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# Differential Diagnosis Of The Hip2010

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Differential Diagnosis of a painful hip.

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• Systematic Review – cochraneCritically appraised individual articles – PEDro – physical therapy evidence database. Journal Articles
• Research – read your journals. CE courses – Clinical Expertise – clinical skill and formulated education
• These statistics are used to describe the effectiveness of special tests in identifying specific disorders. Knowing the diagnostic accuracy of special tests is important to obtain an accurate diagnosis and maximizing treatment outcomes.Sensitivity – Most useful in ruling out a disorderFor Example the Neers Test has a sensitivity rating of 0.93 for detecting subacromial impingement. So, if the test is negative…For Example the Hawkins Kennedy Test has a specificity of 100%, a positive test results = impingementSensitivity – measures the proportion of actual positives which are correctly identified. When a highly sensitive test is negative, you can feel more assured that the patient does not have it. If it is positive you can’t be assured that they have the condition unless the test is highly specific as well.Secificity – measures the proportion of negatives which are correctly identified. When the test is positive, ccan feel better about ruling in the condition. If the test is negative, can’t be assured that they do not have the condition unless the test is sensitive.
• Index measurement that combines the sensitivity and specificity values of a specific test. The LR can be used to gauge the performance of the test. Positive LR (+LR) the proportion of people who test positive and actually have the disorder.
• LR are used for assessing the value of performing a diagnostic test. They use the sensitivity and specificity of the test to determine whether a test result usefully changes the probability that a condition exists.
• A LR of greater than 1 indicates the test result is associated with the disease. A LR of less than 1 indicates that the result is associated with absence of the disease. Ratios close to one are of little help.
• If I know that a FABER test for the hip has an .88 sensitivity for internal hip pathology ( remember it is a screening test, not highly diagnostic ) and it is negative. SnNout – I can feel confident that the pain generator that I am looking for is extra capsular.
• Hochberg #20
• A cane decreases the adductor moment at the right hip. It is painful with an OA hip, so body develops a trendelenburg gait.
• No studies documenting any adverse effects except soreness.
• In evaluation can do a quick 1 leg stand to assess strength for a quick screen.
• The glut medius is weak because of the arthritic joint. Hip flexion is inhibited because of a painful joint – it causes compression. When we walk, the hip adducts, IR and with O-A can’t do that without pain.
• Once I have made my diagnosis from the history, I will select special tests to r/i and r/o diagnosis
• Cluster is for ruling out hip OA. SnNout 86% Hip IR is most specific finding for hip OA. Restriction of any single hip motion correlates to mild/moderate hip O-A
• Gymnastics, cheerleading, golf, jumping and landing on one leg.
• X-ray will show joint space narrowing, osteophytes.
• 3/5 of those = 68%, to 4/5 to = 91%
• Pain with hip IR and Flexion Morning stiffnessIf (+) x-ray with above criteria, Sensitivity – ruling out O-A - very good for ruling out.Mild to moderate O-A LR+ 3.6 limited hip IR, FABER Sn 88% ruling out intra-articular pathologyThe reason the Child’s created a PT CPR is that the orginal one did not use any special tests that are commonly used in the clinic.
• Impingement tests are positive for patients with O-AGait – secondary to weak Glut Med. b/c muscle weakness develops around an arthritic jointWhat muscles would you expect to be weak? Flexors, abductors
• Goal of the Gaenslen is to apply torsion to the joint.
• X-ray will detect in about 3-4 weeks. Bone scan most sensitive
• Martin et al July 2006
• Associated Factors: ipsilateral knee and or hip OA, Female and LBP. These people had normal hip IRSingle leg stance &gt; 30 secondsExternal derotation test – supine with resisted ERIf not weak at Glut Medius – not likely that they have bursitisClinical Diagnosis: TTP, lateral hip pain (+) FABERTrendeleberg Sign – most accurate to predict tendon tear. No warmth, erythema or swelling.
• Bird et al. MRI findings 45% of patients had glut medius tears and 55% had glut medius tendonitis, 1% had bursal distention.If a tendonopathy – how would you treat. With the two patients with bursal distention – also had glut med. Tendonopathy. Bursitis may be secondary to tears. Recently with THA, dissecting bursa and no inflammation found.
