Conservative Interventions for the Hip Region

Transcription

1 Anatomical Considerations Conservative Interventions for the Hip Region Shoulder vs. Hip RobRoy Martin, PhD PT Associate Professor Duquesne University Staff Physical Therapist UPMC/CRS Center for Sports Medicine 1 2 Evaluation Algorithms Purpose Efficient systematic collection of information Determine diagnosis and prognosis. Can work in concert with a classification-based treatment system. Classification-Based Treatment Purpose Define subgroups of patients who are likely to respond to a specific treatment approach Prioritize treatment plan 3 4 Classification System for Physical Therapists Lumbosacral Extra-articular Intra-articular Impingement Hypomobility Traumatic 5 Traumatic Hip vs Lumbosacral Spine Extra vs Intra-Articular ROM: Flexion-Internal Rotation Over Pressure Scours FABER History Altered WB Lumbar ROM Standing Flexion Long Sit Prone Knee Flexion Spring Test Eval and Treat Lumbosacral Pathology Eval and Treat Extra - Articular Pathology Palpation Flexibility tests Resisted tests Impingement Hypomobility Flex-Add-IR DIRI DERI Posterior Rim Distraction Beighton s Scale Log Roll Increased ROM Values- External Rotation Distraction Reduced ROM Flex and IR FABER 6 1

2 Lumbosacral Spine If tests are positive for a lumbosacral disorder, treatment may be directed toward this area. Re-evaluate response to treatment to see if hip symptoms resolve. Lumbosacral Spine Lumbosacral classification system Manipulation/mobilization (3/4 tests, hip >35IR) Stabilization (ASLR, prone instability test) Specific direction preference exercises (flexion, extension, or lateral shift) Traction Delitto A, Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther 37: , Manipulation/ Mobilization Manipulation/ Mobilization The technique involves positioning the patient, with respect to the lumbar spine, in side bending toward and rotation away from the painful side. A force directed anterior to posterior is applied to the ipsilateral anterior superior iliac spine in Grade 5 thrusting maneuver. It should be noted before this manipulation is applied contraindications for a thrust mobilization must be thoroughly cleared Manipulation/ Mobilization Childs et al. developed a clinical prediction rule for the mobilization category that involves the following 5 factors: duration of current symptoms being less that 16 days a score on the work subscale of the fear-avoidance belief questionnaire (FABQ) of less than 19 hypomobility of the lumbar spine (assessed with posterior to anterior pressure) internal rotation of 1 hip greater than 35 degrees symptoms not extending distal to the knee When 4 of these 5 factors were present the patient was very likely to improve with a mobilization treatment When 2 or fewer factors were present the mobilization treatment was almost always associated with failure. These findings are consistent with Brown et al. as it was found individuals with limited hip internal rotation were 3.63 times more likely to have a hip disorder than a spine disorder. Manipulation/ Mobilization Generally, patient s who fall into this category are also given: Lumbopelvic range of motion Stabilization exercises We find patients with hip pain commonly have signs and symptoms consistent with this category and often positively respond to some degree to this mobilization technique

3 Hip vs Lumbosacral Spine Extra vs Intra-Articular Eval and Treat Lumbosacral Pathology Eval and Treat Extra - Articular Pathology Traumatic Impingement Hypomobility 14 Common Extra-articular Pathologies Iliotibial Band/ trochanteric Bursitis Gluteal medius/ Minimus Tendinopathy Adductor Longus Tendinopathy Sports Hernia Deep Gluteal Nerve Syndrome Iliotibial Band Syndrome/ Trochanteric Bursitis The ITB is a wide, flat yet thick piece of connective tissue arising from: tensor fascia lata gluteus maximus muscles. The ITB runs over the Trochanteric bursa down the lateral aspect of the thigh Generally the symptoms are a result of the ITB/bursa rubbing on the greater trochanter. 16 Iliotibial Band Syndrome Iliotibial Band Syndrome Etiology usually an over-use problem The most common cause of ITB syndrome at the hip is a tight ITB. Can also be associated with excessive adduction( lateral lurch, pelvic drop) resulting from weak hip abductors. Training error Tight Adductors Weak Gluteus Medius Leg Length Discrepancy Increased pronation (internal rotation of lower extremity) Worn Shoes Direct trauma can cause trochanteric bursitis Symptoms Lateral hip pain Lateral snapping (Snapping Lateral Hip Syndrome) Epidemiology Incidence Unknown Age years of age Gender ITB Syndrome at the hip is more common in females than males

