PATHOLOGY AND INTERVENTION

IN MUSCULOSKELETAL REHABILITATION

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PATHOLOGY

AND INTERVENTION

IN MUSCULOSKELETAL

REHABILITATION

Editors

David J. Magee, PT, PhD Professor and Associate Dean

Department of Physical Therapy

Faculty of Rehabilitation Medicine

University of Alberta

Edmonton, Alberta, Canada

James E. Zachazewski, PT, OPT, SCS, ATC Clinical Director

Physical Therapy

Massachusetts General Hospital

Boston, Massachusetts

William S. Quillen, PT, PhD, SCS, FACSM Professor

Associate Dean, College of Medicine

Director, School of Physical Therapy and Rehabilitation Sciences

University of South Florida

Tampa, Florida

Editorial Consultant

Bev Evjen Swift Current, Saskatchewan, Canada

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PATHOLOGY AND INTERVENTION IN MUSCULOSKELETAL REHABILITATION ISBN: 978- 1-4160-0251-2

Copyright © 2009 by Saunders, an imprint of Elsevier Inc. Photo Copyright © 2009 for Chapter 8 and Chapter 14, will be retained by Diane Lee Photo Copyright © 2009 for Chapter 8 and Chapter 14, will be retained by Linda-Joy Lee

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HIP PATHOLOGI{S: DIAGNOSIS

AND INURV{NTION Timothy L. Fagerson

Introduction

This chapter explores adult hip pathologies, their diagnosis, and appropriate interventions. Most hip conditions are dis­cussed, except for pediatric conditions and hip joint arthro­plasty, which are covered elsewhere in this text (Chapters 24 and 26 ) . Clinicians need a good working knowledge of hip pathologies so that they can select, perform, and interpret the appropriate tests for the diagnostic process and then decide what interventions need to be included to treat the patient's condition most effectively.

Adult hip pathologies can be divided into six subcate­gories based on the type of disorder (Table 15- 1 ) . It also can be helpful to think of hip disorders in relation to age, because their prevalence rate often is age dependent (Table 1 5 -2) .

Another useful approach is to classify a condition based on the need for diagnostic imaging or laboratory tests to confirm the diagnosis and initiate appropriate medical or surgical management. The following diagnostic classifica­tion system can be applied not only to hip pathologies but also to all clinical problems:!

1. Diagnoses that can be made on the basis of the his­tory and physical examination alone (e .g. , sprains, strains, muscles imbalances, nerve entrapments) . Rehabilitation should be initiated a s appropriate.

2. Diagnoses that tentatively can be made on the basis of the history and physical examination, but nlfther diag­nostic imaging and laboratory studies are necessary to confirm the diagnosis (e.g., osteoarthritis, rheumatoid arthritis, herniated disc). Rehabilitation can be initiated to assist symptom management and maintain maximum fWlCtion while a definitive diagnosis is pursued.

3. Red flag diagnoses (e.g., fracture, dislocation, osteone­crosis, infection, metastatic disease ) . These conditions require definitive medical or sllfgical intervention. Rehabilitation should follow when appropriate.

When possible, a diagnosis should be the lowest common denominator driving a clinical presentation. Table 1 5 -3 presents a summary of musculoskeletal diagnoses for reha­bilitation management.2

When one of these lowest common denominators can­not be identified or associated with an anatomical structure and pathology ( i .e . , if a tissue level or pathoanatomical diagnosis cannot be made), one of the next levels of reha­bilitation diagnosis should be used; for example, compo­nent impairment ( i .e . , the tissue at fault) or nll1ctional limitation ( see Figure 19-9 in volume 2 of this series, Scien­

tific Foundations and Principles of Practice in Musculoskele­

tal Rehabilitation). 3 The primary reason a patient seeks outpatient clinical

care is pain. The exact location of hip-mediated pain varies. Khan and Woolson4 reported that of patients presenting for total hip replacement, 73% had groin pain (Table 1 5 -4) . Other common locations were the lateral hip (trochanter) and buttocks (gluteals ) .4 Hip pain from osteoarthritis (OA) can also refer to the anterior knee and to the low back. Sometimes these are the only symptoms produced by hip OA. Although groin pain often is associated with hip pathology, the groin is not the onJy place that symp­toms originating from the hip are felt; nor is the groin region immune to pain referral from sources other than the hip. In contrast to the findings of Khan and Woolson,4

a study by Wroblewski5 rated the groin area as the fourth most common site of pain in patients with OA of the hip, behind the greater trochanter, the anterior thigh, and the

497

498 CHAPTE R 1 5 • Hip Pathologies: Diagnosis and Intervention

Table 1 5-1

Types of Hip Disorders

Type of Disorder

Soft tissue disorders

Joint disorders

Osseous disorders

Fractures and dislocations

Nerve entrapment syndromes (commonly described types)

Pediatric disorders (not covered in this chapter)

Examples

Bursitis Tendonitis/tendinosis Muscle sU'ain Osteitis pubis Hip pointer Snapping hip syndrome Sports hernia Contracture Hip capsule contracture

Osteoarthritis Femoroacetabular impingement Labral tears Loose bodies

Osteonecrosis Osteoporosis Heterotopic ossification Transient osteoporosis Osteoid osteoma Symptomatic herniation pit Brodie's abscess

Hip fracture Femoral head fracture Acetabular fracture Stress fracture Traumatic dislocation

Piriformis syndrome Meralgia paraesthetica Hamstring syndrome Superior gluteal nerve entrapment

Developmental dysplasia of the hip (DDH)

Congenital coxa vara Acute transient synovitis Legg-Calve-Perthes (LCP) disease Slipped capital femoral epiphysis

(SCFE) Avulsion fracture

knee. Hip OA can also cause medial buttock, shin, and low back pain .5 In addition to pain referred from the hip, the buttock, lateral hip, and groin are common sites of pain referred fi'om the lumbar spine and sacroiliac joints.6,7

Differentiating Hip Disease from Lumbar Disease by Physical Examination

Because the lumbar spine can refer symptoms to the hip region (and to a lesser extent vice versa), the clinician should always rule out involvement of the lumbar spine when a hip problem is suspected. The examination, therefore, may be

Table 1 5-2

Hip Disorders Related to Age

Disorder

Developmental dysplasia of the hip Congenital coxa vara Acute transient synovitis Legg-Calve-Perthes disease Slipped femoral capital epiphysis Avulsed ASIS, AIlS, lesser

trochanter Osteoid osteoma (femoral neck) Malignancy Rheumatoid arthritis Stress fractures Avascular necrosis Paget's disease Osteoarthritis Hip fracture

Age

Newborn/infancy 1-3 years 2-10 years 2-10 years 10-16 years 12-16 years

5-30 years Any age Any age (20-40 years) 14-25 years 20-40 years 40 years + 45 years + 65 years +

Modified from Fagerson TL, editor: The hip handbook, p 40, Boston,

1998, Butterworth-Heinemann.

ASIS, Anterosuperior iliac spine; ATIS, anteroinferior iliac spine.

Table 1 5-3

Manual Therapy Diagnoses

Principal Diagnosis

Pain

Misalignment

Hypomobility

Hypermobility

Weakness

Type of Problem

Mechanical Chemical

Structural Functional

Contracture Adhesion Restriction

Instability Tissue insufficiency

Motor control Muscle imbalance Tissue weakness

Modified from Dyrek DA: Assessment and treatment planning strategies

for musculoskeletal deficits. In Sullivan SD, Schmitz T J, editors: Physical

rehabilitation: assessment and treatment, ed 3, pp. 61-82, Philadelphia,

1994, FA Davis.

extensive, involving the hip, lumbar spine, and pelvis. Brown

et a1 .8 identified a limp, groin pain, and limited hip medial rotation as signs that significantly predicted a hip problem rather tha� a lumbar problem.8 Clinically, Cyriax's screening tests for a noncapsular pattern oftl1e hip and a positive "sign oftl1e buttock" have been identified as predictors for further workup.9 Witl1 a capsular pattern of tl1e hip, the pattern of hypomobility is one where medial rotation, and abduction and flexion are the most limited motions. lo Extension and

Hip Pathologies: Diagnosis and Intervention • C H APTER 1 5 499

Table 1 5-4

Location and Frequency of Hip Pain in Patients

with Intra-articular Hip Pathology

Location Frequency (%)

Groin only Trochanter only Gluteal only Groin/trochanter Groin/gluteal All locations No hip pain Groin only or groin with other locations

43 18

5 12 16 3 3

73

Modified from Khan NQ, Woolson ST: Referral patterns of hip pain in

patients undergoing total hip replacement, Orthopedics 2 1 : 1 23-126,

1998.

lateral rotation may also be limited, and adduction is the least limited in a true capsular pattern.

Cyriax lO described the sign of the buttock as a means of differentiating "- major lesion of the buttock (e .g., infection, tumor, fracture ) from a minor lesion (e.g., bursitis, tendon­itis, arthritis ) . Major lesions obviously are red flags indicat­ing the need for further workup . For the sign of the buttock test, hip flexion is performed in the supine posi­tion, first with knee flexion and then with knee extension. Normally, hip flexion combined with knee flexion results in a greater hip flexion range of motion ( ROM) than does hip flexion with knee extension, because hamstring muscle tension limits the motion when the knee is in extension. However, if the hip flexion ROM is the same with the knee extended and the knee flexed ( i .e . , an empty end feel is noted, usually the result of pain), this is a positive sign of the buttock.9, l o

Signs Predicting a Hip Rather Than a Lumbar

Problems

• Limp • Groin pain • Limited hip medial rotation • Capsular pattern of the hip (medial rotation, abduction, flexion) • Positive "sign of the buttock"

The lumbar spine can refer symptoms into the hip region and lower extremity even when the lumbar spine itself is symptom free . Dermatomes for the lumbar spine are shown in volume 1 of this series, Orthopedic Physical

Assessment. The Ll dermatome covers the anterior and lat­eral hip. The L2 dermatome covers the iliac crest (buttock) and medial thigh. The L3 dermatome covers the iliac crest (buttock) and medial thigh and knee. The clurual nerves, which supply the skin over the buttocks from the iliac crest

to the greater trochanter, originate as the lateral branches of the dorsal primary divisions of the upper three lumbar nerves. A disc herniation at L4-5 can cause groin pain via the sinuvertebral nerve 6

Restricted hip movement often can be an etiological fac­tor in low back pain. Greater limitation of medial than of lateral rotation of the hip is seen more frequently in patients with low back pain (LBP) than in individuals without LBP. l l Limited hip extension also has been correlated with an increased incidence of LBP. 1 2

Adult Hip Pathologies

Soft Tissue Disorders

Soft tissue disorders are considered first, because the soft tissues are essentially the tissues the rehabilitation clinician can influence the most significantly with intervention. The ability of the living tissues of the body, especially tlle soft tissues, to adapt and deform to imposed demands makes strong repair and functional remodeling possible with appropriately directed intervention.

Rehabilitation clinicians usually conceptualize their role in health care using some variation of the Nagi disablement model. 3 Although it is often assumed from the Nagi model that impairments result from active pathology, the converse also is true: active pathology can be partly or fuUy caused by impairments (e .g . , abnormal postural alignment and/or muscle imbalances can lead to OA) . Obviously, impair­ments and pathology can each affect tlle other. Sahrmann13

defines these differing mechanisms as the pathokinesiology

model (pathology causing impairments) and tlle kinesio­

pathology model ( impairments causing pathology) . Soft tis­sue problems are dealt witll first because they frequently are the primary problem at the hip, and they also are com­mon sequelae to other types of pathology (e .g . , OA, hip fracture) .

Trochanteric Bursitis In the region of the greater trochanter, three bursae are consistently present, two major bursae and one minor bursa (Figure 1 5 - 1 ) . 1 4 The subgluteus maximus bursa lies between the greater trochanter and tlle fibers of the gluteus maxim us and tensor fascia lata muscles as tlley blend into the iliotibial band (ITB) . The subgluteus medius bursa lies at the superoposterior tip of the greater trochanter and pre­vents friction between the gluteus medius muscle and the greater trochanter and also between tlle gluteus medius and gluteus minimus muscles. The subgluteus minimus bursa is a minor bursa lying between the gluteus minimus attachment and tlle superoanterior tip of the greater trochanter.

Trochanteric bursitis and gluteal tendonitis are the most common soft tissue disorders affecting the hip. J 5 Some have said that trochanteric bursitis should be considered a

500 CHAPTER 1 5 • Hip Pathologies: Diagnosis and Intervention

Figure 1 5-1 Schematic diagram of bursae around the greater trochanter.

clinical diagnosis rather than an anatomical diagnosis, because it cannot be distinguished from gluteal tendonitis by signs and symptoms alone. Use of the term lateral hip

pain has been suggested when an anatomical source cannot be specified. 16 Another alternative name is greater trochan­

teric pain syndrome. 14 Trochanteric bursitis is more common in arthritic condi­

tions and fibromyalgia and with leg length discrepancy. It also is more common in females than males (2-4: 1 ratio), with a peak incidence occurring between 40 and 60 years of age. 14 Trochanteric bursitis, especially in athletes, may result fi'om a fall onto a hard surface or friction of the ITB over the greater trochanter during repetitive flexion/ extension motion of the hip, such as occurs in running (similar to ITB friction syndrome at the knee).

Trochanteric bursitis is characterized by an aching pain over the lateral aspect of the hip accompanied by distinct tenderness on palpation around the greater trochanter. A widely accepted diagnostic classification for trochanteric bursitis includes both of these features and one of three other findings (Box 1 5_ 1 ) .17 Symptom relief through peri­trochanteric injection of a corticosteroid and an anesthetic is required for more definitive diagnosis of trochanteric bursitis. In a study by Shbeeb et aI., 1 8 77% of patients trea­ted for trochanteric bursitis with glucocorticosteroid injec­tion had relief at I week after the injection, and 6 1 % had lasting relief at 26 weeks.