• Martin JOSPT 2006
• Posterior labral tears are found in the Asian populations and are associated with hyperflexion or squatting.Older than 60 – universally have labral tearsEitology – Statistically significant correlation was found with the grade of labral tear and cartilage abnormality and bone marrow edema. Due to FAI, capsular laxity and cartilage degeneration.
• JOSPT July 2006
• ### Differential Diagnosis Of The Hip2010

1. 1. Differential Diagnosis:Clinical Practice Guidelines<br />Evidence-based diagnosis, prognosisand intervention.<br />
2. 2. Physical Therapy Central<br />
3. 3. Bridgit A. Finley<br />www.ptcentral.org<br />bfinley@ptcentral.org<br />Facebook: Physical Therapy Central<br />Choctaw Chickasha Newcastle Norman <br />OKC Pauls Valley Stillwater<br />
4. 4. Objectives<br />Be able to perform an algorithm based examination.<br />Implement Evidence Based Medicine.<br />Be able to treat patients with hip dysfunctions with manual therapy techniques.<br />Be able to utilize outcome measures.<br />
5. 5. Course Schedule<br />EBP<br />Resources<br />Anatomy<br />Biomechanics<br />Differential Diagnosis<br />Lecture<br />Lab<br />Manual Therapy<br />Therapeutic Exercises<br />Outcome Measures<br />
6. 6. Philosophy of Care<br />Comprehensive Exam<br />Subjective<br />Biomechanics<br />Feet, knees, pelvis and lumbar spine<br />Hands on<br />MFR, Manual Techniques <br />One on One Exercise<br />Specific<br />
7. 7. Vision 2020 The first, best choice in musculoskeletal care.<br />Resources<br />APTA<br />JOSPT<br />Physiopedia<br />Evidence in Motion<br />AAOMPT<br />PEDro<br />Life Long Learners<br />Autonomous <br />Experts<br />Take our game to the next level<br />Specialty Certifications<br />Manual Therapy Certifications<br />DPT<br />
8. 8. Evidence Based Practice<br />Integration of the best research evidence with clinical expertise and patient values.<br />Which will ultimately lead to improved patient outcomes.<br />Levels of Evidence<br />Systematic Reviews<br />Case Series<br />Expert Opinion<br />
9. 9. www.clinicallyrelevant.com<br />Iphone app<br />Orthopedic Clinical Tests<br />250 Tests<br />Purpose<br />Video<br />
10. 10. Sensitivity and Specificity<br />Sensitivity<br />Ability to be positive when a variable is present.<br />0 – 1.0 <br />Good screening exam<br />Sn=High Sensitivity to Rule Out<br />SnNout – sensitive test=negative=rule out<br />Specificity<br />Ability to be negative when a variable is absent<br />Very specific to confirm the diagnosis<br />Spin=High Specificity to rule in a diagnosis<br />SpPin – specificity = positive= ruling in<br />
11. 11. Likelihood Rations<br />The likelihood that a test result would be expected in a patient with the target disorder compared with the likelihood of the results with a patient without the disorder<br />Good Measure of the clinical utility of a test<br />Tells you how much a test result changes the pre-test probability of being correct<br />
12. 12. Likelihood Rations<br />+LR<br />The proportion of people who test positive and have the disorder.<br />= Sensitivity / (1-Specificity)<br />-LR<br />The proportion of people who test negative and who do not actually have the disorder.<br />= (1-Sensitivity)/ Specificity<br />
13. 13. +LR -LR<br /> > 10.0  < 0.1 Generate large and often conclusive shifts in probability  <br />5.0 - 10.0  0.1 - 0.2 Generate moderate shifts in probability  <br />2.0 - 5.0  0.2 - 0.5 Generate small, but sometimes important shifts in probability  <br />1.0 -2.0  0.5 - 1.0 Alter probability to a small and rarely important degree <br />
14. 14. Wikipedia<br />Sensitivity and Specificity<br />
15. 15. So what ?<br />
16. 16. Prevalence<br />O-A hip pain is the most common cause of hip pain in older adults.<br /><ul><li>10-27% of the population > 50 years old.
