multiple choise quiz questions :nagement of Hip
Disorders & Surgeries
- Anterior Pelvic Tilt
Hip flexion & increased lumbar spine extension
Mm: hip flexors and back extensors
- Posterior Pelvic Tilt
hip extension lumbar flexion
mm hip extensors and trunk flexors(abdominals)
- Lateral Pelvic Tilt- Abnormal, hip drop/hike
hike: quadratus lumborum
- Compensate: truck lurtch
Pelvic Movements
Hip Movement
Osteokinematic Arthrokinematic Glide
Flexion→ posterior
Extension→ anterior
ABduction→ inferior
ADduction→ superior & lateral
Internal rotation→ posterior
External rotation→ anterior
● Control of hip motions and positions affects the entire LE alignment
● Hip flexion
accompanied by: flexion of knee/ DF/ flexion of the trunk
● Hip extension
PF, hyperextension of knee
● Hip ABD
High arch supernation/ knee varus- stress on LCL
● Hip ADD
Knee valgus- MCL , pronation ,flat feet/
● Hip ER
● Hip IR
eversion/ pronation / Feet: toe in
LE Functional Relationships in WB
- Decreased flexibility from muscle tightness- psoas , IT band, piriformis,
adductors,
- Hip joint hypomobility - idiopathic joint tightness(joint mob loose/ STM)
- Stretch Adduction. ER extension
- Muscle weakness
- Causing knee pain, knee sprains
- Piriformis syndrome- weak hip extensor and abductor(max&med)-
pirformis overuse
- Hip muscle imbalances
- Shortened TFL/ glut med- ant pelvic tile, slouched posture, flat back
- Dominance of TFL over glut med
- Dominance of rectus femoris(AIIS) over psoas
- Dominance of hamstrings over glut max
- Use of lateral trunk muscles as hip abductors- Overuse QL,
- Asymmetrical Leg Length
- Unilateral short limb
- Coxa Valga or coxa vara
- Anteversion or Retroversion
Pathomechanics
Causes (decreases space in joint)
● Osteoarthritis, bone spurs prevent normal movement (most common)
● Post-immobilization Hypomobility
● RA
● Dislocations(medical side, medical emergency). Ant dislocation is common
● Congenital deformities
○ Leg Calf Perthes Disease / childhood
Common structural/ functional impairments
● Groin pain (anteriorly) refer pain to IS joint
● C-sign, c shape w/hand on hip
● Stiffness after rest-hypermobility cause
● Limited ROM - firm end feel
● Impaired balance
● Gait abnormalities
● Poor posture
Joint Hypomobility
Hip pain plus:
● PROM IR< 25°
● Active hip extension causes pain
● Active hip flexion causes lateral hip pain
● (+) scour test with ADD (pic on bottom) will cause lateral or groin pain
● Pain with squatting
When 3 of the 5 symptoms above are present: 29-68% probability of hip OA
When 4 of the 5 symptoms are present: 91% probability
CPR(clinical prediction rule) - Diagnosis of
Hip OA
Knee flex Hip flex past 90 ADD hi
ER
Common Activity Limitations
● Decrease activity tolerance for ADLs and recreation
Early stages
● ↓ activity tolerance - interferes with recreational activities
● Progressive pain with continued WB at the end of the day interferes with
sleep
● Hip pain at night, Morning stiffness and pain till body warms up
Progression
● ↑ difficulty with sit to stand, stair climbing, walking, squatting
● ↑ difficulty Walking uneven surfaces, gravel, grass, curb steps
● Restricted ADLs
Joint Hypomobility
Normal Gait
● 40 degrees of hip flex
● 10 degrees of hip ext
● 8 degrees of pelvic rotation
● If limited, limping will start****
Max Protect
Joint Hypomobility- do stretch
Pain mgmt - joint mobs
Patient ed on joint health
PROM/ AAROM to
maintain ROM
Aquatic therapy
AD and adaptive
equipment
Isometric exercises
Mod Protect
LE warm-up
Progressively ↑ joint
motion
Joint mobs/ STM/
stretching/ MWMs
Pain-free ROM
(flexibility)
Increase aerobic
capacity
Progress to
strengthening at pt
level
Min Protect
LE warm-up
Progress to isotonic
CKC
Balance exercises
Functional exercises
Patient ed on being
active in painfree
manner
Joint Surgeries
- Arthroscopic Surgeries
- Chondroplasty/ microfracture – repair cartliage
