Hip Region. PHTY2020: Lecture

Transcription

1 Region PHTY2020: Lecture Functional Overview Transfer body weight form trunk to legs Allows leg to adopt numerous positions needed for standing, walking running, stairs, sitting and other ADL eg. putting socks on, cutting toenails etc. Anatomy Ball and socket joint Stable joint Considerable mobility Glutei and ITB help med-lat stability, especially gluteus meduis Femoral Component Convex articulating surface Femoral neck angle 126 degrees to shaft and 12 degrees to frontal plane (angle of femoral torsion) Head faces acetabulum medially, cranially and slightly ventrally Pelvic Component Concave articulating surface (acetabulum) Acetabular labrum continuous with rim Transverse acetabular ligament completes circle Acetabular notch permits vessels and nerves to pass in ligament of head Articular fat pad moves in/out notch with pressure

2 Adipose tissue is highly innervated high potential for pain if we compromise a fat pad Muscles of the gluteal region Biomechanics Compressing force as we stand Body weight is distributed between two legs As soon as you go into single leg stance you get a different biomechanics 3 rd order lever system Weight is being pushed down on the medial side of the femur (A) Ratio of inner arm to outer arm is 3:1 3 times the body weight acting on that lever. The glutei must be able to exert 2x bodyweight in unilateral stance in order to maintain pelvis at equilibrium. Glutei are helped by ilio-tibial band (ITB) Static stabilizer during unilateral stance Tension band: protects femur from excessive medial bending deformation ITB converts tensile load into compression load along lateral femoral cortex Amputees (AK) have +ve Trendelenburg s sign due to loss of ITB stabilizing function Loose-Packed Position Position in which capsule is most relaxed Minimal joint contact Maximal joint play (accessory movement) Flexion 30 Abduction 30 Slight external rotation

3 Close-Packed Position Position in which capsule is most tensed Maximal joint contact Minimal joint play (accessory movement) Maximal extension Slight internal rotation Flight abduction Capsular Pattern Characteristic pattern of decreased movements duet o entire capsule being shortened eg. OA Gross limitation of: flexion // abduction // internal rotation Often limitation of extension Little or no limitation of external rotation Extrinsic Disorders and groin pain due to urogenital or abdominal organ disease eg. appendicitis Disease of local structures eg. lymphadenopathy Referred pain from back, knee, SIJ (buttock pain), L1 L2 radiculopathy and somatic lumbar dysfunction/arthritis Neurological: Spinal Nerves Intrinsic Disorders Groin or lateral thigh pain Buttock or posterior thigh pain infrequently May radiate anteriorly to just above knee or as far as shin Extent of radiation related to degree of inflammation Includes: Osteoarthritis (OA), Femoral neck (NOF) fractures, Femoro-acetabular impingement (FAI), Labral tears, Tendinopathies eg H/S, add/ glut med., Greater trochanteric pain syndrome (GTPS), Peripheral nerve entrapment (LFCN), tumours or metastatic deposits Osteoarthritis Common >50 yrs Pain and xray changes: poor correlation Pain related to loading May have decreased ROM and mm wasting May develop flexion limitation, ER deformity lost range of internal rotation Antalgic, swinging or Trendelenburg gait Patient education Weight loss Passive joint mobilization Exercise: Increase ROM, strengthen glutei and quads, unloaded exercise eg. stationary bike, hydrotherapy OT eg. home modification & walking stick Analgesics, NSAIDs Operative: THR Femoro-acetabular Impingement (FAI) Anatomical variation of femoral head (Cam), acetabulum (Pincer) or both (Mixed) Cause: Genetic, repetitive twisting forces during growth periods 20% population have FAI: ca. 20% of these have hip pain Associated with increased risk of intra-articular pathology eg. labral tears, chondral damage, OA FAI assessment Early identification of FAI in sportspeople with hip pain important Groin/anterior hip pain & decreased ROM +ve FADIR test radiological investigation if sportsperson FAI management Conservative

4 Aimed at avoiding position of impingement Activity modification Stretch tight structures (muscle or capsule) Improve lumbo-pelvic and hip strength & control Surgical If conservative management fails Arthroscopic femoral osteoplasty Labral Tears Common in athletic population Presents with groin pain Usually twisting/loading injury Increase risk in FAI, developmental dysplasia Diagnosis Special tests in isolation have poor specificity MRI, CT, U/S and/or arthroscope Combine clinical and radiological findings Conservative or arthroscopic debridement Tendinopathies Common in athletic populations Adductor/iliopsoas/rectus femoris (groin pain) Gluteus medius/minimus (lateral hip pain) Pain on static contraction, palpation and stretch Exercise without pain Improve lumbo-pelvic and hip strength/control Strengthen local muscles using proven protocols Progress level of activity with regular assessment Greater trochantereric pain syndrome (GTPS) Previously called hip bursitis Trochanteric bursitis and glut med/min tendinopathy probably coexist Common in distance runners and female >40 yrs Caused by compression of lateral hip structures (often poor LL biomechanics) Education: relationship of symptoms to posture Correct abnormal biomechanics Strengthen lumbo-pelvic and hip muscles NSAID s Corticosteroid injections (?) can weaken tissue Nerves

5 LFCN entrapment Compressed by inguinal ligament Burning pain, numbness, tingling or itchiness in anterolateral thigh called meralgia parasthetica No motor loss Extension aggravates Avoid aggravating activities/postures Local massage Cortison injection Microsurgery to decompress nerve Manual therapy Painful hip in an elderly person Fracture Unwilling to weight bear, leg shortened, ER Tumour Past history of cancer Painful hip in a child Slipped femoral epiphysis (when leg is lifted, it won t come up in a straight line) Pain, Limited IR Transient virus or synovitis Diagnostic accuracy of physical examination tests Most special tests of the hip show poor diagnostic accuracy when used in isolation - Often poor sensitivity/specificity - region tests not well investigated - Quadrant and FADIR tests show high sensitivity (good at ruling out hip pathology when the result is ve) - Cluster of +ve findings often better diagnostic value May explain why patients have hip pain often undergo inappropriate imaging, treatment and delayed diagnosis