Rehabilitation intervention for trochanteric bursitis can include modalities such as ultrasound/phonophoresis, ion­tophoresis, and nonsteroidal anti -inflammatory drugs (NSAIDs) to alleviate the inflammatory response; however,

Box 15-1 Clinical Criteria for Diagnosis of

Trochanteric Bursitis

1. Both of the following conditions must be present: • Aching pain in the lateral aspect of the hip • Distinct tenderness around the greater trochanter

2. One of the following three conditions must be present: • Pain at the extreme of rotation, abduction, or adduction,

especially positive Patrick's (FABER) test • Pain on forced hip abduction • Pseudoradiculopathy (pain extending down the lateral aspect

of the thigh)

Modified from Shbeeb MI, Matteson EL: Trochanteric bursitis (greater trochanter pain syndrome), Mayo Clin Proc 71 :565-569, 1996; data from Ege Rassmusen KJ, Fano N: Trochanteric bursitis: treatment by corticosteroid injection, Scand J Rheumatol14:417 -420, 1985.

treatment also should include manual therapy /mobiliza­tion techniques and therapeutic exercises to address poten­tial causative factors, such as ITB contracture; flexion contracture; abnormal lumbopelvic alignment, mobility, and stability; and gluteus medius weakness. The patient should be advised to avoid aggravating activities or posi­tions, such as lying on the painful side or excessive walking and running, until the inflammatory process abates. Use of a contralateral cane can prove useful in acute and irritable cases of trochanteric bursitis.

The location of symptoms and the related diagnostic label (i.e., trochanteric bursitis) often can be merely the tip of the iceberg. The actual cause of the inflammation may be a mechanical problem in the region, such as a soft tissue contracture. The most common soft tissue contrac­tures at the hip are flexion contractures, ITB contractu res, and abduction contractures.

Gluteus Medius/Gluteus Minimus Tears and Tendinosis The quadriceps muscle has been described as "the key to the knee"; similarly, the key muscle for hip joint function is the gluteus medius muscle.3 The gluteus medius is criti­cal for balancing the pelvis in the frontal plane during one leg stance, which accounts for approximately 60% of the gait cycle.3,19 Janda20 has described one leg stance as the most common posture for humans because it is the lowest common denominator during locomotion, the primary functional task that humans perform. When the gluteus medius is weak, Trendelenburg's gait pattern or a compen­sated Trendelenburg's gait pattern is seen (Figure 1 5-2) . During one leg stance, approximately three times the body weight is transmitted through the hip joint, and two thirds of that is generated by the hip abductor mechanism (Figure 1 5 -3 ) . To reduce this load in cases of hip pain or dysfunction, the patient often shows a compensating Tren­delenburg's lean over the affected hip; this reduces

Hip Pathologies: Diagnosis and Intervention • C HAPTER 1 5 501

Figure 15-2 Compensated Trendclenburg's lurch over the left hip.

the lever arm for body weight and therefore the counterba­lancing hip abductor contraction. This counterbalancing effect can stress the lumbar spine, and a cane in the oppo­site hand is an excellent a1ternative.21 The contralateral cane can act as a gait assist to unload the abductors as the patient is progressively rehabilitated. Walking is an excellent endurance and strengthening activity for the hip abductors and is preferred over specific abductor strengthening exer­cises if the abductors are easily irritated. A cane in the con­tralateral hand (Figure 15-4) can help create the noncompensatory mechanical environment that assists a weak gluteus medius and gluteus minimus in regaining their strength.

The gluteus medius has been likened to the supraspina­tus in the shoulder, and the hip can sustain rotator cuff-like injuries.22 If the hip "complex" were compared to the gle­nohumeral "complex," the likenesses would be as follows: the gluteus medius would be comparable to the supraspina­tus, the gluteus minimus to the infraspinatus, the piriformis to the teres minor, the iliopsoas to the subscapularis, and the reflected head of the rectus femoris to the long head of the biceps brachii; these, along with the other deep rota­tors of the hip (i.e., the gemellus superior, obturator exter­nus, gemellus inferior, obturator internus, and quadratus femoris muscles) would be considered the "rotator cuff' of the hip. The tensor fascia lata (TFL) and the gluteus maximus, feeding into either side of the ITB proximally,

Figure 1 5-3

I i I I i II I I i I o 5 10cm

1em = 10kg

Forces exerted on the hip when a person stands on one leg. 55,

center of gravity of the mass of the body acting on the hip (head, trunk, upper limbs, and opposite leg); K, force exerted by the partial body mass; M, force exerted by the abductor muscles to

counterbalance K; R, resultant of forces K and M . (Modified from

Pauwels F: Biomechanics of the normal and diseased hip, New York, 1976, Springer-Verlag. )

act i n a fashion similar t o the deltoid i n the shoulder; they provide a strong, superficial fascial umbrella around the hip. Sahrmann 1 3 emphasized the importance of enhancing motor control of the one-joint hip muscles (i.e., iliopsoas, gluteals, and deep external rotator muscles), which control the position of the femoral head in the acetabulum, over the two-joint muscles (i.e., rectus femoris, hamstrings, TFL-ITB), which have distal attachments that are at a dis­tance from the hip joint center.

"Rotator Cuff" Muscles of the Hip (with Shoulder

Equivalents)

• Gluteus medius (supraspinatus) • Gluteus minimus (infraspinatus) • Piriformis (teres minor) • Iliopsoas (subscapularis) • Rectus femoris (long head of the biceps) • Tensor fascia lata (deltoid) • Gluteus maximus (deltoid)

502 CHAPTER 1 5 • Hip Pathologies: Diagnosis and Intervention

CL CF X D2

Figure 15-4 The balance of torques acting in the frontal plane about a right

prosthetic hip while in single limb support. The diagram depicts a cane

used contralateral to the prosthetic hip. Assuming static equilibrium,

the sum of the clockwise torque produced by body weight (BW)

(dashed circle) equals the combined counterclockwise torques

produced by hip abductor force (HAF) and the contralateral cane force

(CLCF) (solid circles). The prosthetic hip reaction force (PHRF) is shown directed toward the right prosthetic hip. The force vectors are

not drawn to scale. D, Moment arm llsed by HAF; Dl, moment arm used by BW, D2, moment arm used by CLCF. (Modified from

Neumann DA: An electromyographic study of the hip abductor muscles as subjects with a hip prosthesis walked with different methods

of using a cane and carrying a load, Phys Ther 79:1163-1173, 1999.)

Tendinosis and tears of the gluteus medius and gluteus minim us were a common finding in an magnetic resonance imaging (MRI) study of patients presenting with buttock, lateral hip, or groin pain.23 Recent work by Khan et al?4 has shown that most cases of tendinopathy are in fact tendi­nosis, not tendonitis. The primary problem is collagen degeneration, not inflan1mation. Because differentiating ten­dinosis from tendonitis is difficult and because tendinosis is much more common than tendonitis, Khan et al.24 suggested treating all cases initially as if the problem were collagen degeneration. The differences between overuse tendinosis and overuse tendonitis can be found in Table 15-5. Eccentric strengthening has been shown to be the most effective method of treating tendinosis, probably because eccentric muscle action stimulates mechanoreceptors, which encour­age tendon cells to produce collagen. Loading the tendon also improves collagen cross-linking and alignment, resulting in greater tensile strength?4 As mentioned previously, walk­ing is an excellent eccentric exercise for the gluteus medius, and it should be incorporated into any program. Other approaches (e.g., rest, ice, compression, ultrasound treat­ment, and anti-inflammatory medication) can and should

be used when appropriate for acute injury. Soft tissue mobili­zation (e.g., transverse friction, passive stretching) can be helpful in the treatment of a collagen scar and can help improve tissue length.

Twelve musculotendinous structures (the gluteus med­ius, gluteus minim us, TFL, ITB, gluteus maximus, the six short lateral rotators, and the vastus lateralis muscle) attach to or cross over the greater trochanter, making this region the "Grand Central Station" of the hip. The use of soft tis­sue mobilization techniques for muscles attaching to the greater trochanter are extremely beneficial for restoring optimum hip joint mechanics. Particularly beneficial is the application of sustained, deep pressure, load and release techniques to various points in the gluteus medius, gluteus minim us, and TFL muscles above the greater trochanter, combined with sustained ipsilateral passive hip abduction performed in the side lying position (Figure 15-5). This technique helps release the abductor mechanism and thereby paradoxically improves hip abduction ROM by allowing the abductors to fold in on themselves; loading the abductors just proximal to the greater trochanter with the hip in abduction also acts as a medioinferior mobiliza­tion of the hip capsule and pubofemoral ligament.

Iliotibial Band Contracture and Proximal Iliotibial Band Friction Syndrome ITB contracture can lead to trochanteric bursitis by increasing compression and friction of the subgluteus maximus bursa between the ITB and the greater trochanter. The classic test for ITB contracture is Ober's test (see vollune 1 of this series, Orthopedic Physical Assessment). For this test, the patient is in the side lying position with the leg to be tested uppermost. In most cases the hip should be able to adduct so that the knee touches the table without the pelvis moving caudally. To pre­vent a false negative result, the following are important: ( 1 ) the clinician should use one hand to firmly stabilize the patient's pelvis; (2) the hip should be extended to 0°, with the clinician using the other hand to engage the ITB over the greater trochanter; and (3 ) the hip must not be allowed to flex or to rotate medially as the knee is lowered toward the table (Figure 15-6). To prevent a false positive result, the clinician must ensure that the patient is fully relaxed and allows the leg to be lowered toward the table. Performing the test with the knee flexed 90° takes up slack in the rectus femoris and the anterior fascia lata and is more sensitive to change than performing the test with the knee extended. However, care must be taken to avoid excessive valgus stress to the medial knee when the knee is flexed for the test.

ITB coI!tracture is best treated using a combination of soft tissue mobilization and hold/relax-type stretching in the Ober's' test stretch position. In addition, stretching of the rectus femoris and iliopsoas is important, because these muscles are enveloped by the fascia lata. The patient should be taught self-stretching to maintain and improve what is achieved in manual therapy sessions. Foam rollers have

Hip Pathologies: Diagnosis and Intervention • CHAPTER 1 5 503

Table 1 5-5

Implications of a Diagnosis of Tendinosis Compared With a Diagnosis of Tendonitis

Trait Overuse Tendinosis Overuse Tendonjrjs

Prevalence Time required for recovery (early

presentation) Time required for full recovery (chronic

presentation) Likelihood of full recovery to sport from chronic symptoms

Common 6-10 weeks

3-6 months

About 80%

Rare Several days to 2 weeks

4-6 weeks

99%

Focus of conservative therapy Encouragement of collagen-synthesis Anti-inflammatory modalities

Role of surgery Prognosis for surgery

maturation and strength Excision of abnormal tissue 70% to 85%

and drugs Not known 95%

Time required to recover from surgery 4-6 months 3-4 weeks

From Khan KM, Cook JL, Taunton JE, Bonar F: Overuse tendinosis, not tendinitis, Phys Sportsmed 28:38-48,2000.

Figure 1 5-5 Hip abductor soft tissue release technique.

become popular in the personal training arena as a means of self-mobilization of the ITB . Improving the strength and stability of the lumbopelvic region also is important to reduce tension in the ITB . The ITB and hip abductors can tighten in an ineffective attempt to compensate for lack of lumbar control and stability.

Flexion Contracture Hip flexion contracnlre is common with hip dysfunction, probably as a result of protective guarding and the position­ing of the hip into flexion (the resting position) in response to pain. The likely causes of hip flexion contracture can be one or more of the following: shortening of the i liopsoas muscle, shortening of the rectus femoris muscle, shortening of the tensor fascia lata muscle, or contracture of the anterior hip capsule. Hip flexion contracture can occur in response to osteoarthritis, after injury to the hip region, or as part of a repetitive, flexed posture or move­ment habit. As a consequence of hip flexion contracture,

Ober's tcst.

loading through the hip joint is shifted to a thinner region of hyaline cartilage in both the femur and the acetabulum, the pelvis is placed in anterior tilt with increased lumbar lordosis, and the hip extensors are placed in a state of con­stant, low level muscle tension because the line of gravity shifts anterior to the center of mass.25 Therefore it is important for the clinician to examine for flexion contrac­ture and, if it is reversible, to intervene appropriately.

Causes of Hip Flexion Contracture

• Shortening of the iliopsoas • Shortening of the rectus femoris • Shortening of the tensor fascia lata • Shortening of the anterior hip capsule

504 C HAPTER 1 5 • Hip Pathologies: Diagnosis and Intervention

The Thomas test assesses for contracture of the iliopsoas muscle. In this test, the hip opposite the affected one is flexed to the point of flattening the lordosis in the lumbar spine, and the involved hip then is extended. If the involved hip stays flexed (i.e., is not able to extend to 0°), this is a positive test result for a flexion contracture (Figure 1 5 -7). For an accurate test result, it is very important to negate the lumbar lordosis. For a more sensitive assessment when comparing with the opposite side and certainly when the maneuver is used for treatment, the clinician should flex the opposite knee fully to the chest. During treatment, a rolled towel can be placed immediately distal to the ischial tuberosity to minimize anterior rotation torgue of the innominate during hip extension. If the hip stays abducted during the Thomas test, this is indicative of a tight TFL; if the knee cannot be flexed beyond 90° in the stretch posi­tion, this is indicative of shortening of the rectus femoris.

In addition to testing the length of the iliopsoas muscle, it is important that the clinician palpate the iliacus muscle at its origin at the internal superior rim of the iliac crest and palpate the psoas major muscle down to the inguinal ligament to assess for increased density (Figure 15-8).

Figure 1 5-7 Thomas tcst. With the back flat to the table and the contralateral hip

flexed, any tlexion indicates a hip flexor contracture.

Figure 1 5-8 Iliaclls soft tisslIe release.

To ensure that palpation of the psoas major muscle occurs, and not loading of some other abdominal structure, the examiner resists active hip flexion by asking the patient to push up with their thigh against the examiners caudal hand while simultaneously, with the cephalad hand, the examiner palpates the psoas major muscle in the abdomen a few inches lateral to the umbilicus. Because of the abdominal

contents, extreme caution should be observed if this soft tissue technique is to be used; the aortic pulse should be identified

and then avoided with the soft tissue load, and female

patients of childbearing age should be queried about

pregnancy.

