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Exam 4

Lower Extremity: Hip/ Pelvis

ROM for climbing stairs ~70° (1° ext to 60+° flex)
ROM for sit to stand Depends on height of seat: 112° avg. flex
ROM for squats 115° flex
ROM for stooping 125° flex
ROM ideal for most ADL's 120° flex, 20° abd, 20° ER, 10° hyperext
Functional ROM (Gait) -Maximally flexed to 30º at heel strike and a moving into extension for foot flat -Maximally hyper-extended to 10º at heel off
Referred P! Primarily from cutaneous nerve innervation -From SI jt. to glutes, lateral hip, groin -From hip jt. to anterior thigh, possibly knee
Radicular P! from T12-L2 and S1-3 spinal nerves
Lumbopelvic Rhythm -Motion between spine, pelvis, hip -Allows greater ROM -Similar to shld. complex
Hip flexion is accompanied by _____ mm contraction abdominal
Hip extension is accompanied by _____ mm contraction spinal extensor
Hip flexor tightness/ weak trunk flexors cause -Anterior pelvic tilt -Increase lordosis -Knee position may be altered
Tight hip extensors/ hamstrings -Posterior pelvic tile -Decreased lordosis
Hip ER weakness is a predictor of LE injury
Non-arthritic hip joint P! -Femoral acetabular impingement (FAI) -Instability -Labral tears -Chondral lesions Ligamentous teres tears
Osteoarthritis (OA) -Most common cause of hip P!
Femoral acetabular impingement (FAI) risk factors -Genetics -Males>females -Higher activities involving more end range hip motions and higher forces (i.e gymnastics)
OA risk factors -Older age -Previous joint injury -Increasing BMI (overweight/obese) -Occupational activity i.e. deep squats or stairs with or without loads -NOT exposure to sport or physical activity which actually may be protective
FAI Etiology -Genetics- 2-2.8x relative risk for a sibling -Slipped Upper Femoral Epiphysis (SUFE) -Femoral neck fx and/or malunion -Perthes’ Disease- avascular necrosis -Western > Eastern world -3 congenital types
Femoral acetabular impingement (FAI) 3 types: FAI-Cam FAI-Pincer FAI-Mixed
FAI-Cam -Decreased anterior or superior femoral head neck offset (larger femoral head -Head contacts anterosuperior acetabulum -Higher risk of articular cartilage lesion -Twice as common in males vs. females
FAI-Pincer -Acetabular retroversion or coxa profunda (deeper acetabulum) or anterior osteophyte -Neck primarily contacts anterior but possibly posterior labrum (countercoup phenomenon) -Most common in middle aged athletic females
FAI-Mixed Most common
OA Etiology -See tissue healing notes -LBP predicted subsequent OA-related p! and disability in those with hip disease
FAI structures involved -Abnormal shape and abutment of femoral neck, acetabulum, and/or labrum as well as the femoral head aka hip dysplasia -With or without OA/labral tears -Trauma: less common, typically thru forceful rotation in hyperextension
FAI structures involved: Labral tears -Active individuals w/ mechanical groin pain w/out alternative radiological dx -20% of athletes with groin P! -22-55% prevalence in those with hip and groin P! -Prevalent w/ avascular necrosis and OA & chondral damage, the latter up to 73% of pts.
