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Hip Ther Ex

Terms in this set (127)

Bones at the hip joint include:
the ilium of pelvis and the femur.
It is a ball and socket type joint with the femoral head being the _________ surface and the acetabulum of the ilium being the _______ surface of the joint.:
convex, concave
The joint is lined with articular cartilage and the acetabulum is surrounded by a _______________ ring called the labrum which serves to deepen the socket of the joint for more stability.
fibrocartilaginous
There are 3 main ligaments that support the hip joint and reinforce the joint capsule. They are the:
iliofemoral ligament ( y lig lateral anterior and superior posterior) , the ischiofemoral ligament (Posterior) and the pubofemoral ligament (anterior and medial)
The strongest of these ligaments is the:
iliofemoral, or Y ligament of Bigelow.
Hip ligaments provides stability to the joint by
checking motion in the various degrees of motion.
Placing the hip in the open packed position will reduce the tension on the iliofemoral ligament and allow greater mobility during..
joint mobilizations.
Motions of the femur:(OPEN CHAIN) CONVEX femoral head=
Slides opposite direction of femur
Motions of the pelvis: (CLOSED CHAIN): CONCAVE acetabulum=
Slides same direction as pelvis
In the open chain, the femur is moving on the acetabulum. Since the femoral head is convex, the roll of the bone is _________ the direction of the slide so when we move the femur anteriorly into flexion, the femoral head must slide __________ to keep the joint in it's optimal position.
Opposite; posteriorly
As you can see, there are several muscles that surround the hip joint. These include:
the hamstring group, the rectus femoris, the gluteals, and the adductor group.
In the ______________ ___________ __________ the concave acetabulum is moving on the convex femur so when the pelvis rolls anteriorly, so does the acetabulum.
closed kinetic chain
Several smaller muscles serve to rotate the hip joint
externally.
Prime movers for flexion of hip (4):
iliopsoas, Rec fem(also ex knee), TFL (also ab. IR and keeps tension in IT band), Sartorius (also ab, ER, and flex & IR knee)
Secondary Hip Flexors(4) :
Pectineus, Adductor longus, Adductor Magnus, Gracilis
Prime movers of Hip Extension(2):
Gluteus Max (also ER, sup fib insert into ITB), Hamstrings Long head of Bicep fem, semiten, semimem (also flex knee)
Secondary hip extensors (3):
Glute med (posterior fibers), Adductor magnus, Piriformis
Abduction of Hip Prime Movers (3):
Glute med, glute min, TFL ( also flex)
Abduction of Hip Secondary Movers (3):
Piriformis, sartorius, Rec fem
Adduction of Hip Prime Movers (5):
Adductor Magnus, Add longus, Add Brevis, Gracilis, Pectineus
Adduction of Hip Secondary Movers(4):
Bicep fem (long head), Glute max (Pos fibers),
ER Hip Prime Movers (7):
Obturator internus and externus, Gemellus inf and sup, Quad fem, piriformis, Glute max
ER Hip Secondary Movers(4): )
Glute med (post fib), Glute min (post fib) Sartorius, Bicep fem (long head
IR Hip Prime Movers (?):
NADA
IR Hip Secondary Movers (7):
Glute med (ant), Glute min (ant), TFL, Add long and Add brev, Add mag (post), Pectineus
Flexion: Knee flexion, Ankle DF
(stand to sit)
Extension: Knee extension
(ascending stairs)
Internal hip rotation: effects down the chain
Knee valgus, Foot pronation
External hip rotation: effects down the chain
Knee varus, Foot supination
HIP ADDUCTION / ABDUCTION:
Abduction prevents adduction moment (SLS)
Quadriceps angle (Q-angle)
An angle formed by the intersection of two lines: one line is drawn from the anterosuperior iliac spine to the midpatella; the second is drawn from the midpatella to the anterior tibial tuberosity. These lines parallel the quadriceps and patellar tendons.
Why measure Q-angle?