Ely's test (prone knee flexion, then added hip extension) can be used to assess for con tractu re of the rectus femoris muscle; most athletes knees can be flexed to touch the heel to the buttock in prone lying, however, the stretch should be stopped if pain is felt in the knee or lumbar spine. Hip joint capsuloligamentous contracture is distinguished from contracture of the rectus femoris by hip extension in the prone position with the knee extended and also by assess­ment of the end feel on a posteroanterior glide of the hip. Anterior hip capsule restriction can be treated with a com­bined hip extension and posteroanterior glide technique with the patient in the prone position.

Iliopsoas Syndrome (Iliopsoas Bursitis and Tendonitis) Iliopsoas syndrome is defined as anterior hip pain associated with inflammation of the iliopsoas bursa or tendon. This often is the result of repetitive overuse or sudden overload in sports. Iliopsoas bursitis or tendonitis can result from repetitive friction of the iliopsoas myotendon over the ante­rior femoral head or iliopectineal eminence. Signs and symptoms of this syndrome typically include tenderness in the femoral triangle over the iliopsoas myotendon, decreased hip extension ROM, hip flexion contracture, positive anterior snapping hip, and weakness of hip medial and lateral rotation at 90° hip flexion.26

Signs and Symptoms of Iliopsoas Syndrome

• Tenderness in the femoral triangle • Decreased hip extension • Hip flexion contracture • Anterior snapping hip • Medial and lateral rotation weakness at 90° hip flexion

Johnston et a1.26 described a hip rotation strengthening program for treatment of iliopsoas syndrome. The program consists of medial and lateral rotation strengthening exer­cises in sitting to the affected leg (Figure 15-9 ), performed daily for 2 weeks, 3 sets of 20 repetitions on the weaker rotation, 2 sets of 20 repetitions on the stronger rotation.

Hip Pathologies: Diagnosis and Intervention • C HAPTER 1 5 505

Figure 1 5-9 Sitting hip internal and external rotation resistance.

After 2 weeks the frequency of this exercise is reduced to two to three times a week. At the 2 -week point , side-lying abduction/lateral rotation against Thera-Band resistance is introduced (Figure 1 5-10) , with 3 sets of 20 repetitions on the affected side , 2 sets of 20 repetitions on the unin­jured side; this is continued daily for 2 weeks. At the 4-week mark, a one-leg standing minisquat is introduced, keeping the knee tracking over the outside of the foot (Figure 1 5 -1 1 ); the regimen is 3 sets of 20 repetitions on the affected side and 2 sets of 20 repetitions on the wun­jured side. At this point , all strength exercises were per­formed two to three times per week. The hip flexors, quadriceps , lateral hip/piriformis , and hamstrings are stretched daily. The patient is instructed to perform twice as many stretches on the affected side as the uninjured side and to repeat the stretches as often as possible during the day. The stretching program continues as long as the pain persists. Gluteal re-education during gait also is incorporated with a conscious , voluntary contraction of the gluteal muscles of both the affected and the uninjured leg during the middle to late portion of the stance phase of the gait cycle. This is performed a maximum of 10 to 1 5 steps at a time , two or three times per day?6 The advan­tages of this program are that it is cost-effective and practi­cal for a patient to perform independentiy at home. Further research is necessary to corroborate tile good results seen in the preliminary retrospective case series.26

Figure 1 5-10 One-leg squat with contralateral abduction against a wal l .

Hip Capsule Contracture The capsule of tile hip joint can develop a contracture simi­lar to adhesive capslliitis in the shoulder (frozen shoulder). The capsular pattern is the typical pattern of contracture of a joint capsule in cases of arthritis. At the hip joint , tile most limited movements classically were described by Cyriax as "maximum loss of medial rotation, flexion , abduction and a minimal loss of extension." I 0 Extension and lateral rotation can also be limited , and adduction is the least limited motion. In fact, as abduction range decreases , adduction range can be seen to increase in patients with progressing OA of the hip. Kaltenborn27 described the hip capsular pattern as extension more lim­ited than flexion, medial rotation more limited tilan lateral rotation , and abduction more limited tilan adduction. The only difference between tile descriptions of Cyriax and Kaltenborn are the contributions of flexion and extension to a capsular pattern; these authors agree tilat abduction is more limited til an adduction and medial rotation more limited tilan lateral rotation in a true capsular pattern.

The arthrokinematic motions at the hip are anterior glide, posterior glide, medial glide , long axis distraction, lateral distraction , and short axis distraction. (Short axis distraction is a pull in line witil tile angle of the femoral neck, whereas lateral distraction is a direct lateral pull of the proximal end of the femur.) These accessory motions are used for joint mobilization purposes, primarily to treat

506 CHAPTER 1 5 • Hip Pathologies: Diagnosis and Intervention

a capsuloligamentous restnctJon . MUlligan28 described a technique combining arthrokinematic with osteokinematic motions that he called mobilization with movement

( MWM ). Short axis distraction combined with medial or lateral rotation is particularly effective for improving rota­tion ROM (Figure 1 5- 1 2 ) .28 Manual posterior mobiliza­tion can be useful for assessing and treating a posterior hip capsule contracture that would limit flexion and medial rotation ranges of motion (Figure 1 5 - 1 3 ) .

End feel i s a very important component o f joint mobility assessment, both in osteokinematic assessment of the

Figure 1 5-1 2 Mulligan'S mobilization with movement (MWM) technique to

increase range of motion of hip internal rotation.

Figure 15-1 1 Side-lying hip abduction (clam) exercise with Thera- Band. The

focus should be on contraction of the posterior gluteus medius

muscle and deep external rotators.

quality of overpressure and in arthrokinematic assessment of the quality of end range tissue resistance. 3 Normal end feels at the hip are soft tissue approximation for flexion and a firm, capsuloligan1entous end feel for extension,

Figure 15-1 3 Posterior hip mobilization to stretch the posterior capsule of the hip.

Hip Pathologies: Diagnosis and Intervention • C H APTER 1 5 507

medial and lateral rotation, abduction, and adduction. Abnormal end feels common at the hip are a firm capsular end feel before expected end range (e.g., from capsular contracture ), an empty end feel from severe pain (e .g . , very acute bursitis ) , and a bony block (eg. , from oste<?phytes in advanced OA).

Proximal Hamstring Strain Hamstring strains are common, especially in athletes. In American football players, hamstring strains have been reported to be the most common hip region injury and the third most common injury overall, after injuries to the knee and the ankle.29 In a general sports medicine popula­tion, however, hamstring strains are the third most com­mon hip or pelvic injury, after gluteus medius strain/ tendonitis and trochanteric bursitis. I S Two types of ham­string injuries can occur: muscle tears (grades I to III) and tendonitis/tendonosis caused by overuse. Muscle tears tend to occur at the stress risers of the musculotendinous or tenoperiosteal junctions or at the site of scar tissue from a previous injury (an acquired form of stress riser) . The most widely accepted theory about the hamstrings' vulnerability to injury is that they are a two-joint muscle functioning to eccentrically control knee extension and hip flexion. The biceps femoris muscle tends to be the most commonly injured component of the hamstrings, perhaps because the nerve supply to the short head of the biceps femoris is from the peroneal division of the sciatic nerve, whereas the long head of the biceps femoris and the other components of the hamstrings have their nerve supply from the tibial division of the sciatic nerve.29,30 It is proposed that the differing nerve supplies to the biceps femoris result in poor neuro­muscular coordination between the two heads of the mus­cle and thus a greater susceptibility to injury.

During walking and even jogging, the hamstrings are not fully recruited. It is with sprinting that high eccentric resistance from the hamstrings is required to decelerate the rapid leg swing (both knee extension and hip flexion) ; therefore, the hamstrings are most vulnerable to injury dur­ing sprinting. With running, the hamstrings have three pri­mary functions: eccentric contraction to decelerate the leg swing that starts at approximately 30° flexion; eccentric contraction at foot strike to control and facilitate hip exten­sion; and, eccentric contraction at push-off to assist the gas­trocnemius in extending the knee.30 If gluteus maximus recruitment for propulsive hip extension is insufficient at push-off, the hamstrings may have this additional role.

A hamstring injury also can occur during eccentric con­trol of hip flexion in sports (e .g . , lunging for a ball in ten­nis ) . This may occur when a player has not sufficiently flexed the knee, causing tlle hamstrings to strongly contract and lengthen at the same time. An important component of rehabilitation of such hamstring strains is emphasizing to the player tlle importance of bending the knees for practi­cally everything so that even when a lunging, top heavy

Windmill touches for eccentric hamstring contraction.

movement occurs, it does not result in sudden or cumula­tive tissue overload. Another theory on rehabilitation of this mechanism is to strengthen the hamstrings for this type of function with activities such as single leg stand windmill touches (Figure 1 5 - 14 ) . In the controlled rehabilitation environment, this activity is appropriate for the few times this movement might occur in a sport. However, this author discourages lunging with a straight knee and strongly emphasizes lunging in sports over a bent knee to prevent this type of injury; besides, bending the knees is better technique for reaching low in most sports.

Golfers can strain the proximal hamstring of the non­target-side leg from the propulsion required for the drive in the golf swing. The gluteus maximus should contract strongly on the non-target-side leg during the forward swing. Inadequate recruitment from the gluteus maxim us may result in overcompensation and strain of the proximal hamstrings. 3 I

Rehabilitation of hamstring strains using progressive agility and trunk stabilization exercises ( Box 1 5 -2 ) has been found to be more effective than a program emphasizing isolated hamstring stretching and strengthening. 32 Sherry and Best32 reported that only one of 1 3 subjects in the core stabilization group sustained a recurrent injury during the I -year follow-up, whereas in the static hamstring stretch/progressive hamstring strengthening group, seven of 1 0 subjects had recurrent hamstring strains. Fredericson et al. 33 also recommended incorporating eccentric ham­string strengthening based on the rationale that it is the only proven treatment for chronic tendinopathies.24,33

Strain or overload of the hamstring tissues also may be due to a pelvic alignment fault or malalignment that changes tlle lengtll/tension relationship of the hamstrings. Athletes with hamstring strains often show an anterior

508 C HAPTER 1 5 • Hip Pathologies: Diagnosis and Intervention

Box 15-2 Progressive Agility and Trunk Stabilization Approach for Treating Hamstring Strains

Phase 1*

1 . Low to moderate intensityt sidestepping: 3 x 1 minute. 2. Low to moderate intensity grapevine stepping (lateral stepping with the trail leg going over the lead leg and then under the lead leg),

both directions: 3 x 1 minute. 3. Low to moderate intensity steps forward and backward over a tape line while moving sideways: 2 x 1 minute. 4. Single leg stand, progressing from eyes open to eye closed: 4 x 20 seconds. 5. Prone abdominal body bridge (abdominal and hip muscles are used to hold the body in a face down, straight plank position with the

elbows and feet as the only points of contact): 4 x 20 seconds. 6. Supine extension bridge (abdominal and hip muscles are used to hold the body in a supine hook lying position with the head, upper

back, arms, and feet as the pOints of contact): 4 x 20 seconds. 7. Side bridge (i.e., side plank) each side: 4 x 20 seconds. 8. Ice in long sitting: 20 minutes.

Phase 2

1 . Moderate to high intensity sidestepping: 3 x 1 minute. 2. Moderate to high intensity grapevine stepping: 3 x 1 minute. 3. Moderate to high intensity steps forward and backward while moving sideways: 2 x 1 minute. 4. Single leg stand windmill touches: 4 x 20 seconds of repetitive alternate hand touches. 5. Push-up stabilization with trunk rotation (starting at the top of a full push-up, the patient maintains this position with one hand while

rotating the chest toward the side of the other hand as it is lifted to point toward the ceiling; the patient pauses and then returns to the starting position): 2 x 1 5 repetitions on each side.

6. Fast feet in place Gogging in place with increasing velocity, picking up the feet only a few inches off the ground): 4 x 20 seconds. 7. Proprioceptive neuromuscular facilitation trunk pull-downs using a Thera-Band: 2 x 1 5 repetitions to the right and left. 8. Symptom-free practice without high speed maneuvers. 9. Ice for 20 minutes if any symptoms of local fatigue or discomfort are present.

Modified from Sherry M, Best T: A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains, J Orthop Sports Phys Ther 34:116-125, 2004. 'Progression criteria: The patient is progressed from exercises in phase 1 to exercises in phase 2 when the individual can walk with a normal gait pattern and do a high knee march in place without pain. t Low intensity is a velocity of movement that is less than or near that of normal walking; moderate intensity is a velocity of movement greater than normal walking but not as great as sports activity; high intensity is a velocity of movement similar to sports activity.

innominate tilt on the affected side, and manipulation of the sacroiliac joint can enable these patients to regain mus­cle function and return to activity more quickly than those treated with more conservative measures.34 This same response has been identified with runners experiencing anterior or lateral hip pain .35

Muscle Strain Management Management of muscle strains should follow a rational, evi­dence-based progression based on the extent, mechanism, symptoms, and healing stage of the injury. In the acute, or early, phase, the PRICEM regimen should be followed ( P for protect, prevent, promote; R for relative rest; I for ice or cryotherapy; C for compression; E for elevation; and M for modalities, medication, massage, mobilization, and movement). Acute phase management should be used for the first 2 to 5 days and sometimes longer, depending on the extent of the injury. Rehabilitation then progresses through a subacute and a late phase. Return to sport after a muscle strain may take anywhere from a few weeks to many months, depending on the extent of injury 3

I Acute Injury Treatment Regimen

P Protect injury, prevent further injury, promote healing R Relative rest I Ice/cryotherapy C Compression E Elevation M Modalities, medication, massage movement, mobilization

Adductor Muscle Injury As in oth.er regions of the body, contractile tissue injuries at the hip come in two forms: strain (a muscle tear) and ten­donitis (acute ) or tendinosis (chronic) . Participants in sports such as soccer, hockey, and football are susceptible to adductor muscle pulls ("groin" strain ) because of the explosive lateral and rotatory hip movements involved, along with end range abduction stresses. Hyperabduction (overstretching) and forceful abduction of the thigh during adduction (e .g. , during a soccer tackle) are the most

Hip Pathologies: Diagnosis and Intervention • CHAPTER 1 5 509

common mechanisms of groin injury. Overuse adductor muscle injury also is common with repetitive, high velocity limb movement that usually involves a change in direction (e.g. , ice hockey or soccer) . Adductor injuries usually are felt in the groin, and any of the adductor muscles can be affected, although the adductor longus is most commonly injured.36

Defects in the abdominal musculature ( i .e . , "sportsman hernia"), osteitis pubis, inguinal hernia, and referred pain from the hip joint or lumbar spine should be ruled out in any assessment of the hip. A general but useful test to dif­ferentiate abdominal injury from adductor injury is to have the patient perform a siulp or a siulp with trunk rotation; an abdominal injury is most likely to be painful with these maneuvers.

