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Differential Diagnosis Of The Hip2010


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Differential Diagnosis of a painful hip.

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 /><br /><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.<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 />