- Resection or repair of acetabular labral tear
- Osteoplasty and rim trimming- bone abnormality
- Capsular Modification –capsular plication
- Post operative Rehab
- Dependent on patient, surgeon, surgery type
- Follow protocol
- Gain motion
- Strengthen muscles
Indications for surgery
● Severe hip pain with ROM and WB
● Significant loss of ROM
● Joint degeneration
● Non-union fx
● Bone tumor
● Failure of conservative management
Types of hardware/ fixations:
Metal (both components)
Cemented
Cementless (biological)
Total Hip Arthroplasty (THA)
● Patient education on condition and operative
procedure
● Post-operative precautions
● Functional training post-op
○ Transfers - bathing, bed, car
○ Assistive devices
○ Gait - level surfaces, stairs, indoor/
outdoor
● Review post-op exercises
THA Prehab
THA Surgical Approaches
Type Incision Location Benefits Drawbacks
Posterolateral
*
Between glute max & glute
med. Piriformis and hip ERs cut.
Earliest recovery Highest risk of
dislocation
Lateral Through TFL & glute med Less risk of dislocation Weakens hip ABductors
Gait asymmetry
Anterolateral Over greater trochanter
Anterior Distal to ASIS, medial to TFL,
anterior to greater trochanter
Lowest risk of
dislocation
Most difficult to
perform
Minimally
invasive
Modification of any of the
above approaches
Muscle sparing,
↓ tissue trauma
Difficult surgical
procedure
Intraoperative
● Malpositioning of prosthetic
● Femoral fractures
● Leg Length Discrepancy
● Nerve injury
Early Postoperative
● Infection
● DVT
● Pneumonia
● Delaying wound healing, dehiscence
● Dislocation
● Persistent LLD
Late Postoperative
● Loosening or wearing down of components
● Periprosthetic fracture(near the prosthese)
THA Complications
Posterolateral Approach
● No hip flexion >90° → reaching down to tie shoes
● No ADDuction (beyond neutral) → crossing legs
● No IR (beyond neutral) → getting into the car
Anterior or Anterolateral or Direct Lateral Approach*
● No hip flexion >90° (general precaution)
● No hip extension, ADDuction, ER past neutral
● Avoid combined motion of hip flexion, ABD, ER-open
pack
*sleep with Pillow or between legs
*Post-op precautions last anywhere from 6 weeks to 6
months
THA Precautions*
How & why they occur
● Patient age >80
● THA femoral neck fx
● RA rather than OA
● Previous history of hip sx
● Posterior approach
● Malpositioned acetabular component
● Poor soft tissue quality
● Preoperative muscle weakness
Fall –main reason
THA Dislocation Risk
Max Protect
THA Post-Op Management
-Pain management and Pt ed
-PROM -> AAROM in allowed range
-AD and adaptive equipment ed
-Muscle setting - quads, hip ext, hip abd
-Maintain UE and opposite LE strength
-Ambulation WBAT
-Active knee ex’s
-AROM hip ex’s
-CKC weight shifting, heel raises, mini squats
-Bed mobility, transfer training
Goals
● prevent DVT, pneumonia, dislocation
● increase ROM
● prevent flexion contractures
Mod Protect (~4-6 weeks post op)
THA Post-Op Management
-Restore ROM as permitted
-Adaptive equipment as needed
-Isotonic exercises - OKC, CKC - (B) and (U)
-Emphasize hip ABD and Ext strengthening
-Aerobic conditioning
-Improve gait, balance, posture stability
Avoid contractures
Goals
● Improve strength and muscle endurance
● Improve CV endurance
● Restore ROM (maintain precautions)
● Normalize gait, posture
THA Post-Op Management
Min Protect (~12 weeks post op)
Goals
● Maximize function
Activities that are OK ✓
● golf
● swimming
● elliptical
● bowling
● hiking
● stair climbing
● stationary bike
● walking program
● doubles tennis
● pickelball
Activities that are typically restricted
✘
● Running
● High impact aerobics
Types of Hip Fractures
common
- Indications for surgery
- Displaced or nondisplaced intracapsular
femoral neck fractures
- Fracture dislocations of the femoral head
- Stable or unstable intertrochanteric fractures
- Subtrochanteric fractures
Hip Fractures
● In-situ (pins).
