1
Q
Pt Reported Outcomes:
Lower Extremity Functional Scale
LEFS
A
- GENERAL LE measure—–activity based
- **no s/s or impairments
- scores range 0-80 w/ HIGHER SCORES==BETTER FUNCTION
2
Q
Pt Reported Outcomes
Western Ontario and MacMaster Universities Osteoarthritis Index
WOMAC
A
- commonly used in OA outcomes research and care
- HIP and KNEE
- Subscales
- Pain 0-20
- Stiffness 0-8
- Phys Function 0-68
- HIGHER scores on WOMAC === WORSE pain, stiff, functional limits
3
Q
Pt Reported Outcomes
Hip Injury and OA Scale
HOOS
A
- 5 Subscales:
- Pain: P 0-40
- Symptoms: S 0-20
- Act limits Daily Living: ADL 0-68
- Function in sport and rec.: SP 0-16
- Hip related QOL: QoL 0-16
- Pain: P 0-40
- LOWER scores on HOOS === WORSE pain, stiff, functional limits
4
Q
Pt Reported Outcomes:
Hip Outcome Score
HOS
A
- ADL and Sports Scales
- Scores range 0-100 w/ HIGHER SCORES ===BETTER function
5
Q
Pt Reported Outcomes
Harris Hip Function Scale
A
- popular
- Good for pre/post op comparisons
- Emphasizes Pain and Function
6
Q
Minimal ROM req’s for Basic Function:
Gait, Sitting, Bed mobility, stairs
A
- 90deg FLEX
- Normal==120
- 20deg ABD
- Normal==45
- 0deg IR
- Normal==45
- 20deg ER
- Normal==45-60
7
Q
Problem Solve:
- Pt recently had hip spica cast removed as he was recovering from a femoral fx. Current ROM:
- Flexion=105
- ABD= 20
- IR and ER= 5
*
A
- When performing PROM ex’s, which motion should be emphasized for your pt if the goal is to facilitate basic function???
- ER
- As long as FLEX reamins limtd to 105, what functional acts will be difficult?
- compensation w/ trunk flexion
8
Q
Unloading of Hip using ADs
A
- Walker OR 2 Ax Crutches—-WB restrictions!!!
- unloads up to 100% BW
- GOOD/THE choice for NWB, TTWB, PWB up to 50% BW
- One crutch unloads up to 50% of BW
- GOOD choice for PWB IF cleared for 50% or more BW
- Cane unloads up to 40% BW
- GOOD choice for PWB if cleared for 60% or more BW
9
Q
Pathomechanics of Hip Jt Injury
Motion Deficiency
What develops?
A
- Femoral Acetabular Impinge. (FAI)
- Cam
- Pincer
10
Q
Pathomechs of Hip Jt Injury
Excessive and Uncontrolled Motion
What develops?
A
- Structural Instability
- Dysplasia
- Capsular Insuff.
- Global
- Acquired
11
Q
Pathomechanics of Hip Jt Injury
Osseous Overloads
What develops?
A
- Traumatic
- Cumulative (ex. Stress Fx)
- Predisposed
- insufficiency
- Microtrauma
- overuse
- Predisposed
12
Q
MANY roads lead to…..
A
OA
13
Q
Explain OA….
A
- OA
- End-pt for MANY hip patho’s
- Emerging evidence for FAI
- Better estab’d relationship to dysplastic hip
- Fxs linked to EARLIER OA dev.
14
Q
Hip Fx and Rule of Thirds
A
1/3 Recover
1/3 Recover BUT reduced mobility
1/3 Die
15
Q
Hip Fx is one of leading causes of death in older adults.
Why?
A
- Fx results in comorbid condition that results in Death.
- Cycle:
- Hip Fx–> Immob. & INC sedentary time–> PNA (or other med. comps)–> Death
16
Q
Hip Fxs– Prox. Femur
Risk Factors for Falls in Elderly:
A
- Slower walking speed (modifiable)
- Hx of falls
- Sarcopenia
- Poor balance (modifiable)
- Cognitive decline
- Poor vision
- Osteoporosis
- Household obstacles such as rugs, power cords, clutter (modifiable)
17
Q
Hip Fxs – Prox. Femur
Hip Hemiarthroplasty (1/2)
Indications:
A
- Acute displaced INTRAcapsular prox. femur fx
- frail elderly
- Failed int. fixation of INTRAcapsular fx’s
- osteonecrosis of femoral head
- ALSO used for SEVERE DJD of femoral head w/ healthy acetabulum
18
Q
Hip Fx’s – Prox. Femur
Hip Hemiarthroplasty
uni vs bipolar, Sx approach, Rehab
A
- Unipolar
- stem/head is 1 piece
- Bipolar
- SOME mvmt b/w stem and head components
- Sx Approach
- POSTEROLATERAL == MOST COMMON!!!
- Cemented OR Non-cemented
- POSTEROLATERAL == MOST COMMON!!!
- Rehab???
- mimics rehab for THA
19
Q
Hip Fx’s – Prox Femur
ORIF
Indications???
