Orthopedic Management of the Hip

Ed Mulligan, PT, DPT, OCS, SCS, ATC Clinical Orthopedic Rehabilitation Education

Common Injuries of the Hip

Hi Area Hip A P Pain i

Classification-Based Treatment Hip

Intra-articular Extra-articular:

L b l i Lumbopelvic

Pelvic

Strains – Tendinopathy –

Traumatic Impingement Hypermobility

Bursitis

R/I with symptom  location/palpation

Lumbosacral R/O with lumbar  mobility and SIJ  provocation testing

R/O log roll,  scouring and FABER scouring, and FABER‐ FADIR maneuvers

Hypomobility yp y Pediatric

Pelvic Area Injuries

   

Osteitis Pubis Meralgia Paresthetica Piriformis Syndrome Piriformis Syndrome Hip Pointer

Osteitis Pubis • Mechanism of Injury:   – Overuse Overuse injury secondary to excessive  injury secondary to excessive superior/inferior shear forces at the  pubic symphysis p y – most common in soccer players and race  walkers

• Signs/Symptoms:    – ttenderness over the pubic symphysis d th bi h i – symptoms often exacerbated by passive  abduction or resisted adduction of the  hip

Management of Osteitis Pubis • rest, NSAIDs, normalize SIJ mechanics • when acute symptoms subside begin  h b id b i adductor stretching, balance abductor‐ g adductor strength, and abdominal core  strengthening

X X-ray demonstrating d t ti extensive t i erosive changes and widening of the joint space

Meralgia Paresthetica Dysfunction of the (sensory) lateral femoral  cutaneous nerve of the thigh as it passes cutaneous nerve of the thigh as it passes                through or over the inguinal ligament as                             it courses down the anterolateral thigh Predisposing factors Predisposing factors – obesity – pregnancy – “tight tight pants pants” Signs/Symptoms – Pain and paraesthia over the upper  anterolateral thigh anterolateral thigh – No muscle weakness

Meralgia Paresthetica Treatment    

Avoidance of irritating activities ‐ selective rest selective rest Weight loss NSAIDs ADL modifications – – –



Clothing Tool Belts Tool Belts Seat Belts

SIJ Screen/Treatment

Piriformis Syndrome   

Limited and painful passive IR and resisted ER of the hip Affected leg is often externally rotated Affected leg is often externally rotated Deep aching in the buttock and posterior thigh  –

   

usually not beyond the knee

Pain often aggravated by sitting, squatting or                                                 P i f db i i i walking More common in females  Oft Often associated with SI Joint Dysfunction  i t d ith SI J i t D f ti Right leg often affected after driving a long                                                           distance if foot has been in external rotation                                                         while depressing the gas pedal while depressing the gas pedal

Piriformis Syndrome Treatment 

Ultrasound



Soft Tissue Mobilization



Piriformis Stretchingg



Address faulty pelvic (SIJ)   or foot mechanics 



Address postural or work  related contributing factors g

Flex/ER vs. IR/Horz Abd

Maintain vs. lose lordosis

Hip Pointer Iliac Crest Contusion  Mechanism of Injury –



direct blow to iliac crest

Signs/Symptoms –

–

exquisite tenderness in soft tissues  around the iliac crest pain with trunk rotation or hip  motion

Hip Pointer Management • Ice and Elastic Bandage Compression • Gentle, pain‐free trunk and hip ROM to tolerance Gentle pain free trunk and hip ROM to tolerance • upon return to activity of risk ensure properly fitting hip pads  and orthoplast or hard shell protection of the area 

Quadricep Contusion Mechanism of Injury – direct blow to anterior thigh

Severity of Injury y j y – Grade I ‐ > 90 knee flexion – Grade II – 45‐90 knee flexion – Grade III ‐ Grade III 7? ti >7?

NO

YES

Pain Control: activity  Pain Control:  activity mods, PROM, soft tissue  techniques, nitro patches

Is hip rotation or  abduction ROM limited? bd ti ROM li it d? YES

ROM Training

NO

Strength and  Stability Training Stability Training

Mobility/ROM Training

Strength/Stabilization St gth/St bili ti Training

Hamstring Strain  

MOI – maximum eccentric contraction S/S – / –

contractile lesion with reproduction of  symptoms with passive stretch or active  y p p contraction

–

Palpable mass at origin, muscle belly, or  musculotendinous junction with resultant  l t di j ti ith lt t ecchymosis

–

Severity graded as I‐II‐III yg

Interesting study underscoring the importance of functional rehabilitation Sherry MA, Best TM.  A comparison of 2 rehabilitation  programs in the treatment of acute hamstring strains.   i h f h i i J Orthop Sports Phys Ther. 2004;34(3):116‐125.

