Lower Extremity: Hip/ Pelvis
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| ROM for climbing stairs | ~70° (1° ext to 60+° flex)
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| ROM for sit to stand | Depends on height of seat: 112° avg. flex
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| ROM for squats | 115° flex
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| ROM for stooping | 125° flex
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| ROM ideal for most ADL's | 120° flex, 20° abd, 20° ER, 10° hyperext
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| 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
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| Referred P! | Primarily from cutaneous nerve innervation
-From SI jt. to glutes, lateral hip, groin
-From hip jt. to anterior thigh, possibly knee
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| Radicular P! | from T12-L2 and S1-3 spinal nerves
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| Lumbopelvic Rhythm | -Motion between spine, pelvis, hip
-Allows greater ROM
-Similar to shld. complex
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| Hip flexion is accompanied by _____ mm contraction | abdominal
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| Hip extension is accompanied by _____ mm contraction | spinal extensor
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| Hip flexor tightness/ weak trunk flexors cause | -Anterior pelvic tilt
-Increase lordosis
-Knee position may be altered
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| Tight hip extensors/ hamstrings | -Posterior pelvic tile
-Decreased lordosis
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| Hip ER weakness is a predictor of | LE injury
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| Non-arthritic hip joint P! | -Femoral acetabular impingement (FAI)
-Instability
-Labral tears
-Chondral lesions
Ligamentous teres tears
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| Osteoarthritis (OA) | -Most common cause of hip P!
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| Femoral acetabular impingement (FAI) risk factors | -Genetics
-Males>females
-Higher activities involving more end range hip motions and higher forces (i.e gymnastics)
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| 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
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| 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
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| Femoral acetabular impingement (FAI) 3 types: | FAI-Cam
FAI-Pincer
FAI-Mixed
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| 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
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| 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
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| FAI-Mixed | Most common
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| OA Etiology | -See tissue healing notes
-LBP predicted subsequent OA-related p! and disability in those with hip disease
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| 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
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| 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.
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| OA structures involved | -See tissue healing notes
-Often includes FAI tissues also
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| 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
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| 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
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| OA S&S | -FAI S&S plus...
-Stiffness after prolonged positioning
-Less tolerant to weightbearing w/ possible Trendelenburg gait
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| FAI tests & measures | -FAI or FADIR test
-Posterior FAI test
-Modified Thomas test
-Hip quadrant test
-Fitzgerald test
-Deep squat
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| OA tests & measures | -6 MWT
-TUG
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| 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
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| OA PT Rx: | -JM for cartilage proliferation/ mobility
-no addition to exer. @ 9 or 18 wks
-better than exer. out to 7 month
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| 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
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| 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)
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| Pelvis and Hip Joint Prognosis | FAI and labral tears contribute to OA
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| 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
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| 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
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| 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
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| THA surgical considerations | -Incise capsule/extracapsular ligs
-Forcep adjacent structures
-Dislocate hip
-Close capsule
-Full range under anesthesia
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| 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?
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| 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
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| Hemiarthoplasty | -Replace head w/out replacing acetabulum
-Unipolar prosthesis: Austin-moore prosthesis
-Bipolar prosthesis
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| THA Rehab Prognosis | @ 6 to 8 months post-op, physical functioning had generally recovered to about 80% of that controls
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| 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
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| Adhesive Capsulitis (ACH or frozen hip) risk factors | -Thyroid disorder
-Middle aged
-Females
-Diabetes
-Alcoholism, etc
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| 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
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| ACH (frozen hip) structures involved/ S&S | -Hip capsule and ligaments
-S&S: Gradual and progressive loss of motion and P!
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| ACH (frozen hip) Tests & measures | -Clinical presentation
-Arthroscopy
-Biopsies
-Aspirations for inflammatory markers
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| 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
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| ACH Stage II: Freezing | Symptoms: Constant P!, particularly @ night
Irritability: high
ROM: Moderate limitation; similar under anesthesia
End feel: Empty and P!ful
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| ACH Stage III: Frozen | Symptoms: Stiffness > P!
Irritability: Moderate
ROM: Severe limitations with P! @ end range, similar under anesthesia
End feel: Capsular
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| ACH Stage IV: Thawing | Symptoms: Minimal P!