● IM (intramedullary) rod inside the pelvis
ORIF for Hip Fracture
● Intertrochanteric fx with
side plate & in-situ screw
Weight-bearing status for ORIF
● NWB, TTWB, PWB, WBAT
● Based on pt age, bone
quality, fracture location,
type of fixation
● What is the benefit of early
WB?
● What are the risks?
ORIF for Hip Fracture
Max Protect
ORIF for Hip Fracture
Pain management and Pt
ed
PROM (physician
approval)
AAROM -> AROM
Ambulation with AD
Functional mobility -
transfers
Balance, wt shifting
UE and contra LE
strengthening
CKC for uninvolved LE
Muscle setting
*Reasonable for 80-90 deg
of active hip flex in 2-4
wks
Mod Protect
generally ~6 weeks
LE warm-up
Progressively ↑
flexibility
Pain-free ROM
Increase aerobic
capacity
● Biking, walking,
UBE
Bilateral resisted OKC
and CKC exercises
Aquatics
Balance
Min Protect
Return to sport
Activity-specific
Painful Hip Syndromes
Tendinopathies & muscle strains
● Hip flexors
● Glutes
● Hamstrings
● Adductors
Bursitis
● Trochanteric up and down hurt: stair up/down. Hip
snaping syndrome
● Psoas
● Ischiogluteal
Painful Hip
Syndromes
Femoroacetabular Impingement (FAI) - femur/ acetabular
overgrew
● Pain in anterior hip
● (+) MRI confirming bony abnormality
● (+) pain w/ FADIR vs FABER
● May have labral tear, not always!
● Trauma, capsular laxity, dysplasia, and degeneration are causative
factors
FAI: Two bony lesion types:
1. Cam lesion
● Femoral head is not perfectly round, maybe flattened
● More common in men
1. Pincer lesion
● Overcoverage of femoral head by acetabulum
● More often associated with labral tear
● More common in women
● Hurt in IR ADD Flex
Painful Hip Syndromes
- Labral Tears
- Groin pain (anterior lesion)
- Buttock pain (posterior lesion)
- Locking, clicking, popping
- (+) hip scour and FADIR test for anterior tear
- Usually flexibility and strength issues associated
- Gait and SLS affects
Non-Operative Management
FAI & Painful hip syndromes
● Pain management
● Address gait deviations
● It is crucial to address muscular imbalances & mechanics!
● Avoid aggravating activities...
Max protect (acute):
Control inflammation
Develop muscular support in surrounding muscles
Avoid the MOI & Activity Modification
Mod protect (sub-acute):
Regain flexibility and ROM
Increase strength and neuromuscular control
Muscle and CV Endurance
Min protect (chronic):
Functional Activities
Maintenance phase
Address the MOI
FABER
● Pt supine, passively flex, ABduct, ER hip. Apply
controlled overpressure to ipsilateral knee and
contralateral ASIS
● (+) test reproduces pain/ symptoms
● VIDEO
FADIR
● Pt supine, passively flex, ADduct, IR hip.
● (+) test: groin pain
● VIDEO
Scour
● Pt supine, passively flex hip to 90°, apply axial load
through distal femur, move femur through IR/ER and 4-
quadrants.
● (+) test reproduces pain, crepitus, locking
● VIDEO
Hip Special Tests
● Thomas
● Ely
● SLR
● 90/ 90
● Ober’s