A
- Displaced OR non-displaced INTRAcapsular fem. neck fx
- Fx w/ disloc’s of femoral head
- INTERtrochanteric fx’s
- SUBtrochanteric fx’s
20
Q
Hip Fxs—Prox Femur
ORIF
Traction procedure
A
- Pin THRU distal femur + traction system IN hospital bed to provide traction to leg to help w/ reduction of fx
- typ followed by sx
21
Q
Hip Fx’s—Prox Femur
ORIF
In Situ Fixation
A
- Percutaneous nail thru skin from greater troch to femoral head—- NO cutting thru mm or capsule
- Non-displaced fx’s
- Impacted femoral neck fx’s
- ***Fewer precautions vs. THA or Hemi-arthro
22
Q
Hip Fx’s —Prox Femur
ORIF
Dynamic (MVMT) extramedullary fixation w/ a sliding (compression) hip screw and lateral compression plate
A
- allows for sliding b/w plate and screw—> creates compression across fx w/ WB
- mainly for stable intertrochanteric fx’s
- MAY be combo’d w/ an osteotomy for comminuted fx’s
23
Q
Hip Fxs–Prox Femur
ORIF
Static (NO MVMT) interlocking intramedullary nail fixation OR sliding hip screw coupled w/ an intramedullary nail
A
For SUBtrochanteric fx *******
24
Q
Hip Fx’s –Prox Femur
ORIF
Bone force and healing
A
- NO bone force
- UNLIKELY to heal
- Bone req’s FORCE to HEAL !!!
25
Hip Fx--Prox Femur
## Footnote
**ORIF**
**Rehabilitation:**
* EARLY mob. possible due to **stability of fixation**
* **Fx healing typ takes 10-16wks**
26
Hip Fxs--Prox Femur
## Footnote
**ORIF
WB status**
ALWAYS det'd by surgeon
27
Hip Fx's --Prox Femur
## Footnote
**ORIF**
**Procedures that usually allow for WBAT:**
* **_Non-displaced_**, rigidly fixed, OR impacted femoral neck fx's w/ **in-situ fixation**
* **_Stable_ (uncomminuted)** INTERtrochanteric fx's w/ **dynamic hip screw and lateral side plate fixation**
* **_Stable_** SUBtrochanteric fx's w/ **interlocking intramedullary nailing and bone-bone fixation**
**NOTE: notice "non-displaced, stable, stable"**
28
Hip Fx--Prox Femur
## Footnote
**ORIF**
**Factors in determining WB status:**
* age
* bone quality
* **density**
* fx loc.
* fx displacement
* fixation proc's
* post-op stability
29
GOAL of ORIF====\>
* **Restore mobility ASAP to MINIMIZE negative local and systemic results of immobilization**
30
Hip Fx's ---Prox femur
**ORIF
Special considerations for exercise and gait**
* Soft tissue healing takes **@ least 6 wks; BOTH injury (fx) AND sx procedure can impact local musculature**
* ****TRAUMA from Fx
* INCISION from Sx
* **TFL** usually cut during Sx and has to heal\*\*\*
* Return of ABD strength is BIG ISSUE----**slower if glute med cut during sx**
* ****IF glute med NOT cut-----**start ABD ex's sooner**
* INTRAcap Fx's req. **incision INTO capsule during sx----pt MIGHT have post-op ROM PRECAUTIONS in order to AVOID DISLOCATION**
31
Hip Fx--Prox Femur
## Footnote
**ORIF Rehab**
**MAX PROTECTION PHASE**
* 90deg HIP FLEX ROM by **2-4wks**
* EASY **ankle + knee ROM ex's**
* UE ex.
* LOW intensity mm performance ex:
* **submax iso's (guide by pain)**
* **progress to AAROM**
* NO bridging or SLR w/ involved side early on
* Be **careful** NOT to violate **WB precautions!!!**
32
Hip Fx--Prox Femur
## Footnote
**ORIF**
**MODERATE--\>MINIMAL PROTECTION PHASES**
* Progress to **PWB; eventually FWB**
* Stretch any Tight mm's
* Expand **ADL training**
* Aerobic ex.
* Add **resistance** for hip ex's
* Add **balance ex's**
33
S/S of Failure of Int. Fixation following Hip Sx
see Box 20.8
34
Hip OA
## Footnote
**Condition characteristics**
* GLOBAL cart. loss and loss of jt space
* wide-spread loss of normal jt structure and **related loss of function**
* often **cumulative result of an earlier injury pattern progressing over time:**
* Prev injury
* Acetabular labral tear
* Dysplasia (**early onset OA)**
* Avascular Necrosis
35
Normal vs. OA Hip Joint
see pics
36
Clinical Present Hip OA
Cibulka et al, 2009
**Exam Findings**
* MODERATE **Ant and/or Lat. pain**
* **MOST OFTEN PROMINENT DURING WB**
* Pain often prominent in **morning**
* **subsides in \<1hr**
* Typ \>50yo
* **EXCEPTIONS:**
* ****Prev injury
* dysplasia hx
* med-induced AVN
* **Progressive loss ROM---CAPSULAR PATTERN**
* Notable IR (\<15deg) THEN FLEX
* **capsular pattern**
* DECd jt mob or symptom relief w/ **long-axis distraction**
* related Loss of Strength
37
Clinical Present of Hip OA
**Clinical Tests:**
**KNOW THESE!!!**
FABER/Patrick
Scour
38
Typically..... symptomatic and functional changes related to HIP OA are\_\_\_\_\_\_\_\_\_
slow-developing
39
Prognosis of Hip OA ~ related to \_\_\_\_\_\_\_\_\_\_\_
Extent of radiographic changes
40
Well-established option for **end stage hip OA NOT responsive to non-op Tx**
THA
41
Time of progression from **initial Dx of OA to THA procedure is HIGHLY \_\_\_\_\_\_\_\_\_\_**
Highly variable AND pt dependent
42
Clinical course and expected outcomes for Hip OA
current/developing interest in......