OA structures involved -See tissue healing notes -Often includes FAI tissues also
FAI S&S -Referred hip P! into ant. hip/groin (deep pinch) primarily w/ prolonged weight bearing,on hills/ steps& prolonged sitting (boney dose-packed position) -Lateral hip P! possible -P! location not associated w/ lesioned area of joint
FAI S&S cont. -Groin P!/ Stiffness/ clicking -Clicking plus locking, catching, instability, giving way -Weak ER & Abd in chronic conditions -Impaired ROM: flex, IR, H add
OA S&S -FAI S&S plus... -Stiffness after prolonged positioning -Less tolerant to weightbearing w/ possible Trendelenburg gait
FAI tests & measures -FAI or FADIR test -Posterior FAI test -Modified Thomas test -Hip quadrant test -Fitzgerald test -Deep squat
OA tests & measures -6 MWT -TUG
FAI/ OA PT Rx: -PRICED -STM -Modalities for P!/ inflammation -Orthotic/taping to limit hip add/ IR -AD to minimize/ avoid limping- weak support -Wedge to limit hip flexion with sitting -Pt. education- moderate support
OA PT Rx: -JM for cartilage proliferation/ mobility -no addition to exer. @ 9 or 18 wks -better than exer. out to 7 month
OA PT Rx cont. -JM for cartilage proliferation/mobility -Summary: thrust techniques and stretches need to be incorporated in addition to non-thrust techniques with exercise -Better than usual care out to 1 yr. -Moderate support
OA PT Rx cont. -Step w/ optimal stresses -Effective for reducing P! & disability vs. no exercise -Better than usual care out to 1 yr. -Emphasize LE control -Moderate support for flexibility, strengthening, and endurance (tissue proliferation)
Pelvis and Hip Joint Prognosis FAI and labral tears contribute to OA
FAI/ OA MD Rx -Ultrasound/ Fluoroscopic guided injections -Sx- open or arthroscopy for FAI -benefical short/ mid term follow up -No evidence to suggest sx is better than PT -Arthroscopy
THA Prevalence- 285K/yr Incisions: Anterolateral More stable, but not as open Mini- smaller incision with same components Posterolateral Less stable but more open More common
THA Pre-op PT -Purposes: Assistive devices Planning for recovery i.e. initial HEP Expectation management -1-2 sessions -$1215 cost reduction vs. no pre-op PT
THA surgical considerations -Incise capsule/extracapsular ligs -Forcep adjacent structures -Dislocate hip -Close capsule -Full range under anesthesia
THA Prosthetics -Acetabulum is rasped out and the head of the femur is cut off Metal, ceramics, plastic Mobile bearing hip -Prosthesis fixation Cemented > non-cemented; Decreased wt. bearing non-cemented; Why?
THA Complications -Bruising, DVT’s, PE (.4% at 90 days), and mortality (.5%) -Component loosening = 10-40% by 10 yrs. -Dislocation = 1-4% -Metal on metal failure rate > other materials -Metal debris can enters adjacent tissue and possibly blood
Hemiarthoplasty -Replace head w/out replacing acetabulum -Unipolar prosthesis: Austin-moore prosthesis -Bipolar prosthesis
THA Rehab Prognosis @ 6 to 8 months post-op, physical functioning had generally recovered to about 80% of that controls
THA Precautions -Observed following procedure to prevent dislocation - 6-8 weeks at least, MD may say longer -AVOID: hip flex. past 90; hip add. past neutral; rotation IR past neutral w/ posterolateral incision ER past neutral w/ anterolateral incision
Adhesive Capsulitis (ACH or frozen hip) risk factors -Thyroid disorder -Middle aged -Females -Diabetes -Alcoholism, etc
Adhesive Capsulitis (ACH or frozen hip) etiology -Primary- unknown -Secondary- concomitant pathology -Proposed but not proven biomechanical contributions -Pathogenesis of synovial inflammation to capsular fibrosis
ACH (frozen hip) structures involved/ S&S -Hip capsule and ligaments -S&S: Gradual and progressive loss of motion and P!
ACH (frozen hip) Tests & measures -Clinical presentation -Arthroscopy -Biopsies -Aspirations for inflammatory markers
ACH Stage I: Intial Symptoms: Gradual onset/ Achy @ rest/ Sharp with use/ Night P! common/ Unable to lie on involved side Irritability: high ROM: Limited but no deficit under anesthesia End feel: Empty & P!ful
ACH Stage II: Freezing Symptoms: Constant P!, particularly @ night Irritability: high ROM: Moderate limitation; similar under anesthesia End feel: Empty and P!ful
ACH Stage III: Frozen Symptoms: Stiffness > P! Irritability: Moderate ROM: Severe limitations with P! @ end range, similar under anesthesia End feel: Capsular
ACH Stage IV: Thawing Symptoms: Minimal P! Irritability: Low ROM: Gradually improves End feel: Capsular
ACH PT and MD Rx Similar to the shld.