The line of force exerted by the quadriceps is lateral to the joint line mainly due to the large cross-sectional area and force potential of the vastus lateralis. Since there exists an association between patellofemoral pathology and excessive lateral tracking of the patella
In weight bearing positions, when the hip is flexed so is the knee and the ankle moves into
dorsiflexion.
Hip extension in weight bearing as when we are ascending stairs is accompanied by
extension at the knee joint.
When standing on a single leg, the external moment at the hip is one of:
adduction.
Contraction of the gluteus medius is necessary to keep the pelvis:
level.
The most functional example of _________ is the squat or moving from a standing position to a seated position.:
WB fx relationship btw hip flex & knee flex. Standing to sit
With weakness in the abductors of the hip, the femur is allowed to move into more adduction which places increased stress on:
the medial aspect of the knee as increased valgus forces are present.
Le moves into IR & ER during gait => cause the knee to be positioned in more valgum or varum & foot to move =>
pronation or supination when the foot is fixed to the ground during stance phase.
IR = Knee valgus and Foot:
pronation
ER= Knee _______ and Foot Supination
Varus
PT for Valgus/ varus tendencies.. During descending stairs or when landing from a jump we must be mindful to watch for knee positioning during exercises such as
eccentric step downs and plyometric activities such as jumping.
Abnormal Structure/Impaired Function: Decreased Flexibility- Affects gait pattern and force distribution. Hip Abductor, Extensor, ER Weakness=
Valgus Collapse at the knee, Patellofemoral impairment, Anterior cruciate ligament stress, Piriformis syndrome
Impairments in flexibility or strength can cause increased stress to :
other areas in the lower extremity and spine such as the knee and SI or facet joints.
Tightness in the hip flexors, extensors, ab or adductors malaligns pelvis which will impair the body's natural ability to absorb shock:
GRFV as we walk => lead to degeneration of joint & stress to the soft tissues that surround the joints and cause pain and dysfunction.
Why is strength @ hip joint important to treat/ prevent patho?
amt of fem add or IR is not cntrl during gait / mech during landing from jump, patella will not track properly= stress on ACL and sciatic n. compressed under the piriformis m. (piriformis syndrome)
Neuromuscular activation/faulty patterns have the following resulting overuse syndromes:
ITB syndrome, Patellofemoral pain, Trochanteric Bursitis, Lumbar/SIJ pain
Other pathomechanics due to imbalances include faulty muscle activation patterns during functional activities such as:
delayed activation of hip external rotators to control internal rotation during gait.
Overuse syndromes that can be linked to these imbalances and neuromuscular deficits around the hip joint include ITB syndrome, patellofemoral pain, trochanteric bursitis and lumbar/SIJ pain.
Track and train analogy but the train is now the IT Band which is pulled over :
the greater trochanter and the lateral femoral condyle.
Weak mm around hip stress shock absorption on
inert tissue of entire kinetic chain. Strength deficits in the hip abductors, extensors and external rotators may contribute to: valgus collapse of the knee during gait.
Abnormal Structure / Impaired Function: Asymmetrical leg length (structural)
Unilateral shorter femur or tibia.. Assessment procedure/ viewpoint/ eval
Hooklying c malleoli aligned: If knees different heights when viewed from inferior aspect of pt= the tibias are not equal. If the position of the knees appear to be different when viewed from the lateral aspect= femurs are not equal in length. This assessment is commonly done prior to performing the Weber-Barstow and supine to long sit test
Coxa valga medial angle and presentation:
greater than 125 (lets say 170) an a straighter line from femur to head= more abduction and is often paired with genu varus
Coxa vara medial angle and presentation:
less than 125 lets say 100, harsher angle to head and presents with genu valgus
angle of inclination
The angle between the shaft and the neck of the femur in the frontal plane; normally 125 degrees.
angle of torsion
angle between the shaft and the neck of the femur in the transverse plane
Femur neck angulations in trans & frontal plane. Deviations= abnorm distribution of forces in Lwr Kinetic chain. Frontal plane deviations= coxa valga/ vara. Cause:
relative leg length discrepancies and abnormalities @ knee such as genu varum/ valgum. respectively
Abnormal Structure / Impaired Function Asymmetrical leg length (structural) Anteversion and retroversion occur in which plane?