17. 17. No cure but effective non-surgical treatment include: weight loss, manual therapy and exercise.</li></li></ul><li>Function of the hip<br />Support the weight of the trunk<br />Ambulation<br />Transmission of forces between the pelvis and lower extremities<br />If the hip is arthritic, will stress the lumbar spine and opposite leg.<br />
18. 18. Hip Joint<br />Walking – hip supports 240% to 355% times the body weight<br />Running – 550% times the body weight.<br />Good foot wear is important.<br />
19. 19. Cane Aided Gait<br />Cane allows increased BOS, and decreased hip abductor force.<br />Hip can stay more abduction during gait.<br />Decreased acetabular contact pressure by 30-40 %<br />Gluteus medius EMG activity is reduced by 45% during mid and terminal stance.<br />
20. 20. Cane Aided Gait<br />Pushing into the cane – lifts the left side of the pelvis.<br />Lecture notes Dave Thompson, PT<br />
21. 21. Anatomy <br />
22. 22. Hip Joint<br />Hip is a ball and socket synovial joint and is the largest weight bearing joint in the body.<br />Unlike the shoulder, the hip has a tight fit and sacrifices movement for stability. <br />
23. 23. Acetabulum<br />Angled lateral, inferiorly and anteriorly<br />Normal is 10-15 degrees anterversion<br />Labrum deepens the joint<br />Covered with hyaline cartilage<br />
24. 24. Femur<br />Strongest & longest bone of the body<br />2/3 of head covered with cartilage<br />Fovea capitis supplies blood<br />Head Off-set<br />
25. 25. Ligaments<br />& Hip Capsule<br />
26. 26. Hip Capsule<br />From acetabular rim to the base of femoral neck<br />Thicker anterior & superiorly<br />Joint supported by ligaments & muscles<br />Capsule changes with O-A<br />
27. 27. Labrum<br />Labrum contains free nerve endings and sensory end organs<br />Responsible for nociceptive and proprioceptive mechanism<br />Provide negative intra-articular pressure<br />Deepens the socket (21%)<br />
28. 28. Labrum<br />Tear in labrum = destabilizes joint<br />Premature arthritis<br />Reduce contact stress by increased contact area<br />
29. 29. Synovial Membrane<br />Contains highly vascularized synovium<br />Can get pinched and inflammed<br />Hip impingement from neck of femur hitting acetabulam.<br />
30. 30. Hip Capsule<br />Ligaments are weakest posteriorly<br />Ligaments are taut in hip extension -CCP<br />Ligaments are relaxed in hip flexion (mobilize)<br />
31. 31. Muscles<br />
32. 32.
33. 33. Rectus Femoris<br />Attaches to anterior hip capsule<br />Injury can cause capsular adhesions<br />Limit hip extension<br />Hip Impingment – painful with stretch<br />
34. 34. Anterior Hip Capsule<br />Rectus femoris and quads can attach to the anterior hip capsule<br />Muscle blend with hip capsule<br />Job is to tighten capsule with contraction<br />
35. 35. Gluteus Medius<br />Gluteus Medius – main hip abductor<br />Primary stabilizer of hip and pelvis<br />Trendelenburg sign vsgait<br />Muscle weakness around O-A joint<br />
36. 36. Gluteus Maximus<br />TFL envelops the muscles of the thigh<br />Counteracts the backward pull of the gluteus maximums of the ITB.<br />Hip extensors are 3 times as strong as the flexors<br />
37. 37. Psoas<br />Iliopsoas bursa – present in 98% of adults.<br />Lies under the psoas tendon<br />Overuse and impingement syndromes<br />
38. 38. SLR Exercises<br />Must have excellent core strength<br />This is a core exercise, not psoas<br />
39. 39. Hip External Rotators<br />Hip capsule is cut and the ER are retracted so that the joint can be exposed.<br />Hip Scope – no muscles cut and hip capsule intact.<br />
40. 40. Adductors<br />Tight adductors will create a functional short leg.<br />Increase stress on the hip joint.<br />Inhibit glut medius.<br />
41. 41. Biomechanics<br />
