys 4-10

insidious onset of limp with c/o of hip/knee pain

Slipped Capital Femoral Epiphysis

(SCFE)

Adolescent hip disorder characterized by displacement of femoral head on neck

usually kids 11-13

pt often overweight

pt either late pre-puberty or early puberty

SCFE

Direction of slippage?

Always posterior

Often medial

Chronic SCFE

Occurs over several months

Acute SCFE

Sudden femoral head displacement

Chronic SCFE Presentation

Painful limp for several months

aching in thigh

change in hip ROM: loss of abd and IR

Acute SCFE Presentation

Severe pain and limping

Guarded and restricted hip ROM

Often limited WB

SCFE Treatment

Prompt surgical repair

Predisposing factors for Hip DJD/OA

SCFE

Increased femoral anteversion

Leg length disparity

Long standing obesity

previous knee trauma/surgery

Rheumatoid Arthritis

Acetabular Dysplasia (shallow socket)

Hip DJD/OA

Capsular tightness

*accelerates progression of dz through bringing joint continually close-packed position during normal functional activities like walking

Hip DJD/OA

Management in Early Stages

Stretching: hip flexors, adductors, ITB, hamstrings, gastroc

Strengthening: closed chain, SLR all planes, walking, balance, aquatics

Determine underlying factors: obesity, leg length discrepancy, etc.

Hemiarthroplasty

Replacement of only one side of a diarthrodial joint

often used for displaced fractures of femoral neck

Total Hip Arthroplasty

replacement of acetabulum and femoral neck and head

Common Indication for THA

Pain: with movement and at rest

functional limitations: capsular restriction/joint deformity cause decrease ROM

Loss of mobility: stiffness

Intra-articular disease: considered w/ above symptoms

Contraindications for THA

Active infection

Inadequate bone stock

Youth

Obesity

High impact recreational activities

Arterial insufficiency

Neuromuscular disease

Mental Illness

Benefits of Minimally Invasice

Surgical approach to THA

longer life of prosthesis

faster and less painful rehab

quicker return to work and daily activities

Reduced possibility of DVT or clots

Anteriolateral THA outcomes

allows for more ROM post-surgery

lower dislocation rates

greater blood loss and longer operation time

increased likelihood of antalgic gait post-rehab

Posteriolateral THA outcomes

Preserves glut. medius and minimus and vastus lateralis

Quicker normalization of gait

Higher dislocation rate post-surgery

Types of Hip Fixations

Posterior Lateral THA

Precautions

• No combination of hip flex, IR, adduction
• No hip flexion > 90 degrees
• No hip IR

Anterior Lateral THA Precautions

• No hip ext beyond neutral
• No bridging
• No prone lying
• No combined motions of ext and ER

Minimally Invasive THA precautions

• No combination of motions of flex, IR, and adduction
• No hip flex > 90 degrees
• No hip IR