Traditional Stretching/Strengthening Program Warm-up Warm up Stretching Isometrics Ice Warm-up Stretching I t i Isotonics Functional Progression Ice

Functional Rehab (agility - core stability)

Agility Movements Balance Core Stabilization Ice Agility Movements Dynamic Stretching Eccentric Training Ice

Results Traditional stretch  and strengthening  d h i rehab

Progressive agility  and trunk  d k stabilization rehab

Statistically  Statistically significant

37 + 28 days 37 + 28 days

22 + 8 days 22 + 8 days

no

Re‐injury within  2 weeks 2 weeks

6 of 11

0 of 13

yes

Re‐injury within  one year

7 of 10

1 of 13

yes

Mean time to  return to sport

NNT (Number Needed to Treat)

Statistical Impact of Choosing your Rehab Philosophy Incidence of Recurrent Hamstring Strains

Group size

(n)

Adverse Outcomes Risk for Adverse Outcome Risk for Adverse Outcome

Traditional Rehab

Agility/Core Training

10

13

7

1

CER ‐ 70% (a) CER  70% (a)

EER ‐ 8% (b) EER  8% (b)

Relative Risk

(b/a)

11% (c)

Relative Risk Reduction

(1‐c)

89% (d)

Absolute Risk Reduction

(b‐a)

62% (e)

NNT

(1/e)

1.6

For every 1.6 patients you treat with the agility/core stability perspective  you will prevent one patient from sustaining a recurrent injury

Intervention Recommendations 

Restore good pelvic posture –

Not more than 5‐10° APT requiring good  hip flexor and knee extensor flexibility



Ensure good static and  Ensure good static and dynamic hamstring length 

Intervention Recommendations Dynamic Hamstring Training 

Eccentric Hip Extension – – –

Low to High Tension Slow to Fast Speed Limited to Full Arc

Progress Dynamic Hamstring Training Demand

Front Snap p Kicks

Straight g Leg g High g Kicks

Functional Muscle Retraining Double Leg Deadlifts

Single Leg D dlift Deadlifts

Conclusion “A rehabilitation program consisting of progressive  agility and trunk stabilization exercises is more effective agility and trunk stabilization exercises is more effective than a program emphasizing isolated hamstring stretching g g and strengthening in promoting return  to sports and preventing injury recurrence  i thl t in athletes suffering an acute hamstring  ff i t h ti strain”

Proposed Grading Scheme to Determine Severity and Predict Return to Play Time



Older  patients with larger, distal, and retracted tears have  Old ti t ith l di t l d t t d t h slowest recovery

Cohen SB et al Sports Health 2011 Cohen SB, et al, Sports Health, 2011

Iliac Apophysitis Mechanism of Injury –

–

gradual onset of apophyseal     inflammation at the  ossification center of the iliac  crest secondary to repetitive  contractions by the oblique  abdominals, gluteus medius,  and TFL and TFL particularly common in  adolescent runners, soccer  players, or jumpers

ASIS

Lesser Trochanter

Ischial Tuberosity

Iliac Apophysitis Signs/Symptoms – pain pain over the iliac crest at the muscular insertions over the iliac crest at the muscular insertions – increased pain with resisted contraction into hip  flexion or abduction

Management     – 4‐6 weeks of rest with gradual resumption of  training activities – minimize cross body arm swing during running

Complications: Avulsion fractures

Snapping Hips 

Audible “snap” around the hip with movement



External (most common) – ITB crossing the greater trochanter



Internal – Iliopsoas tendon crossing iliopectineal                                   eminence when uncrossing the legs                                from a flexed, abducted, externally                                              p rotated position

Snapping Hip Objective Findings 

External – –



More dramatic “snap” (appearance of a pseudo subluxation) Look for a tight ITB

I Internal l –

–

More subtle, deep “snap” with tender‐ ness to palpation in the femoral ness to palpation in the femoral                                         triangle Look for tight hip flexors

Snapping Hip Treatment Address identified impairments     

Correct LLD Strengthen weak gluteal muscles Train core trunk stability Hip Mobilization p Stretch tight muscles –

ITB (external) and Iliopsoas (internal)

Clinical Criteria for the Diagnosis of

Trochanteric Bursitis

Both of the following are present 1. 2.