42. 42. Ball and Socket Joint<br />Flexion to 130-140<br />Extension 10-15<br />Abduction 30-50<br />Adduction 25-30<br />ER 30-45<br />IR 20-35<br />Rolls anterior glides posterior<br />Rolls posterior glides anterior<br />Rolls laterally<br />Rolls medially<br />Spins anteriorly and laterally<br />Spins posteriorly and medially<br />
43. 43. Mobilization<br />Flexion<br />Extension<br />Adduction<br />Internal Rotation<br />Posterior / Inferior Glide<br />Anterior Glide<br />Lateral Glide<br />Lateral Glide<br />
44. 44. Inclination Angle<br />Angle between femoral shaft and neck is called “inclination angle”<br />Important influences on the hip because it changes the angle of pull of the muscles<br />
45. 45. Inclination Angle<br />CoxaVara <100<br />Usually congential<br />Causes a short leg<br />Positive trendelenburg sign<br />Genuvalgum<br />Compensatory lumbar pathology<br />
46. 46. Inclination Angle<br />Noraml 125<br />Coxa Valga >125<br />Causes a long leg<br />Positive trendelengurg sign<br />Stress on ITB and bursa<br />Genu vara<br />Compensatory lumbar pathology<br />
47. 47. Coxa Valga<br />Changes joint reaction forces to almost parallel.<br />Reduces the WB surface.<br />Shortens the moment arm of the hip abductors.<br />Increases length of LE. <br />Increases mechanical stress on medial knee<br />Hip Dysplasia<br />
48. 48. Femoral Anteversion<br />Normal is 10-15 degrees<br />Have more hip IR<br />Femoral head more anterior in capsule<br />May lead to labral tears, impingement and OA<br />
49. 49. Cyriax<br />Capsular pattern – specific and proportional loss of movement<br />Most common cause of capsular pattern is arthritis<br />
50. 50. Capsular Pattern<br />Cyriax<br />IR<br />Flexion<br />Abduction<br />If capsular pattern of restriction; joint is arthritic.<br />If non capsular pattern; not joint.<br />Cyriax listed in ascending order<br />Loss of internal rotation<br />More than flexion<br />More than abduction<br />
51. 51. Noncapsular Restrictions<br />Fractures<br />Osteomiylitis<br />Labral tears<br />Cancer<br />Bursitis<br />Capsular Irritation<br />Synovitis<br />Impingement<br />
52. 52. Resting Closed Packed<br />Flexion 30 degrees<br />Abduction 30 degrees<br />External Rotation 10-15 degrees<br />Extension<br />Adduction<br />Internal Rotation<br />Stable position of the joint<br />Tighten capsule<br />
53. 53. Manual Therapy<br />Mobilization/manipulation<br />Manual stretching<br />Traction<br />Mobilization (posterior/lateral)<br />5 Weeks<br />81% had positive outcomes<br />More effective than exercise alone<br />Improvement Hip Harris Score<br />
54. 54. Biomechanical Forces<br />Femoral Anteversion<br />Pronation<br />Tibial Internal Rotation<br />Improper Hip Alignment<br />Pelvis <br />Lumbar – will lose ipsilateral rotation (left hip, left rotation)<br />
55. 55. Hip Dysplasia<br />Displacement of femoral head in acetabulum<br />Left hip is more often involved<br />80 % Females<br />Breech birth<br />First born<br />
56. 56. Hip Dysplasia<br />Less degress of femoral head coverage<br />Decreased joint surface area<br />Normal 30-40%<br />Angle of inclination >125 degrees<br />Increased femoral anterversion<br />Acetabular retroversion<br />McCarthy & Lee found 72% of patients with dysplasia had labral tears<br />
57. 57. Dysplastic Hip<br />Head off-set is between femoral head and shaft<br />Off-set is decreases<br />Femoral neck is short and thick<br />
58. 58. X-Ray<br />Demonstrate loss of joint space, osteophytes and sclerosis.<br />Dysplasia<br />tears are more common in individuals with acetabular dysplasia.<br />
59. 59. Glut Medius controls Adductor Moment<br />Hip Abductor function in closed chain is to maintain a level pelvis.<br />
60. 60. Trendelenburg Gait<br />Have patient stand on one leg and assess if the pelvis drops.<br />(+) Trendelenburg Sign<br />
61. 61. Evaluation<br />of the <br />Hip<br />