4 Iliotibial Band Syndrome Clinical exam findings- Reproduce Snapping!!! Flexibility Modified Thomas Obers MMT Gait Leg length Iliotibial Band Syndrome The standard progression of therapy (Decrease inflammation/improve ROM/increase strength and return to activity) is warranted. Proper ITB stretching (Hip extended/adducted/er with sidebending away) is important. It makes sense to incorporate components of hip flexion and extension into the abduction stretch. Increases in length of Tensor and Glut Max will gain additional length in the ITB. Manual stretching Soft Tissue Massage/ Mobilization Modalities may be indicated Treatment- 19 You cannot just treat the lateral hip pain and must correct any biomechanical abnormalities (including tightness and weakness) as well as educate in proper training techniques Foam Roller 24 4

5 25 26 Muscle Strain Common muscles that are involved include adductor longus (groin), gluteus medius, proximal hamstring, Hip flexor (psoas and rectus), and abdominal musculature (i.e. sports hernia). The increased injury risk is likely due to: Percentage of Type II muscle fibers Secondary to their multi-joint nature, the hip muscles are frequently in an elongated position while performing a deceleration (eccentric) task (increased length + eccentric contraction injury risk). The biceps femoris, which is frequently strained, serves as a good example. It is a 2-joint muscle, assists with decelerating the tibia during terminal swing and histologically is comprised predominantly of Type II muscle fibers Muscle Strain Muscle strain injuries range from minor to complete. A fourtier classification system has been proposed: Pain commonly located near the muscle tendon junction. Patients generally report an onset of acute pain during activity. Musculotendinous disorders including muscle strains and/or tendon disorders should be: painful with palpation Stretching resisted movements directed at the involved muscle and/or tendon. If the source of pain is solely from intraarticular origin, palpable pain is rarely present. Grade I Grade II Grade III Grade IV Few muscle fibers involved Moderate number of muscle fibers involved with fascia intact Many fibers involved with tearing of the fascia Complete Tear (rupture)

6 Treatment When treating soft tissues disorders around the hip an injury treatment program will depend on the phase of the injury that can be defined as either: Acute/ inflammatory Subacute Chronic/ remodeling. Acute Acute injuries are treated with: Modalities to promote healing, decrease pain and inflammation Massage Submaximal isometric exercises Passive range of motion Lumbopelvic stabilizing exercises. It is important to emphasize that all of these intervention techniques should be pain free Subacute Concentric movement through a full range of motion can be used as the criteria to progress to the subacute phase. Subacute injuries are treated with concentric exercises including functional closed chain/ weight bearing exercises. Progression includes the addition of lumbopelvic stabilization activities, general flexibility, and progressive balance/ stability exercises. Chronic/Remodeling Criteria to progress to chronic/ remodeling phase can include range of motion equal to uninvolved side and strength approximately 75% of uninvolved side. Pain with resisted testing should be minimal. The remodeling phase should emphasize eccentric exercises and sport specific training. Throughout this rehabilitation process, strengthening of the lumbopelvic stabilizing muscles should be encouraged. However, educating the patient to engage these muscles during sport specific activity we find to be critical Treatment Lower extremity biomechanics and muscle imbalances need to be carefully evaluated and corrected as appropriate. Our program often includes the use of foot orthotics or heel/shoe lift as well as educate in proper training techniques. Decrease Inflammation Restore ROM Improve Strength Return to Function. Education and injury prevention Proper warm-up Stretching strengthening Conditioning Training techniques Modalities

7 This generic program can be used to treat any musculotendon disorder, including those involving the gluteus medius, proximal hamstring, psoas, and abdominals. However, the adductor longus may be the most commonly treated musculo-tendon disorder. Holmich et al. found that compared to a passive physical therapy of massage, stretching, and modalities, an 8-12 week strengthening program produced better outcomes. Both strength and flexibility issues have been found to play a role in the onset of muscular-tendon injuries, however, Tyler et al. found strengthen deficits to play a larger role. 37 General Stretching Stretching Positions Psoas: Hip extension, slight abduction and internal rotation Iliotibial band: Hip adduction, slight extension, external rotation and side bend away Adductor longus: Hip abduction, slight extension and internal rotation Piriformis: External rotation with the hip near 90 degrees flexion General stretching to increase hip ROM can be done with basic physiological movements that are similar to goniometric positioning and movement

8 Deep ROTATOR Stretching in seated position, the patient crosses the leg that will be stretched with the foot positioned next to the knee. The patient pulls the knee towards the contralateral shoulder Prone Eccentrics/Contract Relax Offers new perspective on how to treat the deep rotators and associated neurovascular structures Sciatic Nerve Glides Stretching/manual therapy without causing impingement Further investigation is needed 45 With the patient in a siting position, the patient holds with both hands under the knee. (A) Cervical extension, knee flexion and dorsiflexion. (B) Cervical flexion, knee extension (under the limit for each phase), plantar flexion. The patient can apply lumbar flexion and extension during the exercise. 46 Sciatic Nerve Mobilizations Passive hip circumduction begin at 45 degrees of hip flexion Move to maximum external rotation Engaging the greater trochanter against the ischium to mobilize the sciatic nerve lateral. Traumatic Hip vs Lumbosacral Spine Extra vs Intra-Articular Impingement Eval and Treat Lumbosacral Pathology Eval and Treat Extra - Articular Pathology Hypomobility