In transverse plane
Normal anteversion=
8-15 deg, excess medial femoral torsion = increased anteversion greater than 15 ( W sitting is a key contributor.. squinting patella)
PT can't fix length discrepancy outside of:
recommending heel lift to the patient coupled with correction of any of the strength imbalances that may be present (eg TFL and gluteus medius, the rectus femoris and the iliopsoas or the hamstrings and gluteus maximus. )
Excess lateral femoral torsion=
Retroversion. >8 degrees
Femoral anteversion :
neck is twisted so that the head faces more anteriorly= LE IR.. => squinting patella or toe in posture.
Retroversion:
neck is twisted so that the head faces more posteriorly LE must ER => toe out...
Cannot fix but we must try to compensate for them with extra strength in the muscles of the hip and knee to address any overuse syndrome that may be present.
Hip flexors control hip extension during: terminal stance and pres-swing phase. if weak..
Posterior trunk lean at swing
Hip flexors contract concentrically to
initiate advancement of limb during initial swing.
Weak hip flexors = ___________________ in Swing
Posterior trunk lean (lurching backward- use momentum and trunk musculature to advance the limb)
Hip flexor Contracture:
Less extension = forward trunk/lordosis
The Hip and Gait: Hip extensors - control flexion during loading, extension in stance: If weak.. contracture...
Posterior trunk lean at beginning of stance...Contracture : Less terminal swing
Hip extensors control the hip joint during
loading response and prevent collapse of the hip joint into flexion.
Concentrically, the hip extensors contribute to hip extension during
stance phase.
Weakness of hip extensors may lead to
lurch their trunk posteriorly upon initial contact and loading response in an attempt to shift the external moment at the hip to an extension moment.
With shortening of the hip extensors, terminal swing will be
shortened or the patient will compensate with forward rotation of the pelvis to maintain the stride length.
Other abnormalities might include increased external rotation of the lower extremity due to
the attachment of the gluteus maximus on the femur and ITB.
Hip abductors are very important in
stance phase as they serve to keep the pelvis level during ambulation to maintain efficiency.
The Hip and Gait: Hip abductors - control opposite pelvic drop: dysfxn:
TRENDELENBURG
HIP disorders and surgeries Joint Hypomobility may be caused by
Osteoarthritis (degenerative joint disease), Post-immobilization; Groin pain, stiffness with rest; limited ROM, asymmetry WB, antalgic gait, impaired balance
Contracture of the hip flexors will result in:
decreased hip extension and a reduction in stride length on the opposite side. To compensate for that, the patient will either display an increased lordosis or will walk with the trunk in flexion.
Early stages of hypo =>
Progressive degeneration
OA is the most common arthritic disease of the hip joint with causes including
aging, trauma, obesity, or congenital hip disorders.
Ground reaction forces are translated from the ground and up into the spine through the entire lower extremity and over time this can have severe consequences to the joints especially with
higher impact activities.
Other reasons why the hip joint might be hypomobile is due to
prolonged immobilization such as occurs after fracture or surgery.
Common complaints associated with arthritis at the hip include:
groin pain or lateral hip pain
joint stiffness after periods of rest restricted ROM
antalgic gait
asymmetrical WB
impaired balance and LBP potentially due to loss of hip extension
ROM causing excessive forces on the lumbar spine.
As the disease progresses from more benign complaints of stiffness and dull, achy pain, patients will experience difficulties with activities such as
bathing, dressing and weight bearing activities and transitioning from sit to stand among other activity limitations.
Non operative Management: Protection Phase:
Patient education
Pain control~Assistive device
joint mobs
Elevate seat / grab bars
Non-impact activities
If the hip abductors are weak, there will be a drop of the pelvis on the
opposite side. This is called the Trendelenberg Gait.