62. 62. Diagnosis<br />Bony<br />Osteoarthritis<br />Capsule/ Ligaments<br />Labral tear or Impingement<br />Muscle / Tendon<br />“itis”<br />Muscle tear<br />
63. 63. Subjective History<br />Possibly the single most important part of the examination<br />establishes your interest in the patient<br />establishes the relationship <br />uncovers information not available from the objective examinations<br />estimated to make up about 70% of the diagnosis<br />
64. 64. Summary<br />be focused on the patient’s problems<br />maintain control of the interview<br />be systematic in your interview method<br />follow up answers but do not get side tracked<br />take as long as you need<br />be professional<br />be analytical<br />
65. 65. Causes of hip pain in adults<br />Osteoarthritis<br />Other arthritides:<br />RA<br />Psoriatic<br />AnkylosingSpondylitis<br />Hip Fracture<br />Paget’s disease<br />Avascular necrosis<br />Referred pain<br />Malignancy<br />Infection<br />Painful soft tissue<br />Trochanteric bursitis<br />Snapping hip; ilio-psoas tendon<br />Torn acetabular labrum<br />Muscle strain<br />
66. 66. Differential Diagnosis<br />From the history, form a working diagnosis<br />Use cluster’s test to rule in and rule out<br />
67. 67. Osteoarthritis<br />Most common cause of hip pain<br />Usually >50 yo, but can occur at any age.<br />Will have capsular pattern of restriction<br />X-ray<br />
68. 68. Subjective History<br />DJD (>50 yo)<br />Usually no specific mechanism of injury<br />Groin pain; behind greater trochanter, anterior thigh to knee<br />Stiffness in the morning (1 hour)<br />Capsular pattern for loss of ROM<br />Increased pain with WB (limp)<br />
69. 69. Functional Limitations<br />Walking<br />Stair climibing<br />Putting on shoes<br />Shaving legs/foot care<br />
70. 70. Osteoarthritis – Physiopedia Eric Wilson<br />Diagnostic Cluster <br />Hip Pain<br />IR >15 Degrees<br />Pain with IR<br />Morning stiffness < 60 minutes<br />Ages 50 or older<br />Diagnostic Cluster<br />Hip IR < 15 degrees<br />Hip Flexion < 115 degrees<br />Stiffness < 60 minutes<br />Pain in the hip<br />
71. 71. Risk Factors<br />Age<br />Developmental Disorders<br />Dysplasa<br />Previous hip injuries<br />Trauma<br />Labral Tears<br />
72. 72. Diagnosis Hip O-A<br />Made with certainty on the basis of history and physical exam.<br />X-ray is definitive <br />CPR – Child’s et al.<br />Hip Guidelines – Cibukla<br />Physiopedia<br />
73. 73. Differential Diagnoses<br />Lumbar Referred Pain<br />Stress Fracture<br />Bursitis<br />Labral Tear<br />
74. 74. CPR for Hip Osteoarthritis<br />Self report squatting as an aggravating factor.<br />Scour test with adduction causing groin/lateral pain.<br />Active hip flexion causing groin/lateral hip pain.<br />Active hip extension (walking) causing groin/lateral pain.<br />Passive hip IR < 15 degrees<br />
75. 75. American College of Rheumatology<br />Hip O-A if had hip pain plus<br />Hip IR < 15 degrees - painful<br />Hip Flexion < 115 degrees<br />> 50 yo<br />Morning Stiffness < 60 minutes<br />Sensitivity 86%<br />Specificity 75% <br />LR + 3.44<br />LR – 0.19<br />
76. 76. Special Tests<br />Trendelenburg Gait<br />MMT<br />FABER’s Test<br />Scour Test<br />Empty and painful end-feel<br />Spasm with early stage O-A<br />
77. 77. Lumbar Spine<br />May have radicular pain into the buttock, groin and/or thigh<br />Spine AROM/PROM will produce the referred pain.<br />Must reproduce the pain with the examination<br />
78. 78. SI Joint<br />Pain provocation test<br />Thigh thrust<br />Gaenslen’s<br />video<br />Sacral thrust<br />
79. 79. Hip Fracture<br />Elderly osteoporotic women<br />Fall followed by inability to WB<br />Non-displaced fx, can WB but have increasing pain<br />May need surgical stabilization<br />Overuse<br />Female<br />Groin/thigh pain<br />Occur 2 weeks after initiation in activity<br />Amenorrhea<br />