Hip preservation sx's and use of biologics
43
DJD (OA) of Hip
KEY FINDINGS from **Pt Hx**
* older age
* hx trauma, rep stress, hip develop. disorders/disease
* **stiff in AM upon waking OR after rest**
* Pain in **groin, hip, buttock, ant thigh and/or knee**
* Pain WORSE w/ WB or **@ end of day**
* Pain WORSE w/ squatting
* Limtd functional acts: **esp WB**
* ****inc diff overtime w/ ambulation, stairs, bathing, dressing (don/doff socks, shoes)
44
DJD (OA) Hip
## Footnote
**Observations**
* Antalgic gait
* **lean toward INVOLVED side in STANCE phase**
* **impaired balance**
* **SHORT STEP LENGTH on UNINVOLVED limb**
* Posture--\> **hip flex contracture**
45
DJD (OA) Hip
## Footnote
**Typ. Exam Findings:**
**Impairments**
* limtd mm extensibility/flex
* **hip flexors, TFL/ITB, glute max**
* MM weakness
* **ABD's, EXT's, ER's**
* Painful ACTIVE hip flex
* Painful + Limtd hip PROM
* **firm capsular end feel**
* ROM--\> **limtd IR initially**
* **LATER:**
* ****ABD, EXT, ER also limtd
46
DJD (OA) Hip
Typ. Exam Findings:
**Impairments**
**EARLY STAGES**
Capsular **laxity** & pt reported **instability**
47
DJD (OA) Hip
Typ. Exam Findings:
**Impairments**
**LATER STAGES**
Cartilage breakdown
Capsular fibrosis
Osteophytes
**Basically....STIFFNESS**
48
DJD (OA) Hip
**Selective Tests**
* POSITIVE **Scour Test**
* **MAYBE POSITIVE**
* **FABER**
* ****pain in Hip or Groin w/ OA
* maybe limtd ROM also
* **FADDIR (Flex, ADD, IR)**
* ****Ant. Labral Tear Test
* **POSITIVE Labral Tests**
49
DJD (OA) Hip
## Footnote
**Non-Op Tx**
**Primary Goal------**
RESOLVE IMPAIRMENTS!!!
50
DJD (OA) HIP---
## Footnote
**Non-Op Tx**
**2 things to do:**
* 1. GET THEM MOVING!
* **Stretch tight mm's**
* **Jt Mobs----if limtd mob.**
* **LOW grade===pain relief**
* **HIGH grade + MWM (mob w/ mvmt)=== INC ROM**
* 2. Strengthening
* **LOW impact TE**
* ****aquatics, swimming, stationary bike/recumbent
* PROGRESS to GREATER closed chain WB **as tolerated**
* Begin w/ LOW RESISTANCE & HIGH REPS
51
DJD (OA) HIP
## Footnote
**NON-OP Tx**
**MUST PROGRESS TO HIGHER LOADS**
**(**assuming does NOT inc symptoms)
* do NOT stick w/ easy things
* **more benefits in pushing them**
* Overcome **inhibition== INC strength**
* Strengthening INCs **capacity== raises ceiling**
* ****Stronger you are==LESS effort needed for basic tasks
52
DJD (OA) Hip
**Non-Op Tx**
* PRIMARY GOAL:
* **Resolve impairments**
* **Biomech. Interventions:**
* ****Unloading (single pt cane)
* Heel lift OR orthotic if LLD
* Elevated seats IF flex limtd + painful
* Improve aerobic capacity
* Balance ex's
53
2 most often situations for THA
1. when guys can no longer play golf
2. Women
54
DJD (OA) Hip
## Footnote
**Sx Tx**
**THA**
**Indications?**
* SEVERE hip pain w/ **motion and WB** that has been **WORSENING over time**
* Impaired **function** and reduced **QoL**
55
DJD (OA) HIP
Sx Tx
## Footnote
**THA**
**Prosthetic Components**
* **Acetabulum**:
* high density **plastic or ceramic**
* **Femur:**
* ****metal alloy
56
DJD (OA) HIP
Sx Tx
**THA**
**CEMENTED Polymethylmethacrylate**
**Cemented PMMH**
**explain...**
* good for **older pts**
* those **not able to follow WB precautions**
* OK to **WBAT RIGHT AWAY**
* **ADVANTAGES:**
* ****earlier WB
* shorter + faster rehab
* **DISADVANTAGES:**
* ****GREATER risk of **loosening over time**
* ****cement degrades
57
DJD (OA) HIP
Sx Tx
**THA**
**UNCEMENTED**
\*\*Bone grows INTO prosthetic\*\*
* better for **younger & more active pts**
* **ADVANTAGES:**
* ****LESS chance prosthetic loosening over time
* **DISADVANTAGES:**
* ****protected WB **initially\***
* ****historically **up to 6 wks TTWB,** recently more of a trend for **faster progression of WB**
* LONGER course of rehab
* slower bc waiting for bone to grow into prosthetic
58
DJD (OA) HIP
## Footnote
**THA**
**Hybrid THA:**
* LESS COMMON
* Cemented **acetabulum**
* Press-fit **femoral component**
59
DJD (OA) Hip
Sx Tx
**THA**
Various approaches to gain access to hip jt affect **post-op rehab**
## Footnote
**see pics**
60
Posterolat Approach THA
vs.
Anterior Approach THA
**Advantages vs. Disadvantages**
61
Ant Approach THA
vs.
