Hip-Knee Presentation

8/9/2019 Hip-Knee Presentation

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INSPECTIONP!"P!TION

"ocate #ony lan$mar%s

Anterior Surface of the Hip

' Iliac Crest at the "evel o( ")

' Iliac Tu#ercle'!nterior Superior Iliac Spine

' Greater Trochanter

' Pu#ic Symphysis

Posterior Surface of the Hip' Posterior Superior Iliac Spine

' Greater Trochanter

' Ischial Tu#erosity

' Sacroiliac *oint


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!ssess Range o( Motion +Goniometer,

' Test -le.ion o( the hip +/012,' 34en$ your %nee to your chest an$pull it againstyour a#$omen5

' Test E.tension o( the hip +672,' 3"ie (ace $o8n9 then #en$ your %nee an$ liftit up5

' Test !#$uction o( the hip +)12,' 3"ying (lat 9move your lo8er leg away fromthe mi$line5

' Test !$$uction o( the hip +)12,' 3"ying (lat9 #en$ your %nee an$ move your lo8er leg towardthe mi$line5

' Test E.ternal Rotation o( the hip +)12,' 3"ying (lat9 #en$ your %nee an$ turn your lo8er leg an$ (oot acrossthe

mi$line5

' Internal Rotation o( the hip +)12,' 3"ying (lat9 #en$ your %nee an$ turn your lo8er leg an$ (oot away from

the mi$line5


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Evaluate the Nervous System

' Peripheral Nerve o( the Hip

' O#turator Nerve' Hip !$$uction

' Sensory !rea +Me$ial !spect o( Mi$


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Per(orm an$ Interpret Special Tests

oThomas Test

oTren$elen#urg Test

o-a#er Test


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Per(orm an$ Interpret Special TestsoTren$elen#urg Test

Tests stren#th of #luteus medius muscle

'!s% the patient to stan$ on / leg

' I( pelvis stays at levelNormal strength' I( contralateral si$e o( pelvis $rops +or asymmetric iliac crest, Aea%

gluteus me$ius

' Aea%ness in contralateral si$e that patient is stan$ing on


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o-a#er Test +$le.ion Ab$uction %.ternal otation,Tests for Hip and S' patholo#y

' Press $o8n on patients %nee 8ith leg crosse$ an$ an%le

on opposite %nee +-igure ),

' POSITIBE RES"T elicits pain


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HIP PRO4"EMS &

HIP :ISE!SE/D Osteoarthritis o( Hip0D -emoral Nec% Stress -racture

6D Trochanteric 4ursitis


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Hip :islocation

' Clinical Mani(estation' Present o(ten in athletes

' Pain aroun$ hip an$ pro.imal thigh

' Superiorly $isplace$ $islocations present 8ith the a((ecte$ hip

e.ten$e$ an$ e.ternally rotate$' The in(erior type o( anterior $islocations present 8ith the a((ecte$

hip (le.e$9 a#$ucte$9 an$ e.ternally rotate$

' The posterior type o( $islocation most commonly appears 8ith a

shortene$9 internally rotate$9 an$ a$$ucte$ lim#


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Hip :islocation

' :iagnosis


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Hip :islocation

' Treatment OptionsPost


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-emoral Sha(t -racture

' Clinical Mani(estation' !cute9 severe pain 8ith movement o( lim# or

palpation o( lim#

' Possi#le $e(ormity in the thigh

' Possi#le leg shortening o( the a((ecte$ si$e

' Ecchymosis evi$entD

' 4ruits9 hematomas9 or lac% o( $istal pulses can in$icate vascular

in;ury


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' :iagnosis


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' -ollo8 p' Patient 8ill nee$ crutches an$ have to remain non


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Pelvic -racture

' Clinical Mani(estation' History o( high velocity trauma or

lo8


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Pro.imal -emur -racture

' Treatment OptionsNonoperative ManagementImpacte$ or non$isplace$ (ractures

Mo#iliFe patient

Control painOperative Management

Surgery shoul$i$eally occur 8ithin )K hours o( hospital a$mission

Pro.imal (emur may #e supplemente$ 8ith har$8are9 may #e replace$

8ith a prosthesis9 or the entire hip ;oint may have to #e replace$

' -ollo8 pMo#iliFe patient !S!P9 as tolerate$ +8ith use o( supportive $evices

at (irst,

PT (ocus on strengthening e.ercises an$ ROM


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In(lammatory !rthritis o( Hip

' Clinical Mani(estation


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' :iagnosis


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' Treatment OptionsNonoperative Management

Operative Management

' -ollo8 p


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"ateral -emoral Cutaneous Nerve Syn$rome



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' :iagnosis


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' -ollo8 p


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Osteoarthritis o( Hip

' Clinical Mani(estation' !ntalgic gait an$or use o( assistive $evices +8al%er9 cane,