80. 80. Femoral Neck Stress Fracture<br />Pain with extreme ROM<br />Pain with WB<br />Positive Hop Test – 70% accurate<br />Positive FABER/scour<br />Positive Fulcrum<br />
81. 81. Iliopsoas Bursitis<br />Present in hip flexion : ER & IR for relief<br />Pain with passive hip extension<br />Pain with resisted hip flexion<br />Bursa tender to palpation<br />(+) Snapping Hip & Supine Heel Raise<br />< 30 yo<br />
82. 82. Greater Trochanteric Bursitis<br />Pain<br />Lateral thigh/gluteal area<br />Pseudoradiculopathy<br />Aggravating<br />Lying on affected side<br />Prolonged stand/walk<br />Stair<br />
83. 83. Greater Trochanter Pain Syndrome<br />No warmth, redness or swelling<br />Silva et al, Bird et al.<br />Concur that a bursitis is not the common cause of lateral hip pain.<br />Glut Medius insertion tendonopathy<br />Highest incidence is fourth – six decade of life.<br />
84. 84. GT Bursitis<br />
85. 85. Anatomy<br />
86. 86. Muscle Strain<br />PROM will be pain free<br />May have pain with stretch<br />Painful AROM – when specific muscle is used<br />Most common is Glut Medius<br />Non capsular pattern of loss ROM<br />
87. 87. Malignancy<br />Mets to the pelvis or proximal femur will produce hip pain. <br />Primary bone tumor are very rare.<br />Hx of CA<br />
88. 88. Labral Tear<br />75% of tears are not associated with any injury or cause.<br />Insidious on-set that increases in intensity<br />Age range 20-40<br />Female<br />Anterior hip pain<br />Usually normal x-ray<br />
89. 89. Subjective History<br />Common complaint of pain, clicking, locking, catching, instability, giving way.<br />Anterior groin pain 96-100% of cases<br />Locking 58% of cases<br />Predisposing factor: CoxaValga 87%<br />MOI – hip ER + extension<br />
90. 90. Labrum<br />Inner 2/3 is avascular, only outer 1/3 potential to heal.<br />Labrum is innervated, potential for pain generator.<br />Tears can be degenerative, dysplastic, traumatic and idiopathic.<br />Most labral tears are anterior-superior.<br />
91. 91. Differential Diagnosis<br />Hip Impingement<br />20-40 yo<br />Female<br />Caused by muscle imbalances/biomechanics<br />Tight posterior hip capsule<br />Postural adaptations<br />Pinching of anterior structures<br />Femoral neck against acetabular rim.<br />
92. 92. Examination<br />
93. 93. Differential Diagnosis<br />One of the most common referral patterns to the hip and thigh is lumbar spine <br />Hip pain can refer to knee and below<br />Must clear the SI joint and Lumbar spine<br />
94. 94. Standing Exam<br />Gait<br />Lumbar AROM<br />Posture<br />Atrophy<br />Weight bearing<br />Leg Length<br />Laxity Test<br />Balance<br />Step Ups<br />Single Leg Stand<br />Gluteus medius strength<br />
95. 95. Gait<br />Hip extension<br />15-20 degrees<br />Pelvic<br />Rotation<br />Side bending<br />Observe as walk into clinic<br />Pain with WB – think articular<br />
96. 96. Lumbar AROM<br />Flexion<br />Extension<br />SB<br />Does the movement reproduce “their” pain<br />
97. 97. Posture<br />Atrophy & WB<br />Leg Length <br />Laxity<br />
98. 98. Step up Balance<br />Trendelenburg’s Sign<br />Gluteus Medius Tear<br />
99. 99. Sitting Examination<br />Sit to stand<br />Muscle<br />Reflex<br />Sensory<br />ROM – hip ER/IR<br /> Quick cursory screen<br />
100. 100. Sit to Stand<br />Loss of flexion, adduction and internal rotation<br />Compensate by loading non-painful leg<br />
101. 101. Muscle Test<br />Hip<br />Flexion<br />ER<br />IR<br />Hamstrings<br />Quads<br />Normal except for Flexion<br />
102. 102. Neurological<br />Sensation<br />Reflexes<br />Should all be normal<br />If not, evaluate lumbar spine<br />Disc<br />Nerve root compression<br />Stenosis<br />
103. 103. ROM<br />Loss of hip IR first sign of internal hip pathology:<br />arthritis,<br />effusion, <br />labral pathology<br />impingement <br />