Posterolateral Approach THA
**Precautions**
see pics
62
DJD (OA) HIP
## Footnote
**THA**
**Posterolateral Approach**
* ROM:
* **No FLEX \>90deg, No IR beyond neutral, No ADD beyond midline**
* ****DO NOT CROSS LEGS
* ADLs
* Transfers: **lead w/ UNINVOLVED side**
* **bed--\> chair or chair--\> bed**
* keep knees LOWER than hips when sitting
* RAISE toilet seat, bed, chair
* **\<90deg hip flex**
* Avoid bending trunk over legs when rising or lowering to chair or dressing
* shower chair
* Stairs
* UP w/ GOOD, DOWN w/ BAD
* Pivot on **sound extremity** w/ walker, turn AWAY from involved side when pivoting
* Avoid IR toward INVOLVED extremity when standing
* Sleep Supine w/ ABD pillow
63
DJD (OA) HIP
## Footnote
**THA**
**Anterior Approach**
* ROM: **Avoid Hip EXT, ADD, ER past neutral**
* ****also avoid combo of **ER w/ Flex and ABD**
* avoid excess. FLEX
* IF **glute med disrupted OR trochanteric osteotomy done----\>** do NOT perform anti-gravity hip ABD for **6-8 wks OR until approved by surgeon**
* ADLs
* Do NOT cross legs when sitting
* **avoid ADD, avoid ER**
* Early ambulation: **step-to rather than step-thru op'd side**
* Avoid rotating AWAY from op'd side when **standing**
* **ex.** turn TOWARD op'd side so as to avoid ER of op'd side
64
**THA**
**Post-Op Precautions**
* Typ no **"hard stop"** end date for ROM precautions
* Typ after few mo's ==== **pt begins violating or forgetting about precautions and is OK**
* BUT even down the road.....
* **still not good to combine Hip Flex and ADD**
* ****bending to tie shoes **-- combine FLEX w/ ABD**
* **"Froggy Style"**
65
THA
**Post-op Education or "Pre-Hab"**
* educate pt on expected **ROM precautions**
* rehearse **proper gait pattern w/ AD**
* instruct pt in ex's that will be done **immed. post-op**
66
DJD of HIP
Sx Tx **THA
EARLY PROTECTION PHASE**
**1 Day to 2 Weeks Post-Op**
We want them as mobile as possible!!!
No complications + More Mobile==Go Home
* **Prevent pulm./vascular complications**
* ****ANKLE PUMPS
* DEEP BREATHING
* **Prevent dislocation or subluxation**
* ****Educate pt and caregivers about precautions
* ABD pillow
* higher chairs; commodes
* monitor s/s
* **Achieve independent functional mobility**
* ****bed mob + transfer training
* ambulate w/ AD
* **rolling walker==most common**
67
DJD (OA) HIP
Sx Tx
**THA**
**EARLY PROTECTION PHASE**
**1 Day to 2 Weeks Post-Op**
**continued**
* **Maint strength + function UEs and UNoperated LE**
* **Prevent reflex inhibition and atrophy of the operated LE**
* **Regain active mobility and control of the operated LE**
* _****In Bed_--\> AAROM for hip, assist. heel slides, assist ABD/ADD
* _In Sitting_--\> Knee Flex/Ext, **emphasis on TKE**
* _In Standing_--\> NWB hip AROM w/ knee FLEXED (**easier) &** EXT (**harder)**
* ****_In Standing_--\> B/L squats, heel raises
* \*\*\***Delay in UNCEMENTED\*\*\***
* **Prevent Flex contracture of the operated hip**
* ****AVOID use of pillow under knee of operated hip
* _Posterolateral Approach_
* lying prone when permit'd
* **Thomas Stretch** of the UNoperated side
* single knee to chest but keeping it LESS than 90deg w/ involved side
* _\***if abso. necessary**_
* _Anterior Approach_
* __Do NOT stretch into EXT
68
DJD OA of HIP
**THA**
**MODERATE AND MIN. PROTECTION PHASES**
**1-12 WKS POST-OP**
NO PROGRESS. TO END RANGES
* **Regain strength and endurance ALL extremities**
* ****ESP hip ABD and EXT
* **improve aerobic endurance--**LOW IMPACT
* **Restore functional ROM of operated hip**
* ****Do NOT exceed ROM precautions/restrictions
* **Prepare for full return to functional acts.**
* **** Carrying stuff--- carry on OPERATED side
\*\*NOTE: younger pts will return to sport w/in 1 year
69
Other Hip Sx's
## Footnote
**LESS invasive/aggresive vs. THA**
* Hemi-arthro
* Hip resurfacing
* **prosthetic "cap" over femoral head**
* Arthroscopic mgmt labral tears
* **repair vs. resection**
* Sx debridement of osteophytes for **Ant Acetabular Impingement**
70
Other Hip Sx's
## Footnote
**When THA Fails...**
* REVISION of THA
* **Girdlestone Procedure**
* ****saw off head of femur
71
Femoral and Pelvic Stress Fx's
Describe
* Mech. induced fx of prox. femur or pelvis
72
Femoral and Pelvic Stress Fx
mech. induced fx of prox femur or pelvis as a result of what?
* **Repetitive overload** that overcomes normal structural properties
* **EX. overtraining**
* **Loading** that overcomes compromised structural properties (something already compromised and you make it worse by loading it)