In a study comparing active and passive management of adductor strains, Holmich et al. 37 found the active treat­ment group ( i .e . , those who performed adductor strength­ening, lumbopelvic strengthening and stabilization, and balance work) did much better than the passive treatment group ( i .e . , those who received transverse friction massage, transcutaneous electrical nerve stimulation, laser therapy, and adductor stretching) . These findings support the notion that deficient collagen (quality and quantity) is part of the problem. An active loading program ( including eccentric exercise) stimulates collagen synthesis and pro­duces better long-term results than a passive loading pro­gram. Box 15-3 outlines an active loading program for adductor strain rehabilitation.

A mechanism of groin pain that deserves further study is the effect of a positional fault on the lumbopelvic region. A case example seen by this author was acute onset left groin pain that occurred during the split-step on a serve and volley in tennis. Immediate pain, tightness, and spasm occurred in the adductor muscles and could not be relieved by an adductor stretch. Because stretching to relieve the adductor spasm did not have any appreciable effect and because the mechanism was not likely to have resulted in an adductor strain (the mechanism was a sudden load in slight lumbopelvic-hip flexion ), the author asked the patient to perform a standing lumbar backward bend that immediately and permanently relieved the symptoms. Whether the source of the symptoms was a flexion posi­tional fault in the lumbar spine or pelvis, a lumbar disc bulge that referred the symptoms to the groin, or an iliop­soas spasm, in tllis case lumbopelvic extension was an effec­tive treatment.

Athletic Pubalgia (Sports Hernia) Athletic pubalgia is a complex injury of the flexion/adduc­tion apparatus of tlle hip.38 When surgery is performed, the findings typically include a laddered appearance of the external oblique aponeurosis; separation of the conjoined tendon of the rectus abdominis from tlle inguinal ligament; and laxity of tlle transversalis fascia.39 The syndrome

presents as disabling lower abdominal and groin pain on exertion, typically progressing to involve tlle adductor longus tendon, as well as the abdomen and groin muscula­Ulre on the opposite side. Resisted situps or situps with trunk rotation and resisted hip adduction often can repro­duce the symptoms.38 The condition occurs mostly in male elite athletes in ice hockey, soccer, and football who are involved in vigorous training and competition schedules and whose sport involves repetitive hyperextension of tlle hip along with trunk rotation .39 Abdominal hyperextension with thigh hyperabduction, witll tl1e pivot being the pubic symphysis, has also been reported as a mechanism. 38 Often patients report an initial incident of a hyperextension injury of the hip in which the anterior pelvis or pubic symphysis is the pivot. Both tlle recUlS abdominis and adductor longus tendons insert at the pubic symphysis and are sites of pain in athletic pubalgia.38

Meyers et a1.38 hypothesized tllat the abdominal compo­nent of the injury usually is the initial injury in atllletic pubal­gia and that it allows the pelvis to rotate anteriorly ( as evidenced by tlle fact tlut in tlle cadaver, when a portion of tlle rectus abdominis is cut, tlle pelvis rotates anteriorly with ease) . The anterior tilt of the hemipelvis causes a compartnlent syndrome in the proximal adductors, because the adductors are now relatively unopposed as a result of injury to tlle lower abdominals (creating an unbalanced force couple) .38

Meyers et a1 .38 described tlleir pelvic floor (abdominal ) repair as a broad surgical reattachment of the inferolateral edge of the rectus abdominis muscle and its fascia to the pubis and anterior ligaments. They also performed an adductor release tllat involved complete division of all tlle anterior epimysial fibers of the adductor longus 2-3 cm ( 1 to 1.2 inches) distal to tlle insertion on the pu bis, as well as multiple longitudinal incisions at the tendinous attach­ment site on the pubis 38 Surgical repair for atllletic pubal­gia boasts a 95% success rate. 38,39 A typical postoperative rehabilitating protocol is outlined in Box 1 5-4. Atllletes usually are able to return to competitive sports by 12 weeks after surgery.

A course of conservative management should be attempted for sports pubalgia before surgery is considered. A key component of conservative rehabilitation is core strengthening, including emphasis on eccentric adductor and oblique abdominal strengthening.4o A particularly effec­tive form of core strengthening for atll ietic pubalgia uses diagonal elastic Ulbing resistance between the upper and lower extremities. Alex McKechnie developed this approach and has had considerable success using it with professional athletes.4 1 A key component of this metllod is to have tlle patient simultaneously contract the pelvic floor and transver­sus abdominis and hold a low level contraction while performing activities sllch as squats, lunges, and sport-spe­cific moves repetitively, with additional core resistance com­ing from a Thera-Band wrapped arollnd each tlligh and held in the contralateral hand (Figures 15- 15 and 1 5- 16).

51 0 C HAPTER 1 5 • Hip Pathologies: Diagnosis and Intervention

Box 1 5-3 Postinjury Program for Adductor Strain

Phase I (Acute)

• Rest, ice, compression, and elevation (RICE) • Nonsteroidal anti-inflammatory drugs (NSAlDs) • Massage • Transcutaneous electrical stimulation (TENS) • Ultrasound • Submaximum isometric adduction from knees bent to knees straight, progressing to maximum isometric adduction, pain free • Non-weight-bearing hip progressive resistive exercise (PRE) with weight in antigravity position (all except abduction) • Pain-free, low load, high repetition exercise • Upper body and trunk strengthening • Contralateral lower extremity (LE) strengthening • Flexibility program for noninvolved muscles • Bilateral balance board

Clinical milestone: Concentric adduction against gravity without pain

Phase II (Subacute)

• Bicycling/swimming • Sumo squats • Single limb stance • Concentric adduction with weight against gravity • Standing with involved foot on sliding board moving in frontal plane • Adduction in standing position on cable column or with Thera-Band • Seated adduction machine • Bilateral adduction on sliding board moving in frontal plane (Le., bilateral adduction simultaneously) • Unilateral lunges (sagittal) with reciprocal arm movements • Multiplane trunk tilting • Balance board squats with throwbacks • General flexibility program

Clinical milestone: Involved lower extremity passive range of motion (PROM) equal to that of the uninvolved side and involved adductor strength at least 75% that of the ipsilateral abductors

Phase III (Sport-Specific Training)

• Phase II exercises with increase in load, intensity, speed, and volume • Standing resisted stride lengths on cable column to simulate skating • Sliding board • On-ice kneeling adductor pull-togethers • Lunges (in all planes) • Correction or modification of ice skating technique

Clinical milestone: Adduction strength 90% to 1 00% of abduction strength and involved muscle strength equal to that of the contralateral side

Modified from Tyler TF, Nicholas SJ, Campbell RJ, et al: The effectiveness of a preseason exercise program to prevent adductor muscle strain in professional ice hockey players. Am J Sports Med 30:680-683, 2002.

Snapping Hip Syndrome Snapping hip syndrome ( coxa saltans) is defined as an auru­ble snap or pop as the hip moves through a range of motion, usually when the flexed hip is extended.42 It often is painless, but it can become symptomatic in athletic indi­viduals. The syndrome is more common in young athletic females. The calise of the snapping or clicking can be intra-articular or extra-articular (Table 1 5 -6) .

Intra-articular snapping or clicking can occur as a result of labral tears, loose bodies, synovial chondromatosis, and osteocartilaginous exostosis. In these cases, it is more

commonly a clicking sensation or sound. These problems may not be amenable to conservative treatment and may require arthroscopic intervention . An internal pop, called the suction phenomenon, is related to the hip's natural nega­tive pressure environment. It is benign and usually symptom free.42 .

Extra-articular snapping hip syndrome has been categor­ized into two general subtypes: external and internal snap­ping hip. Extra-articular snapping hip is most likely caused by the ITB snapping over the greater trochanter (external snapping hip) or the iliopsoas muscle-tendon

Hip Pathologies: Diagnosis and Intervention • CHAPTER 1 5 51 1

Box 15-4 Postoperative Protocol for Surgical Repair of a Sports Hernia

0-4 Weeks Relative rest 4-6 Weeks No resistive exercises

Posterior pelvic tilt (5-6 second hold): sets of 1 0 Gentle stretching

5 repetitions, hold 30 seconds each Side bending Hip flexion Quadriceps Hamstrings Adductors

Pool exercises Walking, forward and backward Standing hip abduction/adductio/fiexion/extension:

3 x 1 0 repetitions Partial squats: 30 repetitions Heel raises: 3 x 1 0 repetitions

6 Weeks Progressive resistance exercises Hip flexion/adduction/abduction/extension with

body weight (add resistance in 1 pound [0.45 kg] increments as tolerated)

UE PREs: Light dumbbells Cardiovascular exercise

20 to 30 minutes in any combination of the following: Upper Body Ergometer (UBE) Stairmaster Stationary bike Elliptical glider

Pool exercises Running, forward and backward Side slides Carioca Jumping jacks Swimming (flutter kick; no buttelflYJ

7 Weeks Previous exercises, increase weights as tolerated Strengthening

Abdominal crunches Bridging

Jogging: Y2 mile (0.8 km) Backward jog: 1 00 yards (91 .4 m) x 5 repetitions

8 Weeks Previous PREs Trunk stabilization exercises

Lunges Swiss ball Crunches Bridging Obliques Superman Trunk extension Reverse fly

Jogging: Jt2-1 mile (0.8-1 .6 km) Backward jog: 1 00 yards (91 .4 m) x 5 repetitions Agility drills

Sprinting: 50 yards (45.7 m); avoid sudden starts and stops

Figures-of-eight Cariocas

Plyometrics Rope jumping Side to side Front to back

9 Weeks Previous exercises LE PREs Sport-specific drills

Soccer-No shooting or long volleys 1 0- 1 2 Continued increase in exercise with the goal of

Weeks return to play at 1 2 weeks after surgery

Modified from Meyers W, Ryan J: Drexel University College of Medicine, Department of Surgery, Hahnemann Sports Medicine Center. UE, Upper extremity; PREs, progressive resistance exercises; LE, lower extremity.

snapping over the pelvic brim (internal snapping hip ) .42

Other reported causes are snapping of the biceps femoris over the edge of the ischial tuberosity, snapping of the glu­teus maximus over the greater trochanter as it blends into the ITB, and snapping of the i liopsoas over the anterior femoral head.42

The classic test for snapping of the iliopsoas muscle over the anterior pelvic brim or hip is reproduction of the snap as the hip is extended from a position of flexion, abduction, and lateral rotation (the extension test) . I t i s helpful to identify the location of the snap or click by simultaneous palpation during the test. Often firm manual pressure during the extension test can reduce the snapping by preventing the lateral to medial subluxa­tion of the tendon over the pelvic brim.42 Commonly,

shortening of the iliopsoas muscle and mal alignment of the pelvis are associated with snapping of the i liopsoas muscle.

A test for a snapping ITB is flexion of the adducted hip with the knee extended.43 Ober's test i s also l ikely to

show shortening of the ITB (see the section on ITB contracture ) .

An extra-articular snapping hip often is asymptomatic, but it can result in inflammation of a gluteal tendon or bursa. Treatment with NSAIDs and ice can be helpful in the short term. For long-term benefit, the cause of the snapping must be resolved, or at least its frictional effect must be reduced. This can involve soft tissue mobili­zation and stretching techniques for myotendinous COI1-

tractures, correction of muscle imbalances, correction of

512 C H APTER 1 5 • Hip Pathologies: Diagnosis and Intervention

Figure 1 5-15 McKechnie squat with Thera-Band.

malalignment of the pelvic girdle, movement pattern adjustments to minimize or abolish the click, and prescrip­tion orthotics for patients with pronating feet.

If conservative measures do not resolve symptoms asso­ciated with snapping hip syndrome and surgery is required, good results have been reported for surgical release and length­ening techniques for both the iliopsoas and proximal ITB.42,43

Table 1 5-6

Causes of Snapping Hip

Figure 1 5-16 McKechnie lunge with Thera-Band.

Joint Disorders

Osteoarthritis Osteoarthritis is a complex disorder of synovial joints charac­terized by both deterioration of articular cartilage and new bone formation, resuJting in joint pain and dysfunction .44

Racliographically, the deterioration of articular cartilage pre­sents as joint space narrowing, and new bone formation pre­sents as osteophytes. The hip is one of the more common

Anterior

Intra -articular

Loose bodies

Synovial chondromatosis

Osteochondral injury

Subluxation of the hip

Labral tears

Internal

Iliopsoas tendon snapping over pelvic brim

Iliopsoas tendon snapping over femoral head

Iliopsoas tendon snapping over bony ridge on lesser trochanter

Tendonitis of iliopsoas or rectus femoris

Anterosuperior labrum most common site

External

Iliotibial band snapping over greater trochanter

Gluteus maximus tendon snapping over greater trochanter

Posterior

Long head of biceps femoris tendon sliding over ischial tuberosi ty

From Gruen GS, Sciascia TN, Lowenstein JE: The surgical treatment of internal snapping hip, Am ] Sports Med 30:607-613, 2002.