Irritability: Low
ROM: Gradually improves
End feel: Capsular
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| ACH PT and MD Rx | Similar to the shld.
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| Hypermobility | -Excessive arthrokinematics/joint play
-Etiology:
-Traumatic
-Atraumatic
-Bone or soft tissue abnormality
Shallow acetabulum
Femoral version
-Coxa valga > 140°
Inferior acetabular insufficiency
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| 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
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| 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
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| 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
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| 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
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| Hypermobility risk factor activities | -Running
-Ballet
-Golf
-Hockey
-Soccer
-Excessive rotation, flexion, hyperextension
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| Hypermobility S&S | -Anterior groin or lateral hip P!
-Popping, locking, or snapping present
-Feeling of instability, especially when squatting
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| Hypermobility tests & measures | -FADIR or FABER
-Hip Apprehension
-Hip IR > 30° at 90° flx
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| Hypermobility PT Rx | -Basics
-Visual/verbal cueing or LE control
-Deep rotators are like rot cuff
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| 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
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| SIJ dysfuntion Etiology | -Acute- direct trauma
-Chronic:
joint hypermobility from previous trauma
Adjacent joint hypomobility i.e. hip
-Joint hypermobility likely
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| 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
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| 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
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| 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
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| 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.
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| SIJ Dysfuntion Tests & Measures Summary | -Palpatory and mobility testing virtually impossible
-More must be done
-Cluster testing had higher sensitivity
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| 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
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| 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
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| 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
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| SIJ Dysfunction PT Rx | -Pt education:
Reduce fear
Early mobilization without provocation
General anatomy, biomechanics, benefits of coordination ther ex
Reassurance of good prognosis
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| SIJ Dysfunction MD Rx | -Intra-articular SIJ injections (under imaging guidance) for ankylosing spondylitis
-P!/Anti-inflammatory meds
-No evidence for prolotherapy or fusion
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| 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
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| Hip fracture | -Prevalence= 300k per yr
-Functional Questionnaire:
Hip Fxs- HFRS (Hip Fx Recovery Scale)
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| 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
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| Contusion | -Most common @ iliac crest due to fall
-Rx: PRICED
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| Avascular Necrosis (aka Perthes' Disease) | -Disruption of circulation to femoral head
-Possible causes: slipped femoral epiphysis/ dislocation/ fx/ chronic cortiocosteriod use/ alcoholism
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| 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
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| 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
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| Avulsions | -Rare/ common in eldery
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| Soft tissue injuries | -Bursitis:
Greater trochanteric pain syndrome (GTPS)- most common
-Ischial
-Iliopectineal:
Largest in the body
Communicates with capsule
-Strains
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| 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
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| GTPS structures involved | - 3 bursae
-Glute med/ min
-Glute max
-IT band
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| 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
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| 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
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| 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
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| 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
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| 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
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| Muscle strains/ Tendinopathy | -Hamstrings
-Adductors: aka groin
-Iliopsoas: aka hip flexor
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| Hamstring Tendinopathy | -Prevalence: uncommon
-Risk factors: not specified
-Etiology:
Non-optimal gait/
Training errors/
Muscle imbalances/
Deceleration injury during running
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| Hamstring Tendinopathy structures involved | -Hamstrings:
Musculotendinous junction > belly
Proximal > Distal
-Adductor Magnus:
Shared origin with hamstrings
Fascial connections
-Sciatic Nerve: possibly adhered if tendonosis
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| Hamstring Tendionpathy S&S | -Posterior hip/buttock P!... a deep ache
-Worsened with sitting and running
-TTP, P! with stretch and/or MMT
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| Hamstring Tendinopathy tests & measures | -Bent knee stretch test
-Slump test
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| 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
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| 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.
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| 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
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| Hamstring Tendinopathy prognosis | -Good out to @ least 6 months with 8-10 wks of eccentric exercises, lumbopelvic stabilization, and dry needling
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| 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
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| Thigh Strain Rx | -Kinetic innovations- hip flexor or hamstring dynamic brace
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| Hip special tests for return to sport screening | -Quantity and quality
-Limb symmetry
-Agility tests
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| 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
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