* Fx occuring w/ **osteopenia**
73
Femoral and Pelvic Stress Fx
## Footnote
**Differential Dx**
* Acetabular labral tear
* Hip flexor strain
* Hip ADD strain
* Iliopsoas bursitis
* Osteochondral lesion
* Hip OA
74
Femoral and Pelvic Stress Fx's
FACTS
* MANY cases w/ **delayed dx-----**avg 14wks
* NO reliable clinical tests to **diff. TYPE of stress fx**
* ****imaging will tell you
* if suspected==\> immed. referral
75
Femoral and Pelvic Stress Fx
## Footnote
**Dx Imaging**
**Plain Radiography**
**AP, Frog-Lateral**
**R/O** **other conditions (**OA, tumor, etc.)
Examine for **Displacement**
76
Femoral and Pelvic Stress Fx
Dx Imaging
**Bone Scan**
Demos INCd **focal uptake of radiotracer @ site of fx aka "HOT SPOT"**
**MAY read NEG. for first 24hrs after fx dev.**
77
Femoral and pelvic stress Fx
**Dx Imaging**
**MRI**
Idea in **Sn and Sp**
Yields info about **surrounding tissue (Diff. Dx)**
78
Femoral neck stress Fx and runners
account for 6.6% of stress Fxs in **runners**
79
2 Anatomical classifications of **Femoral Neck Stress Fx**
* **Compression sided (pinching down)**
* ****INF region of femoral neck
* **non-operative mgmt**
* **Tension sided (stretched)**
* ****SUP region femoral neck
* ORIF (if caught late)
80
Femoral Neck Stress Fx
**Clinical Presentatin**
**PAIN**
* Groin + Ant. thigh
* **Potentially Lat. thigh**
* **RARELY in glute region**
* **Potentially MED. knee pain**
* OFTEN **reproducible w/ END RANGE IR + OVERPRESSURE**
* ****MAYBE **reproducible** w/ **SLR or MMT for FLEX and/or ABD**
81
Femoral Neck Stress Fx
**Clinical Present**
**FUNCTIONAL**
* INITIALLY **pain during OR after strenuous act.**
* ****ex. running
* PROGRESSES to **affect lower lvl act.**
* ****ex. walking
* **In Acute stages......**
* ****painful OR restful **@ night**
**\*\*\*\* takes time to get stress on bone\*\*\***
82
Pelvic Stress Fx
* 1.6% of stress fxs in **distance runners**
* Pubic Ramus
* **Palpable rami pain**
83
Femoral and Pelvic Stress Fx's
## Footnote
**If running... 2-3 miles in they can go thru diff dx's**
* BOTH stress fx's present **closely to number of diff. dx's**
* Thoroughy discuss **act. lvl + med. hx**
* Missed dx can be SEVERE------**referral when unsure**
* **Appropriate dx + follow-up----**majority of hip + pelvic stress fx's resolve
* **TENSION SIDE (sup. side) neck stress fx's are MORE LIKELY to req. ORIF**
**\*\*\*Prev. stress fx===MORE likely to have stress fx's**
**\*\*\*CATCH THEM EARLY!!!\*\*\***
84
Osteitis Pubitis
What should you remember???
DIFF bone stress injury
**Can LEAD TO stress fx**
85
Osteitis Pubitis
## Footnote
**Description + Causes**
* Inflamm. of **Pubic Symphysis** thru **several pot. mech's**
* ****REPETITIVE athletic act.
* Degen OR rheumatic causes
* Urological/gynecological procedures OR **pregnancy (non-infectious)**
86
Osteitis Pubitis
## Footnote
**Differential Dx**
* Athletic Pubalgia
* **extra-articular component**
* Adductor strain
* **bc SO close to insertion**
* Lower abdominal strain
* Pubic ramus stress fx
* Pelvic floor dysf.
* Infectious pubic inflamm.
* **Osteomyelitis**
87
Osteitis Pubitis
**Clinical Presentation**
**ONSET**
Acute
Gradual
88
Osteitis Pubitis
## Footnote
**Clinical Presentation**
**PAIN DISTRIBUTION**
* Central symphysis region
* Prox. ADD region
* **stresses pubic symphysis**
* Lower abdomen
* **stresses pubic symphysis**
* Genital region
89
Osteitis Pubitis
## Footnote
**Clinical Presentation**
**FUNCTIONAL LIMITS.**
* Gait
* **Swing Phase**
* Pivoting
* Sport Specific:
* **cutting, jumping, kicking**
****
90
Osteitis Pubitis
**Clinical Present.**
**MUSCLE IMBALANCES**
**\*\*remember location!!!**
* **TIGHTNESS**
* **Rectus abdominus\***
* ADD
* Iliopsoas
* Rec Fem
* **STRENGTH ASYMMETRIES**
* **Adductors\*\*\*\***
**\*NOTE: Rectus abdominus + ADD's=== Antagonistic imbalance==Asymmetrical pull**
**\*NOTE: mm's attach in proximity to ea. other and can create** **_antagonistic imbalance_**
91
Osteitis Pubitis
## Footnote
**Clinical EXAM**
* Hx is **imperative**
* R/O other structures
* **Hip---do clinical tests**
* **Extra-art.---do MMT, length-tests, palpate\***
* Clinical Tests: **min description**
* **Multiposition ADD. Squeeze**
* ****try to recreate pain
* **No sig. data on testing methodology**
* **Often not apparent UNTIL pt does not respond to non-op tx**
* **IMAGIING**
* ****Plain Radiography
* **looking for surf. irregs and degen.**
* MRI
* **Edema**
92
Athletic Pubalgia & Sports Hernia
## Footnote
**what should you remember???**
Pubic "pain" ---\> **NOT ACTUALLY A HERNIA**
**There is NO hernia!!!!**
93
Athletic Pubalgia
"Sports Hernia"
* NOT hernia in trad. sense
* Disruption of **Post. Inguinal Wall OR Ant. Pubic attach's**
* General term describing **chronic pubic/inguinal pain that is NOT INTRA-ART.**
* Syndrome: **mult. causes poss.**
* 1980's----more recognized today
* **Diff Dx is imperative and imaging interp. can be diff.**
94
Athletic Pubalgia
**Involved Structures**
* Pubic Symphysis AND....