Hip Pathologies: Diagnosis and Intervention • C H APTER 1 5 51 3

sites of involvement, and OA of the hip affects approximately 1 .5% of the adult population in the United States.45 Pain from OA of the hip usually is felt in the groin, lateral hip, and/or buttock.4,5 Women account for 2/3 to 3/4 of adults with OA of the hip and OA in general.45

OA can be divided into primary and secondary types. Primary OA occurs without some predisposing mechanical alignment factor. Secondary OA is the end result of another disease 'process. Eighty percent of OA of the hip is second­ary in nature.46 Predisposing factors to secondary OA of the hip are disorders such as osteonecrosis, Legg-Calve­Perthes disease, developmental dysplasia of the hip, slipped capital femoral epiphysis, congenital coxa vara or coxa valga, and hip fracture.

The primary signs and symptoms of OA are joint pain and stiffilCss. Radiographically, OA is characterized by joint space narrowing in the weight-bearing region and by osteo­phyte formation (Figure 1 5 - 1 7) . Rheumatoid arthritis ( RA), on the other hand, shows uniform joint space nar­rowing, which progresses to protrusio acetabuli (protrusion of the femoral head through the acetabulum) at the end stage. Routine x-ray views of the hip usually are sufficient to diagnose �A. Routine views for the hip are an antero­posterior (AP) pelvic view (which captures both proximal femurs, the pelvis, and the distal lumbar spine) , AP hip view, and lateral hip view (either true lateral or frog lateral ) .

Routine X-Ray Views for the Hip

• Anteroposterior (AP) pelvis • AP hip • Lateral view (either true lateral or frog lateral)

Advanced OA of the hip ( i .e . , radiographic evidence of OA with persistent severe symptoms or functional loss) can be very effectively treated with total hip arthroplasty (THA), discussed in Chapter 26. Because THA is not

Figure 15-17 A, Normal hip joints on plain x-ray film, AP view. B, Osteoarthritis of

the hip joint. Note the superior and

lateral joint space narrowing, subchondral sclerosis, superior

acetabular bone cyst, medial femoral neck, and lesser trochanteric sclerosis with buttressing. (From

Frontera WR, Silver JK: Essentials of physical medicine and rehabilitation,

Philadelphia, 2002, Hanley & Belfus . )

without risks and limitations, it is reserved for more advanced cases of OA that have not responded to medical management. A number of nonoperative ( medical ) approaches can be used to manage OA, including pharma­cological and nonpharmacological measures. Nonpharma­cological methods include patient education and physical and occupational therapy, which have been described as the foundation of treatment for patients with OA.47

Rehabilitation management of OA of the hip should be directed toward maintaining function, relieving symptoms, preventing deformity, and educating the patient in ways to protect the hip joint. Function can be maintained by changing the person to fit the environment or by changing the environment to fit the person. Examples of factors that can be changed in the person are inflammation, joint align­ment, range of motion, and muscle length and strength. Changing the environment may involve adaptive equip­ment, home modifications, and social services.

In published trials of nonmedicinal and noninvasive treatments for hip OA, aerobic-type exercise has shown the greatest benefit.48 Exercise therapy with the goals of improving muscle function ( i .e . , endurance, strength, and coordination), range of motion, pain relief, and walking ability has been shown to be effective for OA of the hip.49 However, in a study by Hoeksma et a1 . ,50 manual therapy for the hip was shown to be even more effective than exercise therapy in improving pain, stiffness, hip func­tion, and range of motion. The manual therapy these researchers used was stretching of the i liopsoas, quadriceps, tensor fascia lata, sartorius, adductors, and gracilis. The hold time was 8 to 1 0 seconds for each muscle, repeated 2 times . The stretching was followed by a series of five traction manipulations (long axis traction), as described by Cyriax, starting with the hip in the maximum loose­packed position; with each subsequent manipulation, the hip was placed in a position of more restriction.50,5 1

Acupuncture was found to b e helpful for symptom relief in a group of patients with OA who were awaiting total hip replacement. 52 Pain from OA of the hip and knee has also

51 4 C HAPTER 1 5 • Hip Pathologies: Diagnosis and Intervention

been shown to diminish when patients wear magnetic bracelets. 53

The findings of Hoeksma et al. 50 have been corrobo­rated by this author, who has found manual therapy tech­niques extremely helpful for improving hip function in individuals with OA and other hip conditions. Combina­tions of manual soft tissue techniques, joint mobilization, and manual stretching are very effective in improving ROM, and muscle length, reducing pain, and improving gait and other functions. A published case study has shown that ROM, strength, function, and gait can be improved and pain reduced in a person with hip OA who follows through with a rehabilitation program that includes manual therapy, therapeutic exercise, and educa­tion that addresses the presenting impairments. 54 Often patients with progressive OA may eventually need a hip replacement when walking becomes too painful , but the appropriate rehabilitation intervention can delay the oper­ation and make for a better postoperative outcome. Delaying hip replacement too long, however, especially if function and exercise capability are significantly l imited, is not wise, because it can result in worsening cardiovascu­lar health in particular.55

The decision on whether to change a joint's range of motion depends on whether that joint's range can be expected to increase and whether the hip currently is func­tionally limited . The decision as to whether the joint's range can be increased depends primarily on the end feel. If the end feel is a bony block, the joint's range cannot be changed. If the end feel is not a bony block, the joint's range may be changeable. A balance between symptoms, range, and function must be found. Much of the pain from OA arises from the inflammatory process. In most cases, reducing inflammation produces concomitant symptom and functional improvements. A rationale for improving range of motion is that restricted motion could be causing an inflammatory response from abnormal joint surface arthrokinematics. If this hypothesis is not supported by treatment, the approach for improving ROM must be modified or discontinued.

It is important to teach the patient the principles of hip joint protection, especially considering that normal gait causes approximately three times the body's weight to load through the hip during walking (see Figure 1 5-3 ) . These protection principles can be grouped into body weight reduction, load carrying modification, and assistive device use. For every pound of body weight lost, a 3-pound reduc­tion in load through the hip occurs; therefore body weight reduction is an admirable goal . However, the weight-bear­ing exercise required to lose body weight can irritate the hip. Pool exercises, swimming, and upper body workouts can be used for weight reduction without exacerbating hip inflammation. Workouts on stationary bikes and rowing machines also are often well tolerated until OA is more advanced.

--

Hip Joint Protection PrinCiples

• Weight reduction • Exercise modification • load carrying modification • Use of assistive device

When the patient needs to carry something, it should be as light as possible and should be carried on the back in a knap­sack. If a unilateral load is carried, it should be carried on the side of the hip problem. A cane should be used on the side con­tralateral to the hip problem. Both the contralateral cane and ipsilateral load advice are based on the opposing torque expla-

. 56 F .

natJon. or example, durmg one-leg stance on the right leg, the right hip has body weight creating a counterclockwise torque and the hip abductors creating a clockwise torque ( see Figure 1 5-4) . Use of a cane in the contralateral ( left) hand or holding a weight in the ipsilateral (right) hand also creates a clockwise torque about the right hip, thereby assisting the right hip abductors in clockwise torque generation.

Besides rehabilitation intervention, medication is an important component of nonoperative treatment for OA. The main indication for the use of medication in OA is pain

I · f 57 A .

h .

re Ie . cetamll10p en IS recommended for mild to moder-ate pain because its efficacy is comparable to that ofNSAIDs for this level of pain, and it has a more favorable side effect profile, provided the dosage does not exceed 4 g per day. NSAIDs are recommended for moderate to severe hip pain and in cases in which acetaminophen does not provide signif­icant relief or the clinical presentation suggests significant inflammation.47 Because of the cardiovascular risks asso­ciated with the cyclo-oxygenase-2 (COX-2 ) inhibitors, the nonselective traditional NSAIDs ibuprofen and naproxen are usually recommended as a first line of treatment. How­ever, celecoxib (200 mg daily [qd] ) and naproxen (500 mg twice per day [bid] ) appear to be safer than other agents with regard to cardiovascular risk. 58 For long-term use of a nonse­lective NSAID or in individuals with an increased risk of an upper gastrointestinal adverse event, a gastroprotective agent (e .g. , misoprostol) is recommended.47

Other pharmacological measures for hip OA are intra­articular injection of glucocorticosteroids, intra-articular injection of hyaluran, and opioid analgesics (e .g. , Trama­dol ) .47 Some patients find that glucosamine and/or chon­droitin sulphate help take the edge off their symptoms.

Femoroacetabular Impingement Although femoroacetabular impingement was first recog­nized as a mechanism for early hip OA in 1965, it was not until recently that increased interest in tllis condition as a primary etiological factor behind labral tears and OA has been considered. 59 One recent study has documented that acetabular labral tears rarely occur in the absence of bony

Hip Pathologies: Diagnosis and Intervention • CHAPTER 1 5 51 5

Figure 15-18 Plain x-ray film of the pelvis showing

a "pistol grip" deformity of both proximal femora. This deformity is

so named because the nonspherical

femora resemble pistol grips. (From

Shetty VD, Villar RN: Hip

arthroscopy: current concepts and

review of literature, Br J Sports Med

4 1:64-68,2007.)

abnormalities.6o Femoroacetabular impingement has been identified as the most common cause of end stage OA in young men and a common cause in young women.6 1 Two mechanisms of impingement have been identified: cam impingement, caused by jamming of an abnormal femoral head (e.g., from pistol grip deformity) into the acetabulum with increasing hip flexion; and pincer impingement, which occurs when the acetabular rim contacts the femoral head­neck junction at end range of flexion, causing a leverage of the opposite side of the femoral head up against the poster­oinferior edge of the acetabulum. Pincer impingement is more likely to be seen in patients with retroversion .62

Hip (Femoroacetabular) Impingement

• Cam • Pincer

Symptoms of femoroacetabular impingement typically are seen in athletic, younger middle-aged individuals who experience groin pain with sports activity. The pain initially is intermittent and can be aggravated by increased athletic activity, prolonged walking, and prolonged sitting.62

The impingement test is described as hip flexion of the adducted hip with progressively increasing medial rotation; this elicits groin pain with a positive test result.62 The imag­ing workup should include a cross-table lateral view, which gives good visualization if either flattening of the normally concave femoral neck (pistol grip deformity) and/or a non­spherical femoral head is present (Figure 1 5 - 1 8) ; MRI is necessary to evaluate for acetabular version (especially for a retroversion problem). MR arthrography often is neces­sary to identify labral tears (Figure 1 5 - 1 9 ) .63

Conservative treatment involves modification of activity to avoid the impingement positions and NSAIDs to reduce inflammation. To maintain a higher level of function and to prevent early onset of OA, the surgeon and patient

Magnetic resonance arthrogram showing an acetabular labral tear.

( From DeLee J, Drez D, Miller M: DeLee and Drez's orthopaedic sports medicine, ed 2, Philadelphia, 2003, WB Saunders.)

may opt for arthroscopic debridement of the source of impingement through contouring of the femoral head and neck to a more normal anatomy (cheilectomy), or a periacetabular osteotomy may be needed if an acetabular torsion problem is present.64 During surgery, repair of lab­ral tears and microfracture of any chondral lesions may also be performed. 63

Labra/ Tears With the increasing use of arthroscopy at the hip, labral tears have been found to be more common than previously thought. It is believed that labral tears may precipitate and/ or accelerate the process of osteoarthritis. Most labral tears (86%) are in the anterior quadrant of the labrum. Chondral lesions double in the presence of a labral tear, and 40% of patients with a labral tear have severe chondral lesions.65

516 C HAPTER 1 5 • Hip Pathologies: Diagnosis and Intervention

The mechanism for labral tears is associated with either repetitive microtrauma associated with pivoting and twist­ing movements in sports or with a specific traumatic event. Often the specific traumatic event involves extension and lateral rotation with the femoral head moving anteriorly and overstressing the anterior labrum.65

The symptoms of a labral tear usually are mechanical in nature : buckling, catching, painful clicking, and restricted ROM . Several special tests have been described to assess for labral pathology; these tend to be variations of two pri­mary tests :66,67

1 . The impingement test involves medial rotation of the flexed and adducted hip while it is held in at least 90° flexion and at least 15° adduction. If pain is not reproduced with the test performed slowly, a rapid application of the medial rotation at end range can reproduce symptoms. This test i s sugges­tive of a wide range of anterior hip disorders, including anterior labral tear, anterosuperior impin­gement, and iliopsoas tendonitis.

2. The apprehension test consists of lateral rotation of the extended hip. If symptoms are not reproduced, a rapid application of end range lateral rotation can be performed. With a positive test result, tlllS maneuver elicits apprehension or groin pain and suggests ante­rior hip instabil ity, anterior labral tear, or posteroin­ferior impingement.

The McCarthy hip extension sign is a further test for labral pathology. In tllis test, both hips are flexed, and while the uninvolved hip is kept flexed, the involved hip is extended from the flexed position first in lateral rotation and tllen in medial rotation . Reproduction of the patient's pain is a positive test result. McCarthy considered positive results on three different tests to be tlle key to predicting labral pathology: ( 1 ) pain witll the McCartllY hip extension sign; (2) painful impingement with hip flexion, adduction, and lateral rotation; and ( 3 ) inguinal pain on a resisted straight leg raise.68

McCarthy's Signs Predicting Hip Labral Pathology

• Positive McCarthy hip extension sign • Painful impingement on hip flexion, adduction, and lateral rotation • Inguinal pain on resisted straight leg raise

The active and, if necessary, resisted straight leg raise in the early range (test 3 in McCarthy's three-test battery) has been labeled tlle Stinchfield resisted hip flexion test, and tlle result is often positive with intra-articular disorders such as labral tears, arthritis, synovitis, occult femoral neck fractures, and prostlletic failure or 100sening.69 It also is positive with il iopsoas tendonitis/bursitis.

Fitzgerald70 described the following variations to differ­entiate anterior from posterior labral tears . To test for ante­

rior labral tears, the hip first is flexed with lateral rotation and full abduction and tllen extended with adduction and medial rotation. A positive test result is hip pain with or without an associated click. To test for posterior labral tears, the hip is first fully flexed, adducted, and medially rotated. It then is extended with abduction and lateral rotation. Again, a positive test result is pain wim or without an asso­ciated click.7o Pain Witll a resisted straight leg raise (resisted SLR) and pain with forced hip medial rotation combined with axial traction are otller tests that can load tlle antero­lateral labrum?!

