Download OMM 15- ST Pelvis, Hip, Thigh Hip: a region (junction of proximal

OMM 15- ST Pelvis, Hip, Thigh
Hip: a region (junction of proximal femur and lateral pelvis)
Diarthrosis (Synovial): ball and socket
Look for acute, chronic, overuse, traumatic. Associated pop/click or pain (severity/radiation)
Referred pain: SI dysfunction (trochanteric area); lumbar radiculopathy
Action
Flexion
Extension
Abduction
Adduction
External rotation
Internal Rotation
Muscle
Ilopsoas
Gluteus maximus
Gluteus medius/minimus
Add brevis, longus, magnus, pectineus, gracilus
Internal and external obturator, quadrates femoris,
Superior and Inferior gemelli
Gluteus medius and minimus
Instruction
Bend Knee to chest
Lie face down, bend knee and lift
Lie flat, move leg outward
Lie flat, move leg inward
Lie flat, bend knee across middle
Lie flat, bend knee away from midline
Hip Exam
Inspection:
◦ the hips anteriorly and posteriorly (standing)
◦ note any asymmetry in iliac crest heights,or level of gluteal folds
◦ After appropriate draping, look for: skin changes; redness, swelling, bruising, muscle atrophy
Palpation: while standine and supine, note any instability, tenderness, crepitus
Strength testing/ROM: active and passive
 Examine the ROM of the hips by asking the patient to perform the following movements:
◦ FLEXION - 90 degrees (knee extended); 120 degrees (knee flexed)
◦ EXTENSION – 30 degrees
◦ ADDUCTION – 30 degrees
◦ ABDUCTION – 45 degrees
◦ INTERNAL ROTATION – 40 degrees
◦ EXTERNAL ROTATION -45 degrees
Special testing:
Thomas test: Iliopsoas tightness (thigh off table), key is to hold opposite knee tightly to chest
Ober’s test: IT band tightness
Evaluation:
 When evaluating patients with hip pain it is likely to be from these sources:
◦ hip joint (intra and extra-articular)
◦ soft tissues around the hip and pelvis
◦ pelvic bones
◦ sacroiliac joint
◦ referred pain from lumbosacral spine
 The hip joint is one part of the pelvic girdle:(ilium, pubic ramus, and sacrum) and contains two joints the SI
(sacrum and ilium) and the hip joint (head of the femur into the pelvis)
 (Watch patient walk)-evaluation of gait can give insight to source of problem and potential dysfunctional
compensatory patterns
OMM 15- ST Pelvis, Hip, Thigh
I. Anterior Hip Pain
A. Degenerative Joint Disease (osteoarthritis, DJD): Loss of articular cartilage at the hip joint
Etiology: repetitive overuse, infection genetic , idiopathic
History: Gradual onset, anterior groin pain but may be buttock or lateral thigh, initially relieved by rest ,worse
with weight bearing may proceed to night pain and limited range of motion
Physical Findings: Limited ROM (Internal rotation), then loss of flexion and extension
Imaging: x-ray
Treatment: Strengthening, physical therapy for ROM, anti-inflammatories, surgical
B. Osteonecrosis AVN: loss of trabecular bone in the femoral head/neck usually during 3rd and 4th decade
Etiology idiopathic: Trauma (hip dislocation or femoral neck fracture), alcohol abuse, steroid use, RA, SLE; other
risks: sickle cell, radiation, Crohn’s Disease – these things result in compromise to the blood supply to
the bone
History: Gradual onset, groin pain but may be buttock or lateral to hip, may be sudden if femoral neck collapses
Physical Findings: pain with internal and external rotation of hip and abduction. If femoral neck has collapsed
they have pain with Limited ROM (Internal rotation, flexion, and abduction),
Imaging: x-ray AP pelvis and frog view; sclerosis or femoral neck collapse
Treatment: Strengthening, physical therapy for ROM – Surgical replacement
C. Stress Fractures
Etiology: Chronic overuse
◦ usually compression sided
◦ in Runners, Dancers, Recruits
Diagnosis delayed 5-13 weeks  risk of complications:
◦ AVN, nonunion, coxa vara, chronic pain
History
◦ Anterior groin pain (87%)
◦ Weight bearing activity (recent increase, hills/mileage for femoral neck stress fractures)
Insidious onset
Prior stress fractures
Females: Menstrual cycles, Weight changes, Eating disorders
Physical Examination: pain at extreme ROM (70%), antalgic gait (22%)
Hop test: Femoral Neck
Fulcrum test: femoral shaft
Technique Patient sits on exam table with knee extended Examiner position
Place one hand under sitting patient's femur Other hand placed over knee Maneuver Apply firm
pressure upward on femur Apply firm pressure downward on knee
Use Xrays for healing, bone-scan for injury,
Treatment: strict rest, non weightbearing, fixation (tension vs compression side)
OMM 15- ST Pelvis, Hip, Thigh
D. Avulsion Fractures (anterolateral)
Etiology: ASIS (sartorius), AIIS (rectus), Ischial (hamstring)
Mechanism: Chronic, Acute concentric/eccentric
History: Males, adolescents, local pain, limit motion
Physical Findings: tenderness, limit ROM & weakness
Imaging: AP pelvis, Oblique (iliac crest), CT scan
Treatment: Ice, stretch, gradual return, (>2cm then ORIF) – surgical repair
E. Hip Pointer
Etiology: Direct trauma ASIS, iliac crest
Mechanism: Collision in sports
History: Anterior/lateral pain after direct blow, pain localized, pain with laughing
Physical Findings: Local swelling, pain, ecchymosis
Imaging: xray (R/o fracture)
Treatment: Pain control, NSAIDS, injections
F. Inflammatory Conditions: Local manifestations of systemic disorders
Symptoms – dull aching pain in groin, lateral thigh, or buttocks. Pain is often episodic with morning stiffness,
improvement with moderate activity, and stiffness of hip joint motion
Exam – pain with internal rotation and restriction
Diagnostics – AP pelvis and frog leg views may show decreased bone mineralization or joint effusion; CBC,
CRP,ANA; aspirate joint effusion and send for C&S, cell count with diff, crystal analysis
Differential – broad ankylosing spondylitis, infection, inflammatory bowel disease, Reiter’s syndrome, RA, stress
fracture, SLE, gout
Treatment – tx underlying condition, NSAIDS, immunosuppressive agents; surgery
G. Labral Tear
Etiology: Tear of the fibrocartilaginous labrum usually due to high impact trauma.
Tear usually anterior labrum
Mechanism: Running, Hyperextension at hip, trauma
History: Deep sharp anterior hip pain, deep clicking or snapping, sense of instability
Physical Findings: Anterior hip pain with hip into extension, pain with anterior stress
Imaging: XR/MRI
Treatment: Rest, NSAIDs, Surgical repair
II. Posterior and Medial Hip Problems
A. Dislocation: Dislocation of femoral head from acetabulum
Etiology: Genetic, instability of joint
◦ Most are posterior; injury causes the hip to be adducted, flexed, and internally rotated. An anterior
dislocation would leave the hip abducted, flexed, and externally rotated
Mechanism: Direct blow with hip abducted; non-contact
History: Pain, inability to move, numbness
Physical Findings: Short leg, hip adducted, severe pain, inability to move; Evaluate sciatic nerve function by
asking patients to move toes and ankle and checking sensation on plantar and dorsal aspects of foot
B. Hamstring strain
Etiology: Muscle tearing
Mechanism: Acute overstretching, running, sprinting
Factors: inflexible, fatigue, imbalance, incomplete rehab
History: Local pain, deformity, popping sensation
Physical Findings: Local pain, deformity, poor ROM & strength
Imaging: x-ray (avulsion), MRI, US
Treatment: Ice, stretching
OMM 15- ST Pelvis, Hip, Thigh
C. Groin strain (Adductors)
Etiology: Tearing of Adductor muscle (Micro or macro tears)
Mechanism: Powerful over stretch, abduct, external rotation common in soccer
History: Pain which radiates along the medial thigh, inability to run, cut, start & stop
Physical Findings: Pain over muscle group, increases with resistance, possible defect
Imaging: MRI – if not resolving with conventional measures
Treatment: Rest, ice, stretch
D. Piriformis Syndrome
Etiology: Irritation to piriformis leading to sciatica symptoms
Mechanism: Anatomical variance, tightness, overuse
History: Cramping pain in buttock, tight hamstrings, tender piriformis, pain with sitting, radiating into leg
Physical Findings: pain stretching piriformis, weakness, sciatic tenderness, normal neurologic exam
Imaging: MRI (r/o other causes) if not responding to treatment
Treatment: Rest, stretching, pain control, OMT
III. Lateral Hip Pain
A. Tensor Fascia Latae Syndrome
Etiology: Overuse tendinitis, Bursitis
Mechanism: Running, after foot strike, hip 30o
History: Pain during gait cycle.
Physical Findings: Local pain, weakness of hip flexors; Positive Ober’s Test
Imaging: xray (r/o fracture)
Treatment: Ice, pain control, stretching
B. Greater Trochanteric Bursitis: Pain that originates over the greater trochanteric bursa that may radiate the entire
length of the leg (knee and ankle but not foot)
Etiology: Trauma to the bursa
Mechanism: trauma acute or repetitive
History: Localized pain, worse rising from chair , lessens with early movement then worsens with extended
movement; patients report night pain and cannot lay on affected side ;increases with hip flex/ext
Physical Findings: Local pain, swelling at greater trochanter, pain cephalad to this suggest tendinosis of gluteus
medius tendon
Imaging: x-ray only to rule out other injury
Treatment: Rest, Ice, NSAIDS, Injection, Correct biomechanics
Differential: Osteoarthritis – painful internal rotation
Sciatica – pain posteriorly or on top of foot
Snapping hip – clicking at site
Trochanteric fracture – limp persists with walking and positive Trendelenburg
Risks: lumbar spine disease, intraarticluar hip pathology, previous surgery around lateral hip ( internal fixation
device), RA
Metastatic disease
C. Lateral femoral cutaneous nerve entrapment (meralgia paresthetica) Pain and burning (dysesthesia) or hypoesthesia
over lateral thigh; they may complain of groin pain and pain at SI joint; no motor involvement this is sensory nerve
Risks: obesity, tight clothing, surgery, trauma; nerve exits pelvis near ASIS
Primarily Affects: young muscular women who extend their hips frequently, women with scoliosis
Joggers, rarely pathologic intra-abdominal/pelvic process, Truck drivers
Etiology: Entrapment/ impingement of lateral femoral cutaneous nerve
Mechanism: Inguinal impingement, abdominal (mass)
History: Tingling, numbness lateral thigh. May be painful.
Physical Findings:  sensation localized,  with flexion, extension of the hip
Imaging: EMG (optional), studies of abdomen
Treatment: Loose fitting clothing, wt loss, medications, nerve block, surgical decompression
OMM 15- ST Pelvis, Hip, Thigh
D. Snapping Hip: Tendons around the hip subluxate over bony prominences (iliotibial band over greater trochanter)
Etiology: Several causes: Bursitis, Labral tear, Physiological
Mechanism: Iliopsoas bursitis, overuse, prominence of pelvic brim, muscle tightness
History: Pain and snapping around the trochanteric area; iliopsoas felt in groin area, both experience pain
Physical Findings: Pain with resisted contraction of Hip flexors; have patient stand , abduct and rotate the hip,
the snap is palpated over the lateral hip; snapping of the iliopsoas may be palpated as hip extends from flexed
position
Imaging: AP and lateral hip to R/O pathology; MRI (rule out Labral tear)
Treatment: Ice, Rest, Rehab, Correct biomechanics, NSAIDS, steroid injection, surgery if tx failure and desired
Differential: osteoarthritis, loose body, osteonecrosis, tear of actetabular labrum