* **Musculotendinous insertions in proximity:**
* ****abdominals
* hip flexors
* hip ADD's
* **most often function to CONTROL some combo of excess. EXT or ROT. of the abdomen and excess. ABD of thigh\*\*\*\***
95
Athletic Pubalgia and ROM loss
ROM stopped due to **pain===** **empty end feel (meaning they stop you before you get to ANY end range so NO END FEEL==EMPTY END FEEL)**
96
Athletic Pubalgia
## Footnote
**Mech. of Onset**
* More common in **males** vs. females
* **Repetitive** forces to **pubic symphysis OR tendinous insertions of** **adductors and rectus abdominis**
* **"**High energy **twisting activities** **and thigh hyperABD** in athletes w/ **strong ADD mm's over-powering lower abdominals**
* ****ex. football, hockey, soccer
97
Athletic Pubalgia
## Footnote
**Clinical Present.**
**S/S**
* **Chronic pain---\>** often only during **exertion**
* Sharp, burning pain **local to lower abdomen & inguinal region**
* ****\*\*\*later will radiate to the ADD region and pot. testicular region\*\*\*
98
Athletic Pubalgia
## Footnote
**Diff. Dx**
* **Pain and/or weakness w/ strength testing**
* **Tightness and/or weakness w/ flex. testing**
* Pot. pain w/ **palpation of specific suspected structures**
* \*\*\***NEGATIVE TESTS FOR INTRA-ARTICULAR INVOLVEMENT**
99
Athletic Pubalgia
## Footnote
**Cluster Approach Summary**
Confirming Regional Involvement and Dx
* ****Symptoms:
* **deep groin, lower abs (unilateral) W/ ACTIVITY OR EXERTION**
* Lower abdomen:
* **leg lowering**
* **resisted sit-ups**
* **pubic tub. palpation**
* Thigh:
* **Flex. tests:** iliopsoas, ADD's, abs, rec fem
* **MMT:** hip flexors, ADD's, glute med
* **ADD. origin palpation**
* R/O **primary hip involve.**
* ****NEGATIVE: **FABER, FADDIR, SCOUR**
* **\*\*\*FAI has shown assoc. w/ athletic pubalgia**
* R/O Lumbosacral & SIJ involve
* **LQS as approp.**
100
Athletic Pubalgia
## Footnote
**Prognosis and Tx Implications**
Proper dx is **imperative** and **syndrome class.** necessitates an effective screening process for **mult. regions**
101
Athletic Pubalgia
**Prognosis and Tx Implications**
**Trial of Non-Op Tx typ. indicated...**
* impairment-based interventions
* Rest
* NSAIDs
* Corticosteroid injections
* Biological agents **considered**
102
Athletic Pubalgia
**Prognosis and Tx. implications**
**Various Sx proc's ...**
* Laparoscopic
* Open vs. "Mini" Open
103
Athletic Pubalgia
## Footnote
**Prognosis and Tx Implications**
**Outcomes???**
* Non-consistent outcome reporting BUT **post-sx studies report \>80% "return to sport"**
* Further outcome studies req'd for **both non-sx and sx tx**
104
Meralgia Parasthetica
\***Painful parasthesias**
**What is it and who is @ risk???**
* Irritation or entrapment of **Lateral Femoral Cutaneous Nerve** in the area of the **anteroLAT. hip**
* **~1cm medial to ASIS**
* **@ Risk:**
* ****baseball catchers
* English-style equestrians
* obese indiv's
* pregnant women
* **bc in hip flex. all the time**
105
Meralgia Parasthetica
## Footnote
**How to Test:**
* Push down w/ thumb I**NTO abdomen and UP towards umbillicus** @ lvl **just prox. to and 1" medial to ASIS**
* ****IF this **relieves** pt's symptoms of **lateral thigh burning, pain, parasthesia**
* **== suggests Meralgia Parasthetica**
106
Meralgia Parasthetica
## Footnote
**Intervention:**
* Apply **same pressure to nerve w/ pt in SIDELYING---_while you simultaneously passively EXT hip_**
* **__**push POST and SUP on the nerve (and surrounding tissue) **as you EXT hip, then move back and forth**
107
Femoral Acetabular Impinge. or FAI
## Footnote
**occurs when?**
Occurs when there is **DECd joint clearance b/w femur and acetabulum**
108
FAI
3 types:
* 1. CAM
* **_Femoral_ deformity**
* ****bony overgrowth
* 2. Pincer
* **_Acetabular_** **deformity**
* ****acetabular overgrowth
* 3. MIXED
109
FAI
## Footnote
**CAM**
**aka "Pistol Grip" Deformity**
Excessive bone @ **head-neck junction**
**\*\*bone grows OUT**
110
CAM FAI
**Delamination**
separation b/w layers in the acetabulum
111
Pincer FAI
## Footnote
**Cross-Over Sign**
**Acetabular RETROversion**
**Acetabulum covers TOO MUCH of femoral head**
* Presentation of **Focal anterior over-coverage of hip**
* **Acetabular Retroversion==** ant. wall (AW) being **more lateral that** post wall (PW)
* **In normal hip**
* ****AW lies **more medially**
* **Cranial acetabular retroversion** described also as **Fig. 8 Configuration**
112
Cam vs. Pincer
https://www.youtube.com/watch?v=ENjq5Is94PE
113
FAI and Acetabular Labral Tears
* **Most often FAI is NOT initial dx of interest**
* Pt symptoms MOST LIKELY result from **2\* labral tear, chondral damage, or degen changes IN labrum**
* Changes result in **pain+functional limitation==SYNDROME**
* ****FAI (mechanical) + Clinical Findings (pain, function limits) ==\> **SYNDROME**
114
Clinical Course and Outcomes for FAI
* if clinical present leads you to FAI----**non op tx recommended**
* outcome studies still early in dev.