Millis and Kim67 found that MiD with gadolinium enhancement provides a more sensitive and specific diag­nosis of labral tears than was previously possi ble (although it does not identify all tears present on arthroscopy) , and arthroscopy provides a means to resect or stabilize the tear. 72

The rehabilitation of patients after hip arthroscopy is outlined in Table 15-7. This program follows a gradual rehabilitation progression over the course of several monms. Hyperextension past neutral of the hip is avoided for the first 5 weeks after surgery to protect the anterior labrum as are rotational movements of the hip .

The ideas of Sahrmann 1 3 are worth incorporating into bom the nonoperative and postoperative rehabilitation of patients witll labral pathology. Sahrmann emphasized the importance of keeping the femoral head well seated in the acetabulum. This requires accurate diagnosis of me move­ment impairment syndrome, followed by prescription of the appropriate stretches, motor control and strengthening exercises, and patient education . Sahrmann has identified 1 1 movement impairments at the hip, of which anterior femoral glide is tlle most common. Anterior femoral glide syndrome can result in injury to the anterior labrum of the hip through a directional susceptibility of the hip into extension (common in runners and dancers) that causes the femoral head to increase pressure against the anterior joint structures, causing irritation and injury. Anterior fem­oral glide syndrome can also cause impingement of anterior hip structures (e .g. , the il iopsoas myotendon and anterior labrum) as a result of inadequate posterior glide of the fem­oral head during hip flexion. For treatment, the clinician should advise tlle patient to avoid activities and exercises that load the anterior labrum (e .g. , into end range exten­sion and/or lateral rotation ) and prescribe exercises and activities that encourage posterior glide of tl1e femoral head (e .g. , rocking back and forward in the quadruped position, hinging at me hips, with tl1e back held flat in the neutral spine position), as well as emphasizing control of one joint hip stabilizers (e .g. , iliacus, gluteus maxim liS, and posterior gluteus medius) and de-emphasizing two-joint stabilizers (e .g . , hamstrings, rectus femoris ) . 1 3

Table 1 5-7

Hip Arthroscopy Rehabilitation Guidelines

Range of Motion

Avoid hyperextension

Ankle pumps, circles

Active IR/ER-seated

Active abd/add

AA flexion-heel slides

Seated A/P, lateral weight shift

Single knee to chest

Seated trunk flexion

Hip flexor stretch to neutral

Pelvic tilts

Resistance Training

Isometrics and abdominals (level I)-supine

Standing isometric abduction

Bridging

Unilateral bridging

Three-way SLR (flex, abd, add)

Prone knee flexion

Seated knee extension

Nautilus knee extension

Seated hip flexion

Abdominal bracing

PNF pelvic patterns

Upper body strengthening

PNF diagonals-( full range) LE patterns

Stairmaster

Closed kinetic chain exercises

Heel raises, 1/4 squats

Lunges, full squat

Step-ups

Multihip machine, operative leg

Operative leg extension

Nonoperative leg

Hip Pathologies: Diagnosis and Intervention • C HAPTER 1 5 51 7

Postoperative Week

Phase I Phase II Phase III

1 2 3 4 5 6 7 8

Begin to stretch past neutral

Postoperative Week

Phase I Phase II Phase III

1 2 3 4 5 6 7 8

4-way

--Pain-free range--

Retro

-Abd, add, flex only-

-All directions-

Continued

51 8 C HAPTER 1 5 • Hip Pathologies: Diagnosis and Intervention

Table 1 5-7

Hip Arthroscopy Rehabilitation Guidelines-Cont'd

Phase I

Balance/Coordination 1 2 3

Unilateral stance

Rebounder

BAPS-bilateral to unilateral

Phase I

Conditioning 1 2 3

Stationary bicycle

Swimming-flutter kick only

Running

Upper body cycle

Pool Activities (Wounds must be Phase I

completely healed) 1 2 3

Deep water walking with float

Buoyancy-assisted ROM

Buoyancy-resisted ROM

Postoperative Week

Phase II Phase III

4 5 6 7

Postoperative Week

Phase II Phase III

4 5 6 7

Postoperative Week

Phase II Phase III

4 5 6 7

Shallow water walking Increase speed. Increase stride length as tolerated.

Plyometrics

Postoperative Week

Phase I Phase II Phase III

Sport-Specific Activities 1 2 3 4 5 6 7

Fitter

Slide

Plyometrics

Cutting drills

Sport cords

8

8

8

8

Modified from Dirocco S, McCarthy JC, Busconi BD, et a1 . : Rehabilitation after hip arthroscopy. In McCarthy JC, editor: Early hip disorders: advances in detection and minimally invasive treatment, p. 180, New York, 2003, Springer-Verlag.

Return to sports depends on ful l pain-free range of motion, strength 90% of the opposite limb, and completion of a running or jogging program.

Grey areas indicate the period in which exercises should not be performed.

fR/ER, internal rotation/external rotation; abd/add, abduction/adduction; AA, active-assisted; A/P, anteroposterior; SLR, straight leg raise; flex,

flexion; PNF, proprioceptive neuromuscular facilitation; LE, lower extremity; BAPS, biomechanical ankle platform system ( BAPS) board; ROM,

range of motion.

Hip Pathologies: Diagnosis and Intervention • C HAPTER 1 5 51 9

Sahrmann's Movement Impairments of the Hip

• Femoral anterior glide syndrome without medial rotation • Femoral anterior glide syndrome with medial rotation • Femoral anterior glide syndrome with lateral rotation • Hip adduction syndrome without medial rotation • Hip adduction syndrome with medial rotation • Femoral lateral glide syndrome • Hip extension with knee extension • Hip extension with medial rotation • Femoral hypomobility syndrome with superior glide • Femoral acc'essory hypermobility syndrome • Hip lateral rotation syndrome (shortened piriformis)

From Sahrmann SA: Diagnosis and treatment of movement impairment syndromes, pp. 176-191, St Louis, 2002, Mosby.

Loose Bodies Loose bodies have been more frequently diagnosed at the hip wi til improved arthroscopic technology and tech­nique-and more easily removed. In fact, treatment of symptomatic loose bodies has been described as the most widely reported and accepted application for arthroscopy of the hip.73 Loose bodies are classified as ossified or non­ossified. The ossified group is more frequently diagnosed because the ossification can be visualized on plain x-ray films. The primary symptom of loose bodies is anterior inguinal pain with locking episodes. Other signs and symp­toms include painful clicking, buckling, giving way, and persistent pain with activity. 73 Loose bodies can damage tile articular cartilage of a joi.nt, therefore prompt diagnosis and treatment are essential to prevent progression to OA.

Although arthroscopy has become the ideal method of addressing loose bodies definitively, Cyriax described a technique for repositioning a loose body tllat may have some temporary benefit in lieu of arthroscopic removal . l O

Cyriax l ikened his technique for loose body treatment to repositioning a pebble in your shoe; you shake it around until it moves to a pain-free position. 10 Cyriax described loose bodies as presenting witll sudden, sharp pain on weight bearing. lO The technique for "reducing" a loose body in the hip involves applying strong, long axis traction to the hip while it is in 800 flexion and then lowering the hip to 00 flexion while maintaining the traction and apply­ing several small amplitude, high velocity lateral rotation maneuvers. If tllis method is unsuccessful, the procedure is performed again, but this time small thrusts into medial rotation are used.

Another alternative suggested by Cyriax entails applying traction to tile hip at 900 flexion ( the knee also is at 900 flex­ion), passively moving tile hip to the extreme of lateral rota­tion, and then applying a quick, short overpressure. lO The effect on pain and function should be dramatic if indeed a mobile loose body is the culprit. The clinician should not per­sist if the treatment is not effective after several attempts, but if

it works, it should be repeated as needed. If conservative treat­ment does not provide lasting relief, arthroscopy may be necessary.

Osseous Disorders

Osteonecrosis Osteonecrosis is a multifactorial disease in which osteocyte death occurs in the femoral head via a variety of proposed path­ogenic pathways. It has bOtll clinically and radiographically rec­ognizable patterns to aid diagnosis. Osteonecrosis can occur anywhere in the body but is most common i.n the femoral head.

The two general subtypes of osteonecrosis are traumatic osteonecrosis and nontraumatic osteonecrosis. The trau­matic type often occurs secondary to a hip fracture or dislo­cation, and for this reason, displaced femoral neck fractures are treated by replacement of the femoral head . Witll a hip dislocation the risk for osteonecrosis is increased if hip reduction i� not performed witllin 8 hours?O

Types of Osteonecrosis

• Traumatic • Nontraumatic

In the non traumatic type of osteonecrosis, the symptoms are hip pain (often a fairly abrupt onset of severe pain) , decreased hip ROM, and stiffness. These symptoms are not specific to this condition, and no specinc physical examination tests exist for osteonecrosis. The examiner tllerefore needs to rely on the history as the clue to pursue diagnostic imaging that would result in a definitive diagnosis. The male to female ratio for osteonecrosis is 4 : 1 . The most common age range for onset is between the 3rd and 5t1l decades. Bilateral involve­ment is seen in more than 50% of cases. Red flags for nontrau­matic osteonecrosis include a history of corticosteroid use, alcohol abuse, or sickle ceU disease. Clinicians should keep in mind that plain x-ray films are not sensitive to osteonecrosis in the early stages, tllerefore being alert to any historical red flags is crucial. MRI is both sensitive and specific for diagnos­ing osteonecrosis (Figure 15-20), and tile classic MRI finding is the crescent sign. The crescent sign is seen early on MRI as decreased signal indicative of the necrotic bone; when the crescent sign is observed on plain films at a more advanced stage of the disease process it is from a subchondral fracture between necrotic bone and healthy bone.

Red Flags for Hip Osteonecrosis

• History of corticosteroid use • Alcohol abuse • Sickle cell disease

520 CHAPTER 1 5 • Hip Pathologies: Diagnosis and Intervention

Treatment for osteonecrosis covers the gamut of surgical options for treatment of the hip. Mild cases respond well to core decompression, in which a hole is drilled up into the femoral head to release pressure. Moderately severe cases can be u'eated by osteotomy or vascularized fibular grafts. Severe or late stage cases require hemiarthroplasty or total hip replacement?5

It is very important for clinicians to be aware of osteone­crosis, because patients may be seen for hip pain that is mis­takenly thought to be of soft tissue origin, when the real source of symptoms is osteonecrosis. 3 The prognosis is much better if the problem is diagnosed in the early stage, when core decompression can be performed.

Osteitis Pubis Osteitis pubis is the most common inflammatory disorder affecting the pubic symphysis?6 It generally is a self-limit­ing inflammation that occurs secondary to overuse, trauma, pelvic surgery, or childbirth . Although it can occur at any age, it is most common in males in their 3rd or 4th decade. Those most at risk are athletes who participate in sports involving repetitive shearing forces at the pubic symphysis and multidirectional deceleration and acceleration forces (e .g. , soccer, ice hockey) . Long distance runners are also prone to develop osteitis pubis. The gracilis muscle that attaches to the pubic symphysis has been implicated as a component in the etiology, and contracture or weakness (or both ) of the gracilis often is seen with osteitis pubis.

A "groin burn" is a common complaint in patients with osteitis pubis. Depending on the irritability of the condition, the pain can be brought on by walking, running, climbing

Figure 15-20 Osteonecrosis. Corresponding coronal

T , -weighted (TR/TE, 600/20)

(A) and t:1t-suppressed fast

T2-weighted (TR/TE, 4000/70) (B) spin-echo magnetic resonance

images reveal an area of osteonecrosis

in the right femoral head, with associated articular collapse and joint

effiJsion. Note the diffusely distributed abnormalities in the femoral head and neck compatible with marrow edema

and the crescent sign on the superior

femoral head. (From Resnick D, Kransdorf M J : Bone and joint imaging, ed 3, p 1 076, Philadelphia,

2005, WE Saunders.)

stairs, one leg stance, pivoting, kicking, and even coughing or sneezing. Rest usually relieves the pain . A prolonged, bilat­eral adductor contraction with the patient squeezing the clin­ician's fist between the knees can elicit groin pain . Resisted rectus abdominis contraction (siulp) can also be painful . Ten­derness is present at the superior or inferior pubic ramus (or both), and often both sides can be tender. Other condi­tions to consider in the differential diagnosis are groin strain, pubic rami stress fracture, hernia, and infectious osteitis pubis ( most often occurring after urological or gynecological surgery) .76

The imaging studies of choice are plain x-ray films and radionuclide bone scans. The x-ray findings, which may be negative in the early stage of osteitis pubis, usually include decreased definition of the cortical bone (irregular cortical margins and patchy sclerosis), and widening of the pubic symphysis may be seen. To assess for pubic symphysis widen­ing, one-leg standing (flamingo) views are recommended. Bone scans usually show unilateral uptake at the pubic sym­physis. Imaging helps differentiate osteitis pubis from other causes of groin pain, such as athletic pubalgia.