104. 104. Fulcrum Test<br />(+) if reproduce pain at femoral shaft<br />Testing for stress fractures along femoral shaft<br />
105. 105. Supine Examination<br />Hip ROM – active & passive<br />Sign of the Buttock<br />FABER Test<br />Thomas test<br />McCarthy (Labral) test <br />Active SLR<br />Scour test<br />Trochanteric /PsoasBursitis<br />SI – thigh thrust<br />
106. 106. Hip ROM<br />Watch for compensation at the pelvis.<br />AROM<br />PROM<br />Capsular pattern?<br />End-feel?<br />Pain?<br />
107. 107. ROM<br />
108. 108. Sign of the Buttock<br />Screening Test<br />Identify serious pathology<br />Limited and painful SLR<br />Limited and painful hip and knee flexion <br />Non-capsular pattern of restriction<br />(osteomyelitis, neoplasm or fracture)<br />Screening tests do not identify the exact pathology present<br />Read journal article<br />
109. 109. Sign of the Buttock<br />Limited and painful SLR<br />Limited and painful hip and knee flexion <br />Non-capsular pattern of restriction<br />Strong reproduction of pain with PROM<br />
110. 110. FABER<br />Screening test for hip and SI joint<br />Passively flex, abd., and ER hip<br />Overpressure<br />Pain at groin<br />Pain at SI<br />
111. 111. Thomas Test<br />Positive test<br />Thigh off the table<br />Tight iliopsoas and rectus femoris muscle (knee flexion)<br />
112. 112. Scour Test<br />Move the leg into flexion, abduction-adduction and IR.<br />Compression<br />(+) Hip Pain<br />
113. 113. Log Roll Test<br />Used to assess labral pathology<br />Maximally IR & ER<br />Eliciting a click or popping sensation<br />Also assess capsular laxity<br />
114. 114. McCarthy test<br />Anterior labrum – full flexion, lateral rotation and abduction.<br />Medical rotation, adduction and extension.<br />(+) reproduce pain, popping or catching.<br />
115. 115. Active SLR<br />Patient flexes hip to 30 degrees with knee straight against resistance.<br />(+) reproduce groin pain.<br />(-) if reproduces lumbar spine pain.<br />
116. 116. Impingement test<br />Flex knee 90 degrees – apply flexion, adduction, internal rotation and overpressure.<br />(+) test – pain that is reproduced in the groin<br />Pain with IR = anterior labrum<br />Pain with ER + Abd= posterior labrum<br />
117. 117. Bursa Special Test<br />Will pinch the trachanteric bursa with hip adduction and IR<br />Will pinch the psoas bursa with hip flexion and ER<br />
118. 118. Lateral Hip Examination<br />Ober test<br />Designed to elicit tightness in the ITB and tensor fascia lata.<br />Patient placed side lying with the hip extended and abducted with the knee flexed.<br />Positive test if the leg does not adduct to midline.<br />
119. 119. Psoas Bursitis<br />Iliopsoas Bursitis<br />Subjective History<br />Anterior Hip Pain<br />Worse with hip extension<br />Overuse<br />May complain of snapping<br />Objective Exam<br />Pain with passive hip extension<br />Resisted hip flexion<br />TTP<br />(+) Snapping Hip Maneuver<br />(+) Supine Heel Raise<br />
120. 120. MMT<br />Test strength of <br />Abductors<br />Isolate glut medius<br />Will be weak (inhibited) with arthritic joint<br />
121. 121. Hip Rotation<br />PROM of left hip<br />Loss of IR > loss of hip ER<br />End-feel usually empty and painful for OA hip.<br />
122. 122. Hip Special Tests<br />Martin et al<br />JOSPT July 2006<br />Intra-articular Tests<br />FABER Test<br />Scour Test<br />Resisted SLR<br />Log Roll Test<br />Distraction<br />FAI<br />
123. 123. Hip Arthroscopy<br />Labral tears<br />Chondral lesions<br />90% tears are anterior<br />Occur with twisting motion<br />Lead to early OA <br />Indications<br />Loose bodies<br />Labral tear<br />Chondral flap tears<br />
124. 124. Hip Arthroscopy<br />