* If pt **unresponsive to non-op tx-----ADD. IMAGING**
* ****Radiographs (**FAI)**
* MRA (**labral tear)**
* **A=arthrogram-local dye leaks if tear**
* Dx Injection (**confirms source of sx's)**
115
Clinical Course and Outcomes for FAI
## Footnote
**Sx Options**
* Sx avail. for pts w/ **ongoing pain and function limits** related to INTRA-art. patho of FAI
* **Arthroscopy**
* ****Osteoplasty (prox femur OR acetabular rim)
* **remove the bone**
* ****Labral debridement, repair (**usually most restricted after)**, or reconstruction (**putting something else in like bone- can do mvmt earlier w/ reconstruction)**
* **Open osteoplasty correction of FAI**
116
FAI Progress to Early Arthritis???
EXPLAIN...
* Bedi et al---\> examined cart. degradation markers in athletes w/ FAI
* Compared to controls, **found elevated lvls of:**
* **Inflamm C-reactive PRO**
* **Cart. oligomeric matrix PRO**
* Basically..... **cartilage breakdown even if looks GOOD on imaging**
* **These changes indicate cartilage turnover and stemic inflamm. assoc'd w/ OA**
117
Spectrum of FAI-related Jt. Patho
\*\***one pot. mechanism only\*\***
* FAI==\> altered jt mechs==\> labral lesions==\> chondral damage==\> OA
118
The FURTHER a labral tear goes ___________, the LESS _______ it is
Labral tear further INTO JOINT== LESS REPAIRABLE
119
HIP LABRAL TEAR
SEE PICS
120
Acetabular Labral Tears
## Footnote
**Pt Reported Symptoms**
* Hx of **hyperEXT or pivoting/twisting or fall**
* pain, click, locking and/or catching
* may feel **unstable ("giving way")**
121
Acetabular Labral Tears
## Footnote
**MOI**
most are in **Ant/Sup region of labrum**
122
Acetabular Labral Tears
## Footnote
**Typ. Exam Findings**
**Imaging**
* **Typical Exam Findings/+ Tests**
* **+** FABER (opp of FADDIR)
* **pulls labrum**
* **+** FADDIR---ant labrum test (opp of FABER)
* **pinches labrum**
* **+** SCOUR test
* **+** Labral tests
* \*\***Pain w/ resist. SLR ---**
* ****compensated hip flexors\*\*\*
* **Imaging**
* MRI or MRA (angiography)
123
Acetabular Labral Tears
## Footnote
**Interventions**
* Ex's for **hip stability and strength**
* **Core stabilization** ex's
* AVOID pos's or tx that would **further stress labrum:**
* ****HyperEXT
* End-range OVERpressure
* HIGH GRADE **ant. glides**
* AVOID sheering, pivoting, extreme EXT
* MAY need **arthroscopic repair OR resection**
124
Structural Instability
vs.
Hypermobility
* Structural instability
* **what the pt reports**
\*\***These two are NOT always EQUAL!!!**
125
Components of Jt Stability
3
* 1. Neural (**proprioceptive/sequencing)**
* ****Rehab Focus
* 2. Active (**muscular)**
* ****Rehab Focus
* 3. Passive (**ligamentous/boney)**
* ****Sx Focus
126
The **Structurally Unstable** Patient
\*know **underlying cause\***
* boney architecture
* **Femoral deformities**
* ****Coxa valga, INCd femoral version
* Mis-shaped femoral head
* Shallow acetabulum
* **Anteverted acetabulum**
* **Primary Capsulo-labral Compromise**
* ****ligament/capsule tear in hip
* **Universal** laxity
* **Focal** laxity
* Ligamentum Teres deficiency
* **the "head ligament" ----- blood supply!!!**
127
Dysplasia
**_Labrum_ does MORE work**
**_Bone_** **does LESS work**
* SHALLOW acetabulum
* Predisposes hip to **sublux. AND abnorm contact stresses on femoral head**
* Assoc'd w/ **hyperplastic labrum AND degen**
* Dysplastic hip can LOAD labrum **up to 5x above normal**
* \*\*\***Cannot treat underlying bony patho arthroscopically\*\*\***
128
Capsulo-ligamentous Laxity
aka **Ligamentous Laxity**
* MAY be noted **in conjuction w/ OR instead of boney abnorms**
129
Capsulo-ligamentous Laxity
## Footnote
**aka Ligamentous Laxity**
**2 Categories:**
* 1. **Generalized**
* ****connect. tissue disorders
* **Ehler's-Danlos**
* **Marfan's**
* **etc..**
* 2. **Focal**
* ****iliofemoral ligament attenuation/damage
130
How do we **measure** Generalized/Universal Laxity?
Beighton's Scale
131
Repetitive **Micro-Trauma &** **_Acquired_ Capsulo-ligamentous Laxity**
* Abnorm forces thru hip transmit forces to **iliofemoral ligament AND labrum**
* **Results:**
* ****_Focal_, rotational instability
* _Elongated_ capsule
* _Associated_ labral tear
132
Repetitive Micro-Trauma & Acquired Capsulo-ligamentous Laxity
## Footnote
**MOI**
* Repetitive ER on a **loaded limb ==\>**
* Weakening/disruption of **anterior structures ==\>**
* ****iliofemoral lig.