Aching pain in lateral hip Distinct tenderness around the greater trochanter

O One of the following must be present f th f ll i tb t   

Pain at end range Abd/Add or IR/ER or                                       + FABER test FABER test Pain on resisted hip abduction Pseudoradiculopathy                                                                ( i (pain extending down lateral thigh) t di d l t l thi h)

Greater Trochanteric Bursitis Predisposing Factors      

Older females with wider pelvis or                                ld f l h d l higher Q angles Leg Length Discrepancy Leg Length Discrepancy Excessive crossover in gait Irritated by pressure, direct blows, or tight  iliotibial band Common in rheumatoid arthritis Can also include “snapping Can also include  snapping hip hip” syndrome syndrome

Clinical Criteria for the Diagnosis of

Trochanteric Bursitis Management • Ice – NSAIDs or steroid injection • US Phonophoresis in subacute stages US Ph h i i b t t • Correction of LLD, LE biomechanics,     abnormal ambulation patterns • ITB and TFL stretching • Some suggestion in literature that this  condition may also be microtears at the  gluteus medius insertion causing tendin‐ osis (ultimately addressed with strength‐ ening (eccentrics) and nitro patches)

Plumber’s Helper

IImpactt off E Exercise, i St Steroid id Injection, and Shockwave Therapy

% Recovered

CCSI has short term impact but no long term value as opposed  to exercise intervention and shock wave therapy Rompe JD, et al, Am J Sports Med, 2009

Intra-articular Hip Injuries     

Pediatric – LCP ‐ LCP SCFE Traumatic – Fractures ‐ Dislocations Impingement – FAI: Pincer/Cam Hypermobility – Focal vs. Global Laxity Hypomobility – DJD/OA

Legg Calves Perthes - coxa plana avascular necrosis resulting in a flattening of the femoral head

Axial non-enhanced CT scan through the hip clearly shows the loss of structural integrity of the right femoral head.

Legg-Calves-Perthes Disease • Prevalence: 1:1200 kids (males > females) • Self limiting disease with spontaneous  healing as necrotic bone is replaced by  new bone formation over 1 4 years new bone formation over 1‐4 years • Can have residual effects from incon‐ g gruency and persistent hip abductor  y p p weakness

Legg-Calves-Perthes Disease Signs and Symptoms: – Usually a gradual onset in boys between the age of 4‐8 U ll d l ti b b t th f4 8 – More typical in small for age, hyperactive kids – Mild limp (trendelenburg) following activity with vague hip and groin  pain; symptoms usually relieved by rest – Limitations in Abduction and Internal Rotation

Management: – Rest (reduced activity), crutches prn, maintain ROM (especially  abduction), NSAIDs,  – Surgery indicated if over 8 (femoral or pelvic osteotomy) S i di t d if 8 (f l l i t t )

Slipped Capital Femoral Epiphysis Femoral head slips in a posteromedial  direction on the femoral neck direction on the femoral neck

Slipped Capital Femoral Epiphysis Signs/Symptoms – Obese Obese males between 9‐15 YO (periods of rapid  males between 9‐15 YO (periods of rapid growth spurt) – BEWARE of lateral knee pain – Limited and painful hip internal rotation with hip  Limited and painful hip internal rotation with hip often held in flexion secondary to psoas spasm – Leg Length Discrepancy; involved limb shortens

Post‐op Management – 4‐6 weeks of NWB; followed by gradual resumption       of weight‐bearing and ADL activities

Differentiation of SCFE and LCP



SCFE has more limitation in flexion SCFE SCFE symptoms are usually more severe t ll Evidence of slippage evident on radiograph



Clinical Evidence of Slippage li i l id f li

 





Stable  – vague knee/hip pain; – antalgic limp with toe out gait Unstable – hip flexion accompanied by ext. rotation – unable to walk without crutches

Femoral Stress Fracture   

Most prevalent in runners and military personnel in  training Most common in neck and shaft “Fatigue” injury as a result of excessive training, pre‐ disposing bone pathology and/or poor nutrition disposing bone pathology, and/or poor nutrition  (female athletic triad)

Symptoms – – –

Deep aching in hip; pain often referred into groin and  knee Morning stiffness does not ease  g Symptoms increase with activity

Femoral Stress Fracture Clinical Signs      

+ Fulcrum Test F l T MRI? Gold Standard for Diagnosis is bone scan  ((SN – 100%; SP – ; 76‐100%)) Pain at extreme of hip motions Antalgic Gait Pain/Weakness to resisted hip flexion / k d h fl May have + FABER with anterior hip pain  p and muscle spasm

Femoral Stress Fracture Management 





NWB f 23 k d i t t FWB NWB for 2‐3 weeks and progressive return to FWB  over 4‐6 weeks using absence of hip pain as guide –

Tension (superior) – more likely to progress/displace

–

Compression (inferior)

Initial strength/mobility emphasis is in a non‐ weight‐bearing position g gp Nutritional Counseling –



Adequate calcium and Vitamin D intake

Education on appropriate training IDF d i i i i

Traumatic Hip Dislocation 



Mechanism – Typically high‐velocity collision  T i ll hi h l it lli i resulting in posterior dislocation Management g – Slow, cautious rehab secondary to high  risk for avascular necrosis – NWB for 2‐6 weeks f 26 k – Careful of: – Flexion  Flexion – Adduction  Adduction ‐ IR