9 Hip vs Lumbosacral Spine Extra vs Intra-Articular ROM: *Internal Rotation Over Pressure FADIR Scours FABER Lumbar ROM Standing Flexion Long Sit SI Compression SI Distraction Spring Test Eval and Treat Lumbosacral Pathology Eval and Treat Extra - Articular Pathology Palpation Flexibility tests Resisted tests Impingement: Location of Labral Tear DIRI DEXRI Posterior Rim Traumatic Hypomobility History Impingement Altered WB DIRI Distraction Reduced DEXRI ROM Flex and Posterior Rim IR FABER 49 Bony geometry Validity of Dynamic Impingement Testing for Determining the Location of Femoroacetabular Impingement: A Cadaveric Study Benjamin R Kivlan, et al, BAOJ Ortho : 1 1: 003 The DIRI and DEXRI tests may be used to discriminate the location of labral pathology from anteriorinferior (Zone 1) to posteriorinferior (Zone 5) positions. Femoral Anterversion/ Retroversion Gait Toeing in- Anteversion Toeing out- Retroversion Craig s test 15º Internal rotation normal > 15º Anteversion < 15º Retroversion ROM Increase internal rotation/ Decrease external rotation Anterversion Decrease internal rotation/ Increase external rotation Retroversion MR Arthrogram

10 Classification Based Treatment Impingement Joint Mobilization Work within the Pain-free limits Sagital Frontal Gluteus Medius Strengthening Trunk Stabilization Joint Mobilization Inferior Posterior Traumatic Hip vs Lumbosacral Spine Extra vs Intra-Articular Impingement Eval and Treat Lumbosacral Pathology Eval and Treat Extra - Articular Pathology Hypomobility Beighton Score Range of motion ER/IR Distinguish between femoral version and capsular laxity Distraction Anterior instability Log Roll Ligament Teres Test Squat test 57 Beighton Score Distraction 10

11 Anterior instability Log Roll/Bounce Back Ligamentum Teres LT can be defined as a rotational stabilizer in all hip positions but the primary rotational stabilizer in the upper range of flexion, greater than 90. The function of the LT may be described using a ball and string model where rotational movements of the femoral head that occur in the transverse and frontal planes cause LT to act as a sling as it wraps around the femoral head. LT tightens it pulls the femoral head into the actetabulum to increase stability as the hip is moved closer to end range. This stabilizing function becomes important when the capsular Ligaments are in a loose pack position of hip flexion, in those withosseous risk factors for instability, and may also be more important as the in those with capsular laxity. Martin RL, Martin HD. Function and Clinical Relevance of the Ligamentum Teres: A Current Concept Function and Clinical Relevance of the Ligamentum Teres: Current Orthopaedic Practice. 26: ; 2015 Martin HD, Hatem, MA, Kivlan BR, Martin RL. The function of the ligamentum teres in limiting hip rotation: A cadaveric study. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 30: ; Martin RL, Kivlan BR, Clemente FR. A cadaveric model for ligamentum teres function: A pilot Study. Knee Surgery, Sports Traumatology, Arthroscopy. 21: ; This LT test was performed with the hip moved to 70 flexion and 30 short of full abduction. The hip was then internally and externally rotated through full range of motion assessing for reproduction of pain. Sensitivity and specificity values of.90 and.85, respectively. The authors concluded that partial LT tears could be identified by the LT test. It should be noted that the one subject is this study with a complete tear had a negative LT test. Because this test relies on the reproduction of pain it may not be useful for those with complete LT tears. Ligament Teres Test Kivlan BR, Clemente FR, Martin RL, Martin HD. Function of the ligamentum teres during multi-planar movement of the hip joint. Knee Surgery, Sports Traumatology, Arthroscopy. 21: ; Martin RL, Palmer I, Martin HD. Ligamentum teres: A functional description and potential clinical relevance. Knee Surgery, Sports Traumatology, Arthroscopy. 20: ; O Donnell J et al. The ligamentum teres test: A novel and effective test in diagnosing tears of the ligamentum teres. AM J Sports Med 2014 The LT was found to for a sling in flexion-abduction external rotation in a cadaver study Squat Test Classification Based Treatment Hip Stabilization Proprioception Gluteus Medius Strengthening Kivlan BR, Clemente FR, Martin RL, Martin HD. Function of the ligamentum teres during multi-planar movement of the hip joint. Knee Surgery, Sports Traumatology, Arthroscopy. 21: ; Trunk Stabilization 66 11