* capsule
* labrum
* INCd load thru **soft tissues**
* ****labral tearing--**stress**
* irritation of ABDs and hip flexors
* **as they work to stabilize**
133
Hypermobility Prognosis & Tx Implications
\*\***if clinical presentation leads to impression of HYPERmobility-----NON-op tx measures recommended**
* IF pt unresponsive to NON-op Tx---- **add. imaging warranted:**
* ****Radiographs
* **ID of dysplasia**
* MRA---dye into tear if tear
* **labral pathology**
* Dx Injection
* **confirms source of sx's**
134
Sidenote:
## Footnote
**Hip Dysplasia**
* Medical term for a hip socket that does NOT fully cover the ball portion of the proximal femur.
* allows hip jt to become **partially or completely dislocated**
* **mostly congenital**
135
Structural hypermobility OR laxity DOES NOT ALWAYS result in\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Clinical Instability!!!
136
Extra Articular Hip Injuries
## Footnote
**What is KEY to effective Tx?**
Accurate Dx
137
Extra-articular hip injuries
## Footnote
**Multi-structural involvement**
* **Co-existence** w/ **INTRA-articular involve.**
* ****FAI
* labral tears
* Lumbopelvic component
* **Syndromes**
* ****COMBINED **core and hip musculotendinous structure involve.**
138
Extra-articular Hip injuries
## Footnote
**"Outliers"**
Pelvic floor
Nerve entrap. syndromes
139
Extra-articular Hip injuries
## Footnote
**Give some examples...**
* Greater troch pain syndrome
* ADD-related groin injuries
* Prox. HS injuries
* Hip flexor injuries
* **iliopsoas**
* Assoc'd core patho/Athletic pubalgia (sports hernia **not really a hernia)**
140
Greater Trochanteric Pain Syndrome
## Footnote
**GTPS**
* labeled **trochanteric bursitis in past**
* Trochanteric inflamm IS POSSIBLE BUT....
* **Other structures often involved.....**
* ****Glute Med.
* tendinopathy
* tear
* Glute Min.
* tendinopathy
* tear
141
Gluteal Tendinopathy
FACTS
**MORE common in FEMALES**
**40-65yo**
142
Gluteal Tendinopathy
## Footnote
**Functional Diff's**
* Pain variable w/ walking, S/L, sitting
* Fatigue and **possible gait disturbance**
143
Gluteal Tendinopathy
## Footnote
**Clinical Findings:**
* R/O **intra-articular involve as 1\* source**
* Palpable **tendon attach.** pain
* POST/SUP trochanter== **glute med.**
* ANT == **glute min.**
* Pain w/ **resisted ABD**
* **+** De-rotational test
* Pain w/ **30s SLS**
144
Trochanteric Bursitis
## Footnote
**Pt Report**
PAIN loc'd over **lateral hip** w/ **referral to lateral thigh to knee**
145
Trochanteric Bursitis
## Footnote
**Mech. of Patho.**
* Aggravated by **ITB rubbing over trochanter**
146
Trochanteric Bursitis
## Footnote
**Risk Factors:**
* Risk on **"downhill leg"** if running on banked road
147
Trochanteric Bursitis
## Footnote
**Aggravating Acts:**
* lying on **affected side,** standing asymmetrically w/ hip in **ADD.,** walking/running on **uneven surf. (crested road)**
148
Iliopectineal Bursitis
## Footnote
**Pt Report**
Pain loc'd in **inguinal region referring to the ANT thigh as far as knee**
149
Iliopectineal Bursitis
## Footnote
**Mech. of Patho**
* bursa lies DEEP to **iliopsoas tendon** as it crosses hip joint
* CLOSELY assoc'd w/ **hip jt patho**
* ****DJD
* RA
* etc..
150
Iliopectineal Buritis
**Aggravating Factors**
* Rep'd **hip flexion, rising to stand after prolonged sitting, prolonged walking**
* Pts report pain w/ **crossing legs OR ADD affected LE**
151
Iliopectineal Bursitis
## Footnote
**Interventions**
* Focus on **stretching iliopsoas**
* **hip mobs**
* **soft tissue mobs**
* **therapeutic modalities**
152
Ischiogluteal or Ischial Tuberosity Bursitis
## Footnote
**"Weaver's Bottom"**
**Pt Report**
* Pain over **ischial tubs--esp in sitting**
* ****MAY spread to **sciatic distribution due to swelling**
153
Ischiogluteal or Ischial Tuberosity Bursitis
## Footnote
**"Weaver's Bottom"**
**Mech. of Patho**
* Sedentary indiv's OR direct trauma to region
* **bursa lies DEEP to glute max over isch. tubs.**
## Footnote
****
154
Ischiogluteal or Ischial Tuberosity Bursitis
## Footnote
**"Weaver's Bottom"**
**Aggravating Acts**
* Resisted **hip EXT and HS's painful**
155
Ischiogluteal or Ischial Tuberosity Bursitis
**"Weaver's Bottom"**
**Diff. Dx**
referral from **LS** or referral from **hip** may cause pain in same area
156
Ischiogluteal or Ischial Tuberosity Bursitis
## Footnote
**"Weaver's Bottom"**
**Specific Intervention**
* Using a **doughnut** **pad** to relieve pressure while **sitting**
157
Hip/Pelvis Bursitis
## Footnote
**Interventions**
* STRETCH tight structures around hip
* **ITB/TFL, Glutes, HS's**
* MOBILIZE tight hip/lumbar spine/pelvis structures
* **Foam rolling over ITB and other structures**
* ****don't care WHY it works as long as it WORKS!
* Therapeutic Modal's MAY enhance pain relief and better tolerance to mvmt----**implement if they allow MORE EXERCISE!!!**
* US
* heat
* e-stim
158
MSPT I
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