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Differential Diagnosis Of The Hip2010


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Differential Diagnosis of a painful hip.

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 > 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
  • Transcript

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