Hypermobility -Excessive arthrokinematics/joint play -Etiology: -Traumatic -Atraumatic -Bone or soft tissue abnormality Shallow acetabulum Femoral version -Coxa valga > 140° Inferior acetabular insufficiency
Femoral angles -Vary due to congential factors, trauma, or disease -Angle of inclination: formed by angle between the shaft of the femur and the neck -Frontal plane -125 degrees = normal
Femoral angles: Coxa Valga & Coxa Vara -Coxa Valga Angle of Inclination > 125° Leads to genu vara or bow legged position -Coxa Vara Angle of Inclination < 125° Leads to genu valgus or knock-kneed position
Femoral angles: Angle of Torsion -In the transverse plane, the angle between the femoral condyles and femoral head and neck -12-15° is normal -Anteversion= toeing in -Retroversion= Toeing out
Hypermobility risk factors -Prevalence: Inconsistent gender differences 5-35% of those with hip joint P! Risk Factors: Genetics Osseous abnormalities Ligamentous laxity- just at hip or entire body (Grade 4-6) Connective tissue disorders
Hypermobility risk factor activities -Running -Ballet -Golf -Hockey -Soccer -Excessive rotation, flexion, hyperextension
Hypermobility S&S -Anterior groin or lateral hip P! -Popping, locking, or snapping present -Feeling of instability, especially when squatting
Hypermobility tests & measures -FADIR or FABER -Hip Apprehension -Hip IR > 30° at 90° flx
Hypermobility PT Rx -Basics -Visual/verbal cueing or LE control -Deep rotators are like rot cuff
Sacroiliac jt. Dysfunction (SIJ): risk factors -Incidence 20% during pregnancy 13% not pregnant with LBP -Risk Factors During pregnancy Prior LBP Prior pelvic trauma Not pregnant- no studies Hypermobility Localized trauma Ankylosing spondylitis Hip hypomobility
SIJ dysfuntion Etiology -Acute- direct trauma -Chronic: joint hypermobility from previous trauma Adjacent joint hypomobility i.e. hip -Joint hypermobility likely
SIJ Dysfuntion Synovial, non-axial, planar joint Articular surfaces very irregular Irregularity helps lock surfaces together Fibrous capsule reinforced by ligaments in multiple directions Function- stability & has little mobility (1-2 mm) if any motion
SIJ Dysfunction: Counter Nutation -Sacral base moves posterior & superior -aka posterior tilt or Sacral extension -Occurs with trunk or hip flexion -Increase pelvic inlet in early stages of labor -Involuntary motion
SIJ Dysfuntion: Nutation -Sacral base moves anterior & inferior -aka anterior tilt or Sacral flexion -Occurs with trunk or hip extension -Increase pelvic outlet for actual birthing of a baby -Involuntary motion
SIJ Dysfuntion -Limited sacral & innominate rotation &b tilting may also occur and be minimal -Motion is symptomatic in the pathological jt. and be hypermobile: -During pregnancy due to relaxin hormone loosening SI lig. -Child birth/ direct trauma sprain SI lig.