' "im# length $iscrepancy

' Positive Tren$elen#erg test

' Pain 8ith active an$ passive ROM

+especially 8ith hip (le.ion an$ internal rotation,D Positive heel tap

+8ith occult (racture,D


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' :iagnosis


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' Treatment OptionsOperative ManagementI( la#ral $amage present on MRI9

total hip arthroplasty nee$e$

+contrain$icate$ in patients 8ith a

4MI )7,D

I( la#ral $amage not present on MRI9 consi$er surgical $e#ri$ement o( the

(emoral hea$D

I( the (emoral hea$ has collapse$ (rom necrosis9 patient 8ill nee$ total hip arthroplasty

+seen in the picture,J i( it hasn>t collapse$ (ully consi$er core $ecompression an$ #one

gra(t to restore the #loo$ supply

' -ollo8 p6 months to assess e((ectiveness o( pain management +non


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Osteonecrosis o( Hip

' Clinical Mani(estation' !symptomatic in early stages

' Groin9 thigh9 or #uttoc% pain

' Can #e #ilateral

' May #e secon$ary to in;ury9 ;oint$islocation9 or pressure in ;oint

' Re$uce #loo$ supply to ;oint


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' :iagnosis


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' Treatment OptionsOperative ManagementCore $ecompression

Inner layer o( #one remove$

4one gra(tTransplant o( healthy #one to assist in #one gro8th

Osteotomy

Removes #one a#ove or #elo8 the ;oint to help shi(t 8eight o(( $amage$

#one

*oint replacement

se$ 8hen #one has collapse$se$ 8hen other treatments not 8or%ing


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Snapping Hip

' Clinical Mani(estation' "ateral hip pain associate$ 8ith an au$i#le 3clic%5

' -reuently seen in young9 (emale athletes

' Pain an$ clic% notice$ 8ith repetitive hip (le.ion9 e.tension9 an$

a#$uction' "ateral snapping may #e repro$uce$ an$ (elt 8ith (le.ion an$

e.tension o( a((ecte$ hip

' !nterior snapping may improve 8ith $irect pressure over the

iliopsoas ten$on at the level o( the (emoral hea$

' Pain or snapping 8ith internal or e.ternal rotation o( the a((ecte$hip may suggest an intra


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Snapping Hip

' :iagnosis4ase$ on physical e.am


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Snapping Hip

' Treatment OptionsNonoperative ManagementMay a$minister steroi$ inections to the greater trochanter #ursa or

intra


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Strain o( Hip



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Strain o( Hip



' -ollo8 p


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Strain o( Thigh

' Clinical Mani(estation' !ntalgic gait

' Pain repro$uce$ 8ith active ROM o( the a((ecte$ muscle

' Ecchymosis evi$ent

' S8elling9 palpa#le mass9 or gap inmuscle note$

' Ten$erness to palpation note$ at

point o( in;ury


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Strain o( Thigh

' :iagnosisMainly #ase$ on history an$ clinical presentation

MRI can #e use$ to assess (or (lui$ collection or severity o( tear

' Initial ManagementConservative treatment(irst 1 $aysIce

Rest

Compression +thigh 8rapsleeve,

Elevation


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Strain o( Thigh

' Treatment OptionsOperative ManagementRarely nee$e$

' -ollo8 p' 6 8ee%s #egin active ROM

' 8ee%s increasing sport


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-emoral Nec% Stress -racture

' Clinical Mani(estation' sually seen in young athletes +speci(ically runners,9 or ol$er

patients 8ith meta#olic #one $isor$er

' "ocaliFe$ hip painprimary complaint

' Pain 8orsens 8ith activity an$ improves 8ith rest' Pain typically in the groin an$ possi#ly ra$iating into the thigh an$

%nee

' Possi#le report o( a ne8 activity or an increase in the intensity o(

an activity

' Night pain common' No a#normality on visual inspection

' No palpa#le ten$erness

' Possi#le pain 8ith ROM o( the hip


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' :iagnosisMRI or #one scan nee$e$ to reveal

(racture +t al8ays sho8 it,

' Initial ManagementNon


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' Treatment OptionsOperative ManagementOnly nee$e$ i( (racture progresses

' -ollo8 p' Every ) 8ee%s (or repeat imaging

stu$ies to ensure no change in

(racture pattern or symptoms9 an$ to

evaluate callus (ormation +sign o( healing,


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Transient Osteoporosis o( Hip



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' :iagnosis


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' -ollo8 p


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Trochanteric 4ursitis

' Clinical Mani(estation' Commonly overuse in;ury

' Intermittent or constant lateral hip pain that

can ra$iate $o8n the lateral thigh +see picture,

' Pain 8hen lying on the a((ecte$ si$e' No o#vious s%in color changes or s8elling

' Ten$erness to palpation over the lateral or

posterior aspect o( the greater trochanter

' Pain 8ith e.treme hip a#$uction an$ e.ternal

rotation


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' :iagnosis


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' Treatment OptionsNonoperative ManagementPT re(erral may #e $one +8ill (ocus on

stretching o( the ilioti#ial #an$ an$ strengthening o( the muscles

surroun$ing the hip,

NS!I:s

Trochanteric #ursa corticosteroi$ in;ection

' -ollo8 p

' !s nee$e$ +have patient come #ac% i( no improvement seen (