Non operative Management: Controlled Motion and Return to Function Phase:
Increase joint ROM
Stabilize joint -muscle strengthening
Balance and aerobic capacity
If the hip abductors are weak and the pelvis drops, the femoroacetabular joint will be in a position of adduction and greater _________ forces will be present at the knee joint and predispose the patient to tears or strains of the ACL or MCL, or even patellofemoral pain syndrome.
valgus
PT can slow prog in acute phase:
PT edu- AD's
↓ WB, and spare remaining articular cartilage
↑ROM & ↑ strength using non-impact exercises (aqua & stationary bike are great)
SLR into hip flexion is often not tolerated well (long lever arm of LE) too much force compresses the joint. Instead..
shorten the lever arm. Progres in OKC & CKC as tolerated
C/o stiffness can be dealt with through
frequent motion of the joint during the day and grade
I/II joint mobs at an open packed position.
In the controlled motion phase when symptoms have subsided, grade
III/IV joint mobs can be utilized to increase mobility of the joint capsule and improve ROM.
Also add stretching intervention and HEP
Balance training should now be implemented & aerobic training should continue to be progressed, but still low impact.
In which phase?
Controlled motion
Joint Reconstruction Procedures: Indications:
Advanced arthritis, fractures, deformation, failed surgery
Surgical options for those with advanced arthritis, fractures of the proximal femur, deformity, and failed internal fixation include
total hip arthroplasty, hemiarthroplasty and hip resurfacing.
Those with advanced arthritis of the hip TYPICALLY undergo a
total hip arthroplasty.
Disrupt joint capsule to allow dislocation of the femoral head so the components can be placed. femoral head & neck are removed & replacement components for the femur & acetabulum are put in place. fixated c cement or bone growth into the component.
Cement fixation is chosen for elderly patients typically due to
osteoporosis.
THA - Physically active patients who are under 60 years old will more likely receive
the porous-coated components.
Clinical prediction rule for dx of Hip OA:
aggravated by squat
active hip flex causes pain- laterally, scour test c add = lateral hip/groin pain
active hip ext causes pain
passive IR is > or = to 25 degrees
Precautions to avoid stressing the part of the capsule that was repaired:
Post/post lateral:
1) no hip flx > 90
2) IR past neutral
3) X midline, pivot on sound leg!
ANTERIOR /AL:
1) no hip flx > 90
2) Hip add, ext and ER past neutral alone or combined I.e. crossing legs if glute med or troch ostomy performed avoid antigrav abduction for 6-8 wks - step to not through operated leg to avoid hypertext. Standing and rotating away. TRANSGLUTE (trochanteric osteotomy):
1) avoid add past neutral
2) avoid active antigrav ab for 6-8 wks/cleared
3) X legs
any WB restrictions
Hip resurfacing procedures spare the
femoral head, unlike the total arthroplasty and hemiarthroplasty.
Joint Reconstruction Procedures Dislocation: a closer look:
2-3 months post-surgery. Posterior dislocation. Hip precautions per surgical approach
Precautions for posterolateral approach:
No FLEXION greater than 90 degrees. No Internal Rotation IR (toe in). No ADDuction past midline
Many hip replacements utilize the
posterolateral approach, however, more recently the anterior approach has been utilized as there are fewer precautions in the post-operative period.
lists the features of the minimally invasive THA :
less m and tendon damage.
Post app: btn glut med and piriformis incision, may cut and repair other ERs' abductors intact.

Anterior: incision lat and distal to ASIS along TFL; retract sartorius and Rec fem med and TFL lat= all intact no post op precautions

Lateral: least common splits middle third of glute med, ant lat incision into joint capsule leaves post capsule intact (eliminates posterior dislocation precautions s/p )
Joint Reconstruction Procedures Postoperative Management -Conservative or Accelerated: Early mobility/no immobilization:
WB status depends on surgeon recommendations, Exercise progression, Functional training
Weight bearing status in the immediate post-operative period vary from toe-touch to WBAT depending on the
surgeon's recommendation.
ORIF Hip Fracture: Post-op Management:
Possible motion precautions, Early mobility, transfers, ambulation with AD. WB status per surgeon. Interventions to address impairments: ROM, strength, balance, functional mobility. Sites of Fractures
Hip fractures that are addressed with ORIF include
femoral neck fractures, intertrochanteric fractures and fractures to the head of the femur.