Treatment should begin with rest from the causative activ­ity (e.g., soccer or running) and avoidance of aggravating activities. NSAIDs and ice can be helpful for the inflammation. IfNSAIDs are not helpful, a corticosteroid injection into the site of max'irnwn tenderness can be considered. Prolotherapy injections are also effective in some cases. Once the symptoms have abated, progressive rehabilitation stretching and strengthening of the hip musculature are initiated. Exercise in water can be particularly helpful. Heat-retaining compres­sive shorts can be helpful for dry land exercise and sport.77

Hip Pathologies: Diagnosis and Intervention • C HAPTER 1 5 521

less Common Bone Pathologies

Like osteonecrosis, other bone pathologies can be the source of hip pain but can present with tenderness on pal­pation and produce positive results on hip tests (e .g. , Patrick's test, the flexion/adduction test) and 'decreased ROM. Often these pathological conditions are not identifi­able on plain x- ray films, and M RI may not be thought to be warranted. In addition to red flags in the history, a non­capsular pattern of ROM restriction suggests the need for further diagnostic workup. Examples of such bone pathol­ogies are transient osteoporosis of the hip and symptomatic herniation pit.78

Transient Osteoporosis Transient osteoporosis is a self-l imiting, painful osteopo­rosis, usually of the proximal femur. Its cause is unknown, but the condition is most common in women in the third trimester of pregnancy and in men in their 4th or 5th decade. The onset of pain from transient osteoporosis can be sudden or gradual. Range of motion is often l im­ited because of pain, and weight bearing is painful . X-ray films initially are normal, but by 6 weeks they usually show severe osteopenia with indistinctiveness of subchon­dral cortical bone?9 MRI shows a nonspecific, diffuse pattern of bone marrow edema. Because the condition is self-limiting and usually resolves within 6 to 12 months, treatment involves protected weight bearing for pain relief and to prevent insufficiency fractures. The clinician should reassure the patient that this is a self-limiting con­dition . The patient should be encouraged to use touch­down weight bearing, or "feathering" ( less than 1 0% of body weight ), with crutches, and during pregnancy a wheelchair may also be helpful to limit the distance walked (e .g . , for physician visits at a hospital ) . Rehabilita­tion intervention may be necessary to prevent the second­ary effects of limited mobil ity, particularly a flexion contracture . An aquatic program has been described as an effective mode for ROM, hip strengthening ( forward, backward, sidestepping ambulation) , and trunk stabiliza­tion exercises postpartum.80

Symptomatic Herniation Pit A herniation pit in the femoral neck is a normal variant in 5% of the population. It can become painful, at which time it becomes clinically significant. The pathogenesis of a her­niation pit is related to an abrasive effect to the femoral neck from the iliopsoas tendon where it is tightly applied to tile medial part of the capsule. The herniation pit can become symptomatic in atilletes when rapid and forceful shortening and lengmening of tile iliopsoas occurs. The pit also can enlarge and cause a painful cortical fracture.8 l

Femoroacetabular impingement has also been implicated as a cause of herniation pits.62

Fractures and Dislocation

Hip (Proximal Femur) Fracture Hip fracture is the ortllopedic problem with tile highest inci­deIKe, cost, and risk.82 More than 300,000 hip fractures occur each year in me United States, Witll a I -year mortality rate of nearly 25%, a l ife expectancy reduction of 25%, and lifetime health care costs approaching $25 billion.83 The morbidity rate after fracture is 32% to 80%.83 One interpreta­tion of mis data is mat a hip fracture is part of a downward spiral of health. Although partly true, this view ignores evi­dence mat many older adults are able to tolerate and make improvements in physical attributes and function.84·86

Approximately 90% of hip fractures result from a simple low energy fal1 .87 The most common risk factors for falls (and thus hip fractures) are age, gender, race, institutionali­zation/hospitalization, medical co-morbidities (cardiac dis­ease, stroke, dementia, prior hip fracture, osteoporosis ), hip geometry, medication, bone density and body habitus, diet, smoking, alcohol consumption, fluorinated water, urban ver­sus rural residence, and climate.88 A fall results from poor balance reactions and decreased strengtll . The fall results in a hip fracture because the bone is weaker ( usually osteopo­rotic), less soft tissue padding is present for shock absorption in the frail elderly, and older elders tend to fall on the hip because of meir slower gait speed ( Figure 1 5 -2 1 ), whereas younger elders often fall forward onto an outstretched arm, resulting in a Colles' fracture at the wrist (Figure 1 5 -22) .89

Risk Factors for Falls and Hip Fractures88

• Older age • Female • Caucasian • Institutionalization • Medical co-morbidities • Poor balance • Decreased strength • Hip geometry • Medication • Bone density • Body habitus • Diet • Smoking • Alcohol consumption • Fluorinated water • Urban residence • Climate

Hip fracture is defined as a fracture of the proximal third of the femur. Most hip fractures need to be treated surgically. The type of fixation required depends on tile location and degree of displacement of the fracture. Hip fractures are most simply categorized as intracapsular or extracapsular. Femoral neck fracture is me typical intracapsular fracture, and

522 C HAPTER 1 5 • Hip Pathologies: Diagnosis and Intervention

intertrochanteric fracture is the typical extracapsular fracture. A nondisplaced femoral neck fracture can be treated with pins or screws. A displaced femoral neck fracture requires hemiarthroplasty because the blood supply to the femoral head has been disrupted.

The two types of hemiarthroplasty are the unipolar type and the bipolar type. The bipolar implant has a pole of movement within the prosthesis that is designed to reduce wear on the acetabular cartilage. The bipolar endoprosth­esis is more expensive than the unipolar design and is used with younger patients (approximately those less than 70 years of age) who might require revision to a total hip replacement during their l ifetime usually because of acetab­ular cartilage degeneration. The original unipolar design (e .g. , the Austin-Moore prosthesis) tends to be used on less active and older patients who are unlikely to outlive the hip implant. Recently, total hip arthroplasty has been advocated as the optimum treatment for displaced femoral neck frac­tures in tl1e elderly. THA is associated with more indepen­dent living, it is more cost-effective, and there is a longer interval to reoperation or death than with open reduction and internal fixation ( ORIF) and unipolar or bipolar hemiarthroplasty.9o

Figure 15-21 A fal l that occurs while a person is

standing still, walking slowly, or

slowly descending a step has little

forward momentum. With little

forward momentum, the principal

point of impact is near the hip.

(Modified from Cummings SR, Nevitt MC: A hypothesis: the cause

of hip fractures, J Gerontol 44: M I 07-Ml l l , 1 989.)

Figure 1 5-22 A fall that occurs while a person is

walking rapidly has enough forward momentum to carry the individual

onto tile hands or knees instead of

the hip. ( Modified from Cummings

SR, Nevitt MC: A hypothesis: the

cause of hip fractures, J Gerontol 44: M I 07-M l l l , 1 989 . )

For intertrochanteric fractures (stable or unstable), the sliding hip screw, which is available in a variety of designs, is the implant of choice.87 Unstable intertrochanteric frac­tures sometimes are treated with an intramedullary device, but no difference in functional outcomes has been seen between it and tl1e sliding hip screw.87 THA is recom­mended for treatment of intertrochanteric fractures in patients with RA.9 J Figure 1 5 -23 shows some of the implants commonly used in hip surgery.

Rehabilitation after a hip fracture must be intensive and multidisciplinary, because appropriate rehabilitation efforts can restore many patients to a prefracture functional status.3

Weight bearing as tolerated (WBAT) for gait has been found to result in improved function for hip fracture patients over partial weight bearing ( PWB) restriction, without deleteri­ous effect to the surgical fixation.92 In tl1e acute care setting, more than one physical therapy visit per day has been shown to be predictive of achievement in basic func­tion and of discharge home from the acute care setting.82

Binder et al .85 found that 6 months of extended outpatient rehabilitation, including progressive resistance training, for frail elderly patients with a hip fracture improved the patients' physical function and quality of l ife and reduced

Hip Pathologies: Diagnosis and Intervention • C HAPTER 1 5 523

A B c

-= ------ --

o E F - G -

Figure 15-23 Various types of hip reconstructions and implants. A, Normal hip joint.

B, Total hip arthroplasty. C, Hemiarthroplasty. D, Levels of proximal femoral fractures: 1, Subtrochanteric; 2, intertrochanteric;

3, basicervical; 4, transcervical ( femoral neck); 5, subcapital . E, Multiple screw fixation ofa femoral neck fracture. F, Screw and plate fixation of an

intertrochanteric hip fracture. G, Blade plate fixation of a proximal

femoral osteotomy. In this drawing, no rotation of the proximal

fragment was performed (Modified from Shinar AA: Surgeries of the hip:

the approaches and the basics. In Fagerson TL, editor: The hip handbook,

p. 239, Boston, 1 998, Butterworth-Heinemann. )

their disability compared with a low intensity "standard" home exercise program . Mangione et al.86 found that a sample of frail elderly patients who had O RIF or hemiar­throplasty for a hip fracture could tolerate a moderate to high intensity home exercise program of either resistance training or aerobic exercise with appropriate supervision .

Table 1 5-8

Acetabular Fracture Acetabular fractures are socket-side hip fractures but are categorized with fractures of the pelvis, unlike fractures of the proximal femur, which are designated as hip frac­tures . Most acetabular fractures occur as a result of high energy trauma, and they can be displaced or non displaced . Displaced acetabular fractures are treated with OlUF to

allow earlier ambulatory function and to reduce the risk of post-traumatic arthritis. The OlUF hardware ( screws and plates) is placed outside the joint to act as an "internal cast" until the bone heals. The hardware is not routinely removed .93

Perhaps more than in most other hip conditions or sur­geries, application of a knowledge of in vivo force and pres­sure data is extremely important in the rehabilitation of surgical or nonsurgical acetabular fractures. Table 1 5 -8 pre­sents an evidence-based loading progression that is partiClI­larly useful for rehabilitation of acetabular fractures based on data from in vivo force and pressure measurements at the hip.2 1 Most patients with an acetabular fracture begin with touch-down (feathering) weight bearing (TDWB) , which, when performed correctly, results in less acetabular contact pressure tl1an even non-weight-bearing ( NWB), which can cause joint loading from hip muscle co-contrac­tion. The exercise program should also follow a graduated loading progression that mirrors the healing stages of the fracture and is in synchronization with the physician 's pre­scribed weight-bearing status.

Traumatic Hip Dislocation Dislocation of the hip is most conUl1on after total hip arthroplasty; tl1e incidence ranges from less than 1 % to as high as 9%?4 Dislocation of the hip in nonsurgical instances

Progression of Activities of Daily Living and Exercise Based on in vivo Force and Pressure Data at the Hip

Low Load Low Moderate Load

TDWB gait PWB gait performed correctly Chair rise with technique*

NWB gait Stairs with technique PROM AROM (supine and AAROM prone) no resistance Submaximum quad Submaximum gluteal

sets isometrics Bridging Bridging Double leg stance Bicycle (no resistance)

Moderate Load

FWB gait AROM (standing) with support One-leg stance (with support) Hip abduction (side lying) no external resistance

Low resistance exercise (supine and prone)

High Moderate Load

AROM (standing) no support

Maximum isometrics

One-leg stance no support

Slow jogging

High Load

Getting into and out of low chairs

Up and down stairs Accidental stumble Abductor resistance Jumping Running

Modified from Fagerson TL: Home study course: mrrent concepts of orthopaedic physical therapy-hip, La Crosse, WI, 200 I , Orthopaedic Section, American Physical Therapy Association .

• With technique refers to the use of a load moditying variable, which a physical therapist can teach a patient. For example, for a chair rise, this could

involve use of the armrests, having the affected leg out in front, sitting in a higher chair, or a combination of these. For stairs, with technique could

involve ascent and descent one leg at a time, use of a banister and a crutch, or both.

TDWB, touch-down weight bearing; NWB, non weight bearing; PROM, passive range of motion; AAROM, active-assisted range of motion; PWB,

partial weight bearing; AR OM, active range of motion; FWB, full weight bearing.

524 C HAPTER 1 5 • Hip Pathologies: Diagnosis and Intervention

is very rare; it usually occurs secondary to some form of trauma and often is associated with an acetabular and/or a femoral head fracture. Most traumatic hip dislocations are posterior ( 85% to 90%), and this usually is related to a mech­anism of injury in which the hip is flexed and in some degree of adduction and the knee is flexed while a dislocating force drives the femoral head posteriorly out of the acetabular socket.94 The classic mechanism is the dashboard injury in motor vehicle accidents, although the use of seat belts is reducing the incidence of this injury. In contact sports (e .g. , football, rugby, ice hockey, wrestling), a fall or tackle onto a flexed hip and knee can also drive the femur posteriorly.

Posterior hip dislocations can be recognized based on the mechanism of injury. The patient has considerable pos­terior thigh and buttock pain, and the leg appears short­ened and is held in flexion, adduction, and medial rotation. Prompt recognition and early reduction are essen­tial for a good outcome. Before reduction under anesthesia is attempted, plain x-ray films should be taken to rule out a fracture of the femoral head or acetabulum. Reduction of a dislocated hip should be performed within 6 to 8 hours to reduce the risk of avascular necrosis of the femoral head, which occurs as a later complication in 1 0% to 1 5% of patients after posterior hip dislocation . For dislocated hips that are not reduced within 8 hours, the rate of femoral head osteonecrosis increases to 40%. Most traumatic dislo­cations of the hip are reduced using spinal or general anes­thesia. However, before anesthesia is administered, one attempt at reduction can be made with an analgesic for pain and muscle spasm using the Allis or Stimson methods.74

These methods use hip traction in 90° flexion with firm counterstabilization of the pelvis. The Allis method is per­formed with the patient in the supine position, whereas in the Stimson method the patient is prone with the hip flexed over the end of the examination table?4

A complication of hip dislocation for which the clinician should monitor is sciatic nerve palsy. Sciatic nerve injury occurs in 1 0% of posterior dislocations, and although it resolves in most cases over time, in some cases permanent footdrop develops. Vascular insufficiency is rare but can occur with anterior or open dislocations.

Fracture-dislocations usually require open reduction because attempts at closed reduction could further displace the fracture and increase the rate of complications. If less than 20% of the posterior margin of the acetabulum is frac­ulred, conservative management is acceptable; however, larger fractures require ORIF.74

Once the dislocated hip has been reduced, management may require limited motion with a hip brace and patient edu­cation about risk positions. The risk position for posterior dislocation is combined flexion, adduction, and medial rota­tion. The risk position for anterior dislocation is combined extension and medial rotation. These movements, done rap­idly, further increase the risk for redislocation.

Risk Positions for Hip Dislocation

• Posterior: Flexion, adduction, and medial rotation • Anterior: Extension and lateral rotation

Stress Fracture Stress fractures in the hip region usually are seen at the femo­ral neck, pubic rami, and proximal femoral shaft. Although most stress fractures occur in the lower leg and foot, 8 .8% of lower extremity stress fractures are reported to occur in the hip and pelvic region.95

Stress fractures typically occur as a result of repetitive over­use that exceeds the intrinsic ability of bone to repair itself. Osteoclastic old bone resorption typically exceeds osteoblas­tic new bone formation by 3 to 4 weeks, and increased stress to the bone during this time (e.g., an increase in running mileage) can result in microfractures, which result in a stress fracture if the increased stress to the bone is continued. Rest­ing and unloading the bone can allow the osteoblastic new bone formation to catch up.96

Early detection and appropriate management of stress fractures of the proximal femur are very important, because these fractures have a high rate of complication from non­union, progression to complete fracture, and osteonecro­sis.97 A study of 23 athletes with femoral neck fractures found that the diagnosis was not confirmed, on average, until 1 4 weeks after the onset of symptoms, and this delay forced elite athletes to end their careers; this underscores the importance of keeping an open mind to diagnostic pos­sibilities and ordering the necessary imaging earlier rather than later in the course of management.98 The recom­mended imaging modalities for diagnosing stress fractures are bone scans or MRI, because stress fractures often can be missed on plain x-ray films.99 Computed tomography (CT) also can be used.