SIJ Ligaments -Necessary for stability Includes: Anterior SI ligament/ Interosseous SI ligament/ Short posterior SI ligament/ Long posterior SI ligament/ Sacrotuberous ligament/ Sacrospinous ligament/ Lumbosacral ligament/ Multiple fiber directions
SIJ Dysfuntion: Hamstrings blend with ___ lig. & Thoracolumbar fascia blends with ___, ___, and ___ ligaments -Hamstrings: sacrotuberous lig -Thoracolumbar fascia: lat, erector spinae, iliolumber lig -All equal posterior kinetic chain
SIJ: Pubic symphysis -Pubic Symphysis Located in the midline of the body -Right and left pubic bones joined anteriorly with fibrocartilage disk between -Amphiarthrodial joint Little movement More moveable in women during pregnancy
SIJ Dysfuntion S&S: -Localized to SIJ (100% of the time)and/or pubic symphysis -Referred pain into glutes and posterior thigh -Symptoms and limitations with prolonged positions, including standing, walking, and sitting -Pelvic obliquity -LLD
SIJ Dysfuntion Tests & Measures: palpatory/ mobility tests (most unreliable) -Overtake (Vorlauf) phenomenon -Spine test -Lateroflexion test -Sitting flexion test -Long sitting test -Translation SIJ -Prone knee flexion test -Maitland test -Gillet marching test -Flexion–adduction test
SIJ Dysfuntion Tests & Measures: p! and provocation tests -Reliable: Gaenslen test P4/post thigh thrust -Inconclusive reliability: Gapping or distraction test Patrick’s Faber sign test Compression test -Unreliable: Sacral thrust Cranial shear test Flexion- add hip
SIJ Dysfuntion Tests & Measures: Cluster testing -Four palpatory tests: Standing trunk flexion test Sitting PSIS palpation Supine long-sitting test Prone knee flexion test -Four provocation tests: Compression Distraction P4/Post thigh thrust Sacral thrust
SIJ Dysfuntion Tests & Measures Summary -Palpatory and mobility testing virtually impossible -More must be done -Cluster testing had higher sensitivity
SIJ Dysfuntion Tests & Measures Summary -SIJ Pain: P4/thigh thrust Patrick’s/FABER test Palpation of the long dorsal SIJ ligament Gaenslen’s test -Symphysis: Palpation of the symphysis Modified Trendelenburg test of the pelvic girdle -Functional pelvic test- ASLR
SIJ Dysfuntion Tests & Measures Summary -No gold standard so validity is unknown -Imaging: radiography/CT- poor sensitivity, MRI is the most effective, SIJ injections are not recommended
SIJ Dysfunction PT Rx -PRICED -STM/ muscle energy techniques/ modalities/ acupuncture for P!/ muscle guarding -Pelvic belt -JM -Improved symptoms /clinical tests -NOT shown realignment so likely a positive soft tissue response STEP- local stabilization and coordination
SIJ Dysfunction PT Rx -Pt education: Reduce fear Early mobilization without provocation General anatomy, biomechanics, benefits of coordination ther ex Reassurance of good prognosis
SIJ Dysfunction MD Rx -Intra-articular SIJ injections (under imaging guidance) for ankylosing spondylitis -P!/Anti-inflammatory meds -No evidence for prolotherapy or fusion
SIJ Dysfunction Prognosis -Rapidly declines during first 3 months after pregnancy -“Serious pain” during pregnancy left 21% with symptoms 2 years later -Stiffer with age and less effective as a shock absorber
Hip fracture -Prevalence= 300k per yr -Functional Questionnaire: Hip Fxs- HFRS (Hip Fx Recovery Scale)
Fracture Rehab -PRICED- ice even w/ cast -Isometrics while immobilized -Exercise non-immobilized parts -STM/JM to improve ROM/cartilage proliferation after prolonged immobilization -STEP w/ optimal stresses -Treating immobilization of tissues
Contusion -Most common @ iliac crest due to fall -Rx: PRICED
Avascular Necrosis (aka Perthes' Disease) -Disruption of circulation to femoral head -Possible causes: slipped femoral epiphysis/ dislocation/ fx/ chronic cortiocosteriod use/ alcoholism
Avascular Necrosis: Ligamentum teres- intracapsular Attaches: proximally in acetabulum & distally in fovea of the femoral head -Contains a blood vessel to supply head of femur -Questionable role with support