125. 125. Complication Rates<br />.05 and 5%<br />Most often related to distraction, procedures > 1 hour<br />Sciatic, femoral, peroneal or pudendalneuropraxia<br />Avascularnecrosis<br />Fracture<br />
126. 126. Candidates<br />Mechanical symptoms – catching, locking, clicking<br />Failed to respond to conservative therapy<br />Extent of articular cartilage has the most direct relationship to surgical outcomes<br />
127. 127. Lower Extremity Function Scale<br />Ordinal Scale 0 “extreme difficulty” to 4 “no difficulty”<br />Patient rate ability to perform 20 different activities<br />0 to 80 scale, 80 no limitations.<br />Minimum detectable change 9 scale points<br />
128. 128. Harris Hip Score<br />Scores on 10 different variables<br />Pain<br />ROM<br />Gait<br />ADLs<br />Score range from 0 “worst” to 100 “best”.<br />Harris Hip Score<br />
129. 129. Non-musculoskeletal Causes<br />Retrocecal Appendicitis<br />Hernia<br />Renal<br />Ureteral<br />Regis University<br />
130. 130. Treatment<br />
131. 131. Rehabilitation Protocol<br />Individualized<br />Modify per patient status<br />Per Physician<br />Age<br />Health Status<br />Control pain and swelling<br />Surgical Procedure<br />Change WB and precautions<br />
132. 132. Rehabilitation Goals<br />Control edema/effusion<br />Muscle Balance<br />Joint Capsule & Motion<br />Biomechanics<br />Balance & Proprioception<br />
133. 133. Patient Goals<br />Normal gait<br />Stairs<br />Squat<br />Put on shoes and sox<br />Shave legs/clip toenails<br />
134. 134. Exercise Therapy<br />Flexibility<br />ROM – improve function<br />Strengthening<br />Normalize gait will decrease impact loads<br />Cardiovascular<br />Endurance 60-80% for 15-30 minutes<br />
135. 135. Muscle Imbalances<br />Tightness<br />Psoas<br />Adductors<br />Quadratus Lumborum<br />TFL<br />Piriformis<br />Release<br />Weakness<br />Glut Maximus<br />Glut Medius<br />Quads<br />Hip ER<br />Core Muslces<br />Abs<br />Errectorspinae<br />
136. 136. FACILITATED MUSCLES<br />Iliopsoas<br />Rectus Femoris<br />TFL<br />QL<br />Hip Adductors<br />Piriformis<br />Hamstring<br />Lumbar Erector Spinae<br />
137. 137. Treatment<br />Modalities<br />MFR/ Massage<br />PROM- watch precautions<br />Balance<br />MET / Mobilization/Manual Stretching<br />Cardiovascular<br />Core Stabilization<br />
138. 138. Manual Therapy<br />MFR<br />ITB<br />Piriformis<br />Psoas<br />Psoas release<br />
139. 139. Hip PROM<br />Watch for compensation at the pelvis.<br />Capsular pattern?<br />End-feel?<br />Pain?<br />
140. 140. MET – manual stretching<br />Soft tissue and capsular tightness<br />Have not moved hip though this motion in years<br />
141. 141. Gait<br />Hip extension<br />15-20 degrees<br />Pelvic<br />Rotation<br />Side bending<br />
142. 142. Muscle Energy Technique<br />Hamstrings<br />Psoas<br />Lumbar Spine<br />
143. 143. Week 4-5<br />(-) Trendelenburg Sign<br />Initiate Hip PRE<br />Neutral alignment lumbar spine<br />Full PROM<br />
144. 144. Treatment<br />Myofascial Release<br />Psoas<br />Posterior Hip Capsule<br />PROM/Jt. Mobilization<br />Core Stabilization<br />Proprioception<br />Balance<br />
145. 145. Mobilization<br />Leg traction – inferior glide<br />Distraction – inferior or caudal glide.<br />Mobilization with movement<br />Belt<br />MET to restore IR/ER or hip flexion<br />
146. 146. Joint Mobilization<br />
147. 147. Proprioception<br />Arthritic hips lose input secondary to loss of articular cartilage.<br />THR – no input from the hip joint. Must retrain neuromuscular system.<br />Balance activities.<br />
148. 148. Therapeutic Exercise<br />Strengthen the glutes<br />Do not strengthen the hip flexors<br />
149. 149. S.E.R.F. Strap<br />Pulls the hip into ER<br />JOSPT September 2008 Vol 38, N 9<br />50% self report decrease pain<br />Decreases hip impingement<br />
150. 150. Questions & Answers<br />
151. 151. Conclusion<br />