Risk Factors for Stress Fractures97

• Participation in sports involving running and jumping • Rapid increase in physical training program • Poor preparticipation physical condition • Female gender • Hormonal or menstrual disturbances • Low bone turnover rate • Decreased bone density • Decreased thickness of cortical bone • Nutritional deficiencies (including dieting) • Extremes of body size and composition • Running ·on irregular or angled surfaces • Inappropriate footwear • Inadequate muscle strength • Poor flexibility • "Type AU behavior

Hip Pathologies: Diagnosis and Intervention • CHAPTER 1 5 525

The classic symptom of a lower extremity stress fracture is progressive, activity-related pain that is relieved by rest. Local tenderness often is present. A single leg hop test usu­ally reproduces symptoms, and percussion of bone distal to the fracture site may reproduce symptoms. I OO .A femoral neck stress fracture causes anterior thigh or groin pain (often an ache) that is relieved by rest, although 'night pain may be present in chronic cases. An antalgic (painful) gait, pain at the extremes of hip rotations (especially medial rota­tion)' and pain with axial compression are common find­ings. t ol Clinicians should consider referral for further workup for stress fractures if continuous therapeutic ultra­sound increases the patient's pain; this has been reported for lower leg stress fractures, and although it is not a sensi­tive tool for this diagnosis, the occurrence of increased pain with ultrasound used in treatment of suspected soft tissue injury should be a prompt for further workup. l02

Stress fractures can be defined as fatigue or insufficiency fi·actures. Fatigue fractures tend to occur in young and middle-aged individuals from repetitive mechanical stress (e .g. , distance running or military training). Insufficiency fractures tend to occur in older individuals when the bone is weakened from disease states, such as osteoporosis or osteomalacia. Fullerton and Snowdyl03 defined femoral neck fractures as compression, tension, and displaced frac­tures. Compression stress fractures tend to occur in the inferomedial femoral neck, and because they tend to be more stable, they can be treated with protected weight bearing and follow-up x-ray films ( to ensure that no frac­ture displacement occurs during the healing process) until d1e patient is pain free. Tension stress fractures occur on d1e superolateral femoral neck, and because they are poten­tially unstable, d1ey should treated with multiple screws or a sliding hip screw. Displaced fractures should be treated with ORIF. 19

Nerve Syndromes

Theoretically, any nerve in d1e hip region can be injured. The nerves of the hip can be categorized into three groups of five nerves: five major nerves ( the sciatic, femoral, obtu­rator, superior gluteal, and inferior gluteal nerves); five minor nerves ( the nerve to the quadratus femoris and infe­rior gemellus, the pudendal nerve, the posterior femoral cutaneous nerve, nerve to the obturator internus and supe­rior gemellus, and d1e lateral femoral cutaneous nerve) ; and five "referring" nerves (d1e iliohypogastric nerve, the ilioin­guinal nerve, the genitofemoral nerve, the cluneal nerves, and the sinuvertebral nerve) . Irritation of nerve roots of the lumbar and sacral plexuses can also refer symptoms to the hip and buttock region.

Nerve injuries occur as a result of one of three mechan­isms: compression, traction, or ischemia. The three types of nerve injury are neuropraxia, axonotmesis, and neurotmesis (described in greater detail in Chapter 20) . Most nerve

injuries about the hip have been described as a complica­tion of total hip replacement, in which injury to the sciatic nerve is by far the most common complication. Surgeons also are very aware that the incision must not be extended more than 6 cm (2 .4 inches) directly proximal beyond the tip of the greater trochanter, to avoid causing denervation of a branch of the superior gluteal nerve. 1 04

In the nonsurgical setting, most nerve injuries at the hip occur as the result of mechanical entrapment, which causes a neuropraxia. Neuropraxia is an intact neural structure with decreased function because of local pres­sure, which produces ischemia and contusion of the nerve; usually full function is recovered after appropriate management. These nerve entrapments often are related to alignment, contractures, and repetitive or a single excessive overload or overstretch. The two most common nerve entrapments in relation to the hip are sciatic nerve entrapment by the piriformis muscle in the greater sciatic foramen and lateral femoral cutaneous nerve entrapment at the lateral edge of the inguinal ligament. Entrapments of other nerves in the hip region also have been reported in d1e literature, including the ilioinguinal nerve, femoral nerve, obturator nerve, genitofemoral nerve, lateral cuta­neous branches of the subcostal and il iohypogastric nerves, and entrapment of the sciatic nerve at the level of the ischial tuberosity (hamstring syndrome) .2 1

Nerve entrapments o r injuries are easiest to diagnose when the symptoms include specific neurological features ( i .e . , motor weakness, sensory changes [numbness or tin­gling], and reflex change) . Nerve entrapments are most dif­ficult to diagnose when the primary symptom is pain, especially buttock pain or groin pain that mimics a muscle strain or tendonitis. Causalgia-like pain or reflex sympa­thetic dystrophy occasionally complicates recovery after a nerve injury. l04

The two more common nonsurgical nerve entrapments at the hip are piriformis syndrome and meralgia paresthetica.

Piriformis Syndrome Piriformis syndrome is a confusing diagnosis, because some practitioners believe that it is overdiagnosed, od1ers d1at it is underdiagnosed, and some do not believe that it exists! 1 05 Often it is a diagnosis of exclusion, when no other reason for pain in the buttock can be determined. Pirifor­mis syndrome may account for up to 5% of cases of low back, buttock, and leg pain. It most commonly is seen in d1e 30 to 40 age range, and it often is associated wid1 some form of trauma to the buttock. t o6 Buttock tenderness is present over the piriformis muscle (especially in the greater sciatic notch) and surrounding tissues, and referred leg symptoms can arise from sciatic nerve irritation or from trigger points in the muscle itself. Flexion, adduction, inter­nal ( medial) rotation (FLADIR) of the hip usually causes buttock pain with piriformis syndrome. Numerous tests for piriformis syndrome have been described in the

526 CHAPTER 1 5 • Hip Pathologies: Diagnosis and Intervention

literature. Basically, they involve either passive stretching or resisted contraction of the piriformis muscle, and a positive test result is reproduction of symptoms in or emanating from the buttock.3

The piriformis is the only muscle that passes through the greater sciatic notch, along with six nerves ( sciatic nerve, superior gluteal nerve, inferior gluteal nerve, pudendal nerve, posterior femoral cutaneous nerve, and the nerve to the quadratus femoris ) and three vessel sets ( superior gluteal artery and vein, inferior gluteal artery and vein, and internal pudendal artery and vein) . There­fore a problem with the piriformis logically would have magnified effects because of its close anatomical relation­ship to numerous other neurovascular structures. A change in sacral or innominate alignment can also change the posi­tion of or tension in the piriformis in relation to these structures and thus potentially cause buttock and/or referred pain.

Several definitions of piriformis syndrome have been presented in the l iterature. lo6 This author believes that treatment is best guided by an approach in which a diag­nosis of piriformis syndrome is complemented by a state­ment of symptom mechanism and a statement of symptom distribution (e .g . , "local buttock pain from fal l onto buttock," or, "buttock and posterior leg pain to foot from sciatic irritation by piriformis in greater sciatic notch" ) . Differentiating piriformis syndrome from other lumbopelvic causes of referred pain into the buttock and posterior leg is i mportant.

Piriformis syndrome is characterized by symptoms in the sciatic nerve distribution . Pain in the buttock alone is not piriformis syndrome; the term piriformis syndrome is associated with sciatic nerve irritation by the piriformis muscle. As mentioned, the piriformis muscle is the only muscle that passes through the greater sciatic foramen, which makes it the most l ikely muscular source of sciatic entrapment.

Likely aggravating factors for piriformis syndrome are walking, stair climbing, and activities involving trunk rotation. Less severe cases of piriformis syndrome can be exacerbated by repetitive or resistive lateral rotation (e .g . , from kicking a soccer bal l ) . 3 A positive piriformis test produces buttock pain with possible radiation into the leg. Travell and Simonsl07 described the piriformis as "the double devil ," because it can refer pain from irrita­tion of the sciatic nerve or irritation of the piriformis trigger points. I 07

Treatment can include gentle, static stretching; ice mas­sage; a vapocoolant spray and stretch technique; ultra­sound; and NSAIDs. Techniques to promote balanced and optimal alignment, mobility, and stability of the lumbo-pelvic region are also worth pursuing. A heel insert of up to 0.64 cm ( 1,4 inch) on the nonaffected side may take some tension off the piriformis. Rest from sporting activity for several weeks often is necessary. 3

Meralgia Paresthetica Entrapment of the lateral femoral cutaneous nerve of the thigh as it emerges from the pelvis adjacent to the anterior superior ischial spine (ASIS ) can result in tingling, numb­ness, and pain in the nerve's sensory distribution on the anterolateral thigh . This condition is called meralgia par­

esthetica. It can present during pregnancy, in obese indivi­duals, in laborers who carry heavy tool bags around their waists, and from direct trauma near the ASIS during sports. Sensory testing can confirm the diagnosis, and a positive Tinel's sign may be elicited by tapping adjacent to the ASIS and inguinal ligament. The diagnosis should not be made before other hip, lumbar, or intrapelvic pathology has been ruled out. Treatments that can be beneficial include correction of mechanical contributing factors, as well as rest, ultrasound, and NSAIDs if needed. In some cases, injection of an analgesic and a corticoste­roid is warranted. In rare cases, when conservative mea­sures have failed, surgical release of the nerve can be performed. lo8

Summary

Applying the information presented in this chapter to live clinical situations requires good clinical j udgment. The most logical method for making clinical decisions is the risk-reward ratio: balancing cost (risk) against benefit ( reward) . The F balance (Figure 15-24) is an expansion of the risk-reward ratio tl1at can be particularly helpful to tlle clinician in making decisions about a person presenting with hip pathology. In rehabilitation terms, clinicians bal­ance achievement of best possible function against the risk of tissue failure (tissue breakdown or damage) . Controlled forces (e .g . , movement, mobilization, exercise) are used to improve form (e.g. , strength, flexibility, endurance, bal­ance) , and both controlled forces and improved form are

Forces

Function " Feel" Failure

Form

Figure 1 5-24 The F balance: A model for clinical decision making. ( From Fagerson

TL, editor: The hip handbook, p. 248, Boston, 1998, Butterworth­

Heinemann.)

Hip Pathologies: Diagnosis and Intervention • C HAPTER 1 5 527

used to optimize function (e.g. , transfers, walking, stairs, sports activity) . The patient should always be the focus of the rehabilitation process; "feel" at the center of the F-bal­ance refers to the importance of asking "how does the patient feel?" and incorporating his/her goal� into the treatment plan .

References

To enhance this text and add value for the reader, all refer­ences have been incorporated into a CD-ROM that is provided with this text. The reader can view the reference source and access it online whenever possible. There are a total of 1 08 references for this chapter.

KNU: LIGAM{NTOUS AND PAULLAR T {NDON INJURI{S Michael M. Reinold, Eric M. Berkson, Peter Asnis, James J. Irrgang, Marc R. Safran, and Freddie H. Fu

Introduction

Successful nonsurgical and surgical management of knee

ligament and patellar tendon injuries requires knowledge

of the functional anatomy and biomechanics of the knee.

This understanding forms the basis for the physical exami­nation of the knee and foundation for treatment options.

When a patient sustains a knee ligament injury or patellar

tendon injury, the clinician must be able to integrate this

information to evaluate the knee and to develop an appro­

priate treatment regimen.

The following chapter presents the scientific back­

ground of the principles of treatment of knee ligament

and patellar tendon injuries . The functional anatomy and

biomechanics of the knee are brought to a clinical level as

the physical examination of the ligamentous injuries are

presented . Specific ligamentous injuries are then discussed

in terms of epidemiology, operative and nonoperative

approaches to treatment, and rehabilitation.

Foundation for Surgical and Nonsurgical Management of Ligament and Patellar Tendon Injuries of the Knee

Functional Anatomy and Biomechanics of the Knee

The tibiofemoral joint is the articulation between the distal

end of the femur and the tibial plateau. The femoral con­

dyles are convex in the anterior and posterior and the

medial and lateral directions. They are separated by the

intercondylar notch, which serves as the site of attachment

528

for the anterior and posterior cruciate ligaments. The width

of the intercondylar notch may be an important consider­

ation for the risk of injury to the cruciate ligaments and

for the development of loss of extension after reconstruc­

tion of the anterior cruciate ligament. The transverse anterior to posterior dimension of the lateral femoral

condyle is greater than that of the medial femoral condyle ( Figure 1 6- 1 ).1 As a result, the lateral femoral condyle pro­

jects farther anteriorly than the medial femoral condyle,

providing a bony buttress to minimize lateral displacement

of the patella. The radjus of curvature of the femoral con­

dyles decreases from anterior to posterior and is shorter

on the medial side than on the lateral side .2 The anterior

to posterior length of the articular surface of the medial

femoral condyle is longer than that of the lateral femoral

condyle. 1 The longer articular surface of the medial femoral

condyle facilitates external rotation of the tibia as the knee

approaches terminal extension.

Static (Passive) Restraints of the Knee

• Joint capsule

• Menisci (2)

• Ligaments, primarily:

o Medial collateral ligament

o Lateral collateral ligament

o Anterior cruciate ligament

o Posterior cruciate ligament

o Posterior oblique ligament

o Arcuate popliteus complex (meniscofemoral ligaments;

ligaments of Humphrey and Wrisberg)