Avascular Necrosis aka Perthes’ Disease Rx -Gait training with an assistive device is often necessary to protect the femoral neck -PT directed primarily at circulation/boney optimal stress -May end up having a Hemiarthroplasty or possibly a THA
Avulsions -Rare/ common in eldery
Soft tissue injuries -Bursitis: Greater trochanteric pain syndrome (GTPS)- most common -Ischial -Iliopectineal: Largest in the body Communicates with capsule -Strains
Greater trochanteric pain syndrome (GTPS) etiology -Increased friction over gluteal bursae at the greater trochanter -TFL/IT Band shortening -Hip Abd (Glute med) weakness -Excessive femoral Add/IR
GTPS structures involved - 3 bursae -Glute med/ min -Glute max -IT band
GTPS S&S -Localized pain over greater trochanter without and with palpation- poor specificity -Lat hip P! with Add PROM -Possible antalgic gait -Impaired LE mechanics i.e. excessive pronation and hip IR/Add -Weak hip ER/abd -Shortened IT Band
Greater trochanteric pain syndrome (GTPS) tests & measures -Similar to tendonitis for ITB -Positive Special tests -Greater trochanteric bursitis test -Ober's for shortened ITB -Resisted external de-rotation test -Single limb balance test -Trendelenberg
Ischial Bursitis -Rare -Mechanism: overuse and/or shortened hamstrings and or direct trauma -Symptoms: pain at tuberosity without/with palpation -Positive signs: Similar to tendonitis/ Positive SLR and Popliteal angle tests for shortened hamstrings
Iliopectineal Bursitis -Rare -Symptoms: pain over iliopsoas without/with palpation -Mechanism: overuse and/or shortened iliopsoas -Positive signs: Similar to tendonitis for iliopsoas/ Positive Thomas Test for shortened hip flexors
Bursitis Rx -PRICED -STM/modalities for inflamm. phase & mm guard -Activity modification- possible cane -STM/ROM to increase length short tissue -Address impaired LE mechanics w/ foot orthotic -STEP w/ optimal stresses -Hip coord./strength/endurance
Muscle strains/ Tendinopathy -Hamstrings -Adductors: aka groin -Iliopsoas: aka hip flexor
Hamstring Tendinopathy -Prevalence: uncommon -Risk factors: not specified -Etiology: Non-optimal gait/ Training errors/ Muscle imbalances/ Deceleration injury during running
Hamstring Tendinopathy structures involved -Hamstrings: Musculotendinous junction > belly Proximal > Distal -Adductor Magnus: Shared origin with hamstrings Fascial connections -Sciatic Nerve: possibly adhered if tendonosis
Hamstring Tendionpathy S&S -Posterior hip/buttock P!... a deep ache -Worsened with sitting and running -TTP, P! with stretch and/or MMT
Hamstring Tendinopathy tests & measures -Bent knee stretch test -Slump test
Hamstring Tendinopathy PT Rx -Acute strain: exercise, eccentrics reduced return to play time/ agility training and trunk stability reduced re-injury rates/ stretching and strengthening showed high re-injury rates
Hamstring Tendinopathy PT Rx -Eccentric training reduce hamstring injury- related pain -Nordic curls prevented strains -Lumbopelvic stabilization to improve hamstring activity -Ham/ trunk exer. on unstable forces -Dry needling -Lumbar JM increases hamstring length -Neural mob.
Hamstring Tendinopathy PT Rx & MD Rx -Extracorpeal shock wave therapy: improved P! and function -MD RX: Acute strain used platelet rich plasma injections but showed no support
Hamstring Tendinopathy prognosis -Good out to @ least 6 months with 8-10 wks of eccentric exercises, lumbopelvic stabilization, and dry needling
Thigh strain Rx -PRICED -Compression wrapping prn to help with muscle contraction and action -STM/Modalities for inflammatory phase and guarding -STEP and STM with optimal stresses especially for muscle elasticity and eccentric control
Thigh Strain Rx -Kinetic innovations- hip flexor or hamstring dynamic brace
Hip special tests for return to sport screening -Quantity and quality -Limb symmetry -Agility tests
Hip special tests -SEBT (Star excursion balance tests) -Single limb squat test -FMS ( Functional movement screen) -Hop tests: common in knee and ankle -Agility tests
Created by: alovedaytn
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