Hip fx: lateral surgical approach is used and the hardware may include intramedullary nails, lag screws, pins or extramedullary fixation with sliding hip screws and a lateral side plate. For fractures to the femoral neck, the joint capsule...
A must be incised and subsequent motion restrictions in the post-operative period may apply.
WB precautions:
bone graft = time for bone to heal, WB more restricted after traditional, TTWB to WBAT for hybrid or porous. Typically WBAT for cement. Transglute/trochanteric osteotomy = NWB for 6-8 or 12-16 wks depending
ORIF Rehab focuses on early mobility with WB status as directed by the surgeon, safe transfers and bed mobility. Exercise prescription and progression will be dependent upon
the location and stability of the fracture site, the type of fixation used and the degree of soft tissue trauma that was sustained as a result of the injury or the surgery. Soft tissue typically takes about 6 weeks to heal and bone takes 10-16 weeks.
Hemiarthroplasty involves replacing the proximal femur. This is most commonly performed through the
posterolateral surgical approach.
Treatment for Painful hip syndromes:
Gentle stretching, gradual strengthening, address functional cause, avoid re-aggravation, correct asymmetries, aerobic endurance
Other orthopedic issues at the hip joint include
muscular strains, tendinitis, labral pathology and bursitis.
Muscle strains at the hip commonly include:
the hamstring, adductor or hip flexors. Strain related injuries occur during activity and are typically related to reduced flexibility and fatigue.
Programs for Tendonitis/ bursitis should include:
gentle stretching of tight structures, aerobic conditioning, and progressive strengthening of weak muscles as tolerated by the patient in order to correct asymmetries and avoid re-aggravation of symptoms.
Convex/concave rule to determine which motions should be avoided by the patient based on.
Which procedure was performed. confirm understanding so the joint does not get put into a vulnerable position and risk dislocation.
Precautions are typically in place for_____________ ; however, if a minimally invasive procedure has been used, there may be not be any precautions. When in doubt, err on the side of caution and then check with the PT who can confirm with the surgeon.
12 weeks
In the post-operative period for total hip arthroplasties, early motion is encouraged. When the patient is in bed, an ___________ __________may be used to increase stability of the joint while while resting and sleeping.
abduction wedge
Painful Hip Syndromes: Nonoperative Management: Strains or Tendinitis:
Strain - acute. Tendinitis - overuse / overexertion
Painful Hip Syndromes: Nonoperative Management: Labral pathology:
Bursitis- Trochanteric bursitis
Tendinitis and bursitis are more related to
repetitive trauma or overuse.
Like any other pathology caused by overuse or repetitive trauma we need to consider the entire kinetic chain to determine what might contribute to these pathologies. Major influences are similar to those that contribute to patellofemoral pain such as tightness in the TFL/ITB, weakness of hip abductors, extensors and external rotators; adaptive shortening of soft tissue around the pelvis related to faulty postures; and structural issues in the kinetic chain such as genu valgum, pes planus, the Q-angle, and femoral anteversion.
Pathology involving the labrum will cause patients to complain of
clicking, locking, catching or giving way. The tear can be anterior or posterior and symptoms will present in the groin or the buttock, respectively. Surgery is typically indicated, however, if a conservative approach is used, the focus of treatment should be on correcting imbalances in strength and flexibility, specifically strength of the glutes, abductors, hip flexors and external rotators and flexibility of the hamstrings.
nonoperative treatment for painful hip syndromes
gentle stretching
gradual strengthening
address functional cause
correct asymmetries
avoid re-aggravation
aerobic endurance
pathology involving the labrum will cause patients to complain of
clicking
locking
catching
giving way
Anterior Labral Tear Test
-Patient supine
-PT moves patient into full hip flexion, external rotation and full abduction
-Once in this position, extend the hip combined with medial rotation and adduction
-Positive = reproduction of symptoms with or without click
with anterior labrum pathology, pt reports symptoms in what area?
groin
with posterior labrum pathology, pt reports symptoms in what area?
buttock
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