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13 73 74 Eval and Treat Extra - Articular Pathology Pearls and Perils Myofascial pain Psoas Rectus femoris Gluteus Medius/Minimus Piriformis/Short Rotators Treatment Soft-tissue mob Stretching Strengthening Pearls and Perils Pearls and Perils tape 13

14 Pearls and Perils Hip vs Lumbosacral Spine Eval and Treat Lumbosacral Pathology Extra vs Intra-Articular Eval and Treat Extra - Articular Pathology Traumatic Impingement Hypomobility 80 Classification Based Treatment Hypomobility Joint mobilization Distraction Inferior Posterior Strengthening Pain free protected weight bearing ROM DEFICITS Joint Mobilization Long Axis Distraction Inferior Glide Posterior Glide Lateral Distraction Stretching Hand-Heel Rock Classification Based Treatment Hypomobility Joint mobilization Distraction Inferior Posterior DJD Treatment Education Assistive device Exercise Stretching/ joint mobilization Strengthening Pain free protected weight bearing

15 Aquatic Exercises DJD Education Patients should be counseled with respect to activities that negatively impact the disease process and alternative exercises suggested. Patients should be encouraged to move their hips frequently throughout the day to limit the stiffness and improve joint nutrition. Weight loss should also be discussed when indicated. It was found that for each pound of weight loss there is a 4-fold reduction in the load exerted per step at the knee during daily activities De-weighter DJD Assistive device Assistive device (i.e. cane) for use on the contra lateral (unaffected) side should be recommended if necessary to relieve pressure on the joint. The use of a cane for ambulation can be encouraged as 25% of the body weight can be offloaded from the lower extremity by using this device. Additionally, adaptive devices may be necessary to raise the height of chairs and commodes to make the process of sit stand transfers DJD Stretching and Joint Mobilization Increases in joint motion may be achieved by instituting a progressive series of joint mobilization techniques followed by stretching as tolerated. Given the capsular pattern of the hip, the posterior and inferior portions of the capsule should be addressed Improvements in motion should allow the patient a greater range in which to ambulate more normally and perform ADLs

16 Posterior Glide Joint Mobilization DJD Exercise Patients should be encouraged to participate in regular exercise that minimizes joint reaction forces. Specifically, aquatic exercise and cycling are excellent activities for the patient with hip OA. Strengthening All weak muscles should be addressed however the hip abductors are often characteristically weak. Sufficient weakness of the gluteus medius may cause the gait deviations. Strengthening of the gluteus medius in order to be effective must really be performed with the hip in extension avoiding external rotation. Increases in strength should assist with absorbing externally applied forces thereby lessening pressure at the joint. CLINICAL GUIDELINES MICHAEL T. CIBULKA, DPT DOUGLAS M. WHITE, DPT JUDITH WOEHRLE, PT, PHD MARCIE HARRIS-HAYES, DPT KEELAN ENSEKI, PT, MS TIMOTHY L. FAGERSON, DPT JAMES SLOVER, MD, MS JOSEPH J. GODGES, DPT Hip Pain and Mobility Deficits Hip Osteoarthritis: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association

17 Recommendations* Pelvic and Trunk Stability Interventions Patient Education: Clinicians should consider the use of patient education to teach activity modification, exercise, weight reduction when overweight, and methods of unloading the arthritic joints. (Recommendation based on moderate evidence.) Functional, Gait, and Balance Training: Functional, gait, and balance training, including the use of assistive devices such as canes, crutches, and walkers, can be used in patients with hip osteoarthritis to improve function associated with weight bearing activities. (Recommendation based on weak evidence.) Manual Therapy: Clinicians should consider the use of manual therapy procedures to provide short-term pain relief and improve hip mobility and function in patients with mild hip osteoarthritis. (Recommendation based on moderate evidence.) Flexibility, Strengthening, and Endurance Exercises: Clinicians should consider the use of flexibility, strengthening, and endurance exercises in patients with hip osteoarthritis. (Recommendation based on moderate evidence.) Gluteus Medius Quadratus Lumborum Erector Spinae Abdominals i.e. Scapula stabilization Gluteus Medius Gluteus Medius Gluteus Medius Quadratus Lumborum Serratus and Lower Trap of the pelvis

18 Quadratus Lumborum Erector Spinae Erector Spinae Abdominals Athletic Pubalgia/ Sports Hernia PAIN PRESENTATION IN ATHLETIC PUBALGIA Term describing a spectrum of chronic pubic/inguinal pain A sports hernia, also known as athletic pubalgia, is a tear in the muscles of the lower abdomen

19 Treatment Muscle strain progression Will depend on the phase of the injury that can be defined as either: Acute/ inflammatory Subacute Chronic/ remodeling Conclusion We have integrated a general evaluation algorithm and classification based treatment that includes considerations for the: lumbosacral spine extraarticluar soft-tissue intraarticular structures Impingement hypomobility

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