Acetabular Labral Tears Acetabular Rim Syndrome

Acetabular Labral Tears Epidemiology – – – – –

20% of athletes with chronic or unresolved   f hl h h l d groin pain 55% of adults with undiagnosed 55% of adults with undiagnosed                    mechanical hip pain Most common area is anterior‐superior labrum Posterior involved if hip dislocation major etiological factor in the development of  osteoarthritis of the hip osteoarthritis of the hip

Acetabular Labral Mechanism of Injury 

Degenerative in older patients



Minor to major trauma in youth



Increased risk if dysplasia or  Increased risk if dysplasia or decreased anteversion

Mechanisms of Injury 







Trauma (most often hip extension and ER) i ti /Pi ti ( lf ti h k b b ll t ) – T Twisting/Pivoting (golf, gymnastics, hockey, baseball, etc) Femoral Acetabular Impingement (FAI) – Cam – large femoral head g – Pincer – abnormal acetabulum                                                              with overcoverage Capsular Laxity Capsular Laxity – Cause or result? Acetabular dysplasia

Acetabular Labral Symptoms 

Pain Location – –

92% groin; 59% lateral hip; 52% anterior  l lh thigh/medial knee; 38% buttock area 85%+ have sharp pain with activity and                              pp y painful mechanical locking Burnett RS, J Bone Joint Surg, 2006



Clicking/Catching –

100% specificity/85% sensitivity  Narvani, Knee Surg Sport Traumatol Arthrosc, 2003 i S S l h 2003

Acetabular Labral Symptoms 

May have full PROM but pain in quadrant                                position (hip FADIR position which often indicates FAI) position  (hi FADIR iti hi h ft i di t FAI)



+ FABER test



+ Scour test S



Limited and/or painful flexion and IR



 discomfort with active SLR or                                                          end range hip extension

Non-Op Rehabilitation Considerations    

Rest and limited weight bearing as necessary Focus on controlling hyperextension and ER forces if hyper‐ Focus on controlling hyperextension and ER forces if hyper‐ mobile and end‐range flexion and abduction if FAI Trunk stabilization and LE proprioceptive control A id Avoid  – symptomatic SLRs – sit‐ups with hips flexed – Lunges – prone hip extension at end range – weight‐bearing rotation g g – cycling on upright bike

Non-Operative Management Yazbek PM, et al,  May 2011 issue

Case series demonstrating con‐ servative success in 4 subjects

Post-Op Rehabilitation Considerations 

PWB for first 2‐4 weeks dependent upon  resection vs repair resection vs. repair



Careful of end range flexion and abduction in  p first couple of weeks



Expect full PROM in 2‐4 weeks



Isometrics can begin 2 g nd p post‐op day; AROM at  p y; about 2 weeks



Weight bearing PREs can began as tolerated  when non‐antalgic FWB gait h l

Prognosis 

Failed conservative intervention over 4‐6 weeks  i is probably a good indicator that arthroscopic  b bl d i di h h i hip surgery should be considered

Good resource for post-op guidelines

www.bryankellymd.com

Hip Osteoarthritis

Degenerative Joint Disease 

Progressive deterioration of the articular                                    cartilage and overgrowth of periarticular cartilage and overgrowth of periarticular                                         bone (osteophytes)



Can be primary (idiopathic) secondary to aging



Can be secondary (traumatic) or as a result of                                      congenital abnormalities that alter biomechanics – – – –

Coxa vara Coxa vara LLD LCP AVN

Hip Osteoarthritis Signs/Symptoms 

Anterior groin pain



Stiffness after prolonged rest



Decreased ROM in extension, IR,                                       Decreased ROM in extension IR and loss of end range flexion



Antalgic gait and pain with ADLs Antalgic gait and pain with ADLs

Classification Criteria (non-medical) for

Hip OA   

Hip Pain Hi IR 15˚ Hip IR  50

Sensitivity of  86% and Specificity of 75% ((medical criteria that are used include radiographic  di l i i h di l d di hi evidence and ESR)

+ LR = 3.4; 3 4; - LR = 0.19 0 19

Preliminary CPR to Identify Hip OA The following 5 variables constitute the Hip OA rule: 1 Self‐reported squatting as an aggravating factor 1. Self‐reported squatting as an aggravating factor 2. Active hip flexion causing lateral hip pain 3. Scour test with adduction causing lateral hip or  groin pain groin pain 4. Active hip extension causing pain 5. Passive hip IR less than 25˚

3/4 = + LR of 5 3/4 LR f 5 4/5 = + LR of 24 Sutlive T, et al, JOSPT, 2008 , , ,

Hip OA Imaging and Prognosis Kellgren‐Lawrence Scale – Joint Space Narrowing  Normal joint space should be 3‐5 mm N lj i t h ld b 3 5  Reduction > .5 mm is considered significant  Disease severity considered moderate