The Hip Exam for the Generalist Alan Zhang MD Assistant Professor - PDF document

11/20/2017 The Hip Exam for the Generalist Alan Zhang MD Assistant Professor Sports Medicine and Hip Arthroscopy UCSF Department of Orthopaedic Surgery The Layers of the Hip  To treat hip pathology-  1 st task is to understand the source of hip pain  Bryan Kelly et al Arthroscopy 2012 • Layer 1- Osteochondral • Layer 2- Inert • Layer 3- Contracile • Layer 4- Neuromechanical 2 1

11/20/2017 Layer 1- Osteochondral  Structures • Femur • Acetabulum • Articular cartilage  Pathology • Cam impingement • Pincer impingement • Subspine impingement • Articular cartilage delamination 3 Layer 2- Inert  Structures • Capsule • Labrum • Ligamentum teres  Pathology • Labral tear • Capsular instability • Adhesive capsulitis 4 2

11/20/2017 Layer 3- Contractile  Structures • Muscles crossing hip • Pelvic floor • Lumbosacral muscles  Pathology • Gluteus medius tear • Hip flexor strain • Proximal hamstring strain • Adductor tendinopathy 5 Layer 4- Neuromechanical  Structures • Neuro-vascular structures in hip region • Regional mechanoreceptors  Pathology • Pain syndromes • Neuromuscular dysfunction 6 3

11/20/2017 Location, Location, Location  Anterior/groin • FAI • Arthritis • Flexor strain  Lateral/thigh • Trochanteric pathology • Snapping hip  Buttock/posterior • Low back/sciatic nerve • Referred pain 7 Physical Exam  Asses ambulation • Antalgic gait ‒ Arthritis/acute injury • Trendelenberg gait/Single leg stance ‒ Trochanteric pathology ‒ Gluteus tear • FAI gait ‒ Loss of peak hip extension 4

11/20/2017 Trendelenberg Gait FAI gait  FAI gait • Loss of peak hip extension  Zhang et al AJSM 2016 • Increased hip joint loading in FAI patients 5

11/20/2017 Supine Exam  ROM  Strength testing  Provocative exams 11 Range of Motion  Flexion (0-130)  IR @ 90 degrees of flexion (0-30)  ER @ 90 (0-60)  Abduction (0-60)  Extension (0-20)  Arthritis- decreased globally  FAI- decreased IR and flexion 6

11/20/2017 Strength/Muscle Exam  Rectus—hip flexion against resistance  Abductors—push out legs  Adductors—pull in legs Provocative Exams  Log roll  FADIR  FABER  Labral stress test/ Scour test  Sports hernia exam  Straight leg raise 14 7

11/20/2017 Log Roll  Assess for intra-articular hip pathology 15 Flexion ADduction Internal Rotation 8

11/20/2017 FADIR for FAI FABER Test  SI pathology  Sometimes anterior labral pathology 9

11/20/2017 Flexion ABduction External Rotation Labral Testing/Scour Test 10

11/20/2017 Sports Hernia (Athletic Pubalgia)  Strain or tear of soft tissue in lower abdomen or groin area • Inguinal disruption • Adductor injury • Abdominal wall injury 21 Sports Hernia Exam  Palpation • Pubic symphysis/Pubic tubercle • Insertion of rectus (confluence of structures) • Adductor origin (AL, AB, pectineus) • Superficial inguinal ring ‒ Rule out true hernia ‒ Size of ring (dilation indicates weakened area) ‒ Check tenderness of posterior wall 22 11

11/20/2017 Sports Hernia Exam  Special maneuvers • Resisted sit up (legs straight, 10-30 deg trunk flexion) • Adductor Squeeze test (0 deg and 90 deg of hip flexion) – pain/strength • Valsalva 23 Straight Leg Raise  Hamstring tightness  Radiating pain (lumbar radiculopathy) 12

11/20/2017 Lateral Exam  OBER test • IT band tightness  Palpate Greater Trochanter • Trochanteric bursitis  Gluteus Medius strength testing Ober Test 26 13

11/20/2017 Gluteus Medius Strength Test 27 Prone exam  Hamstring exam • Palpate for defects • Evaluate for weakness 14

11/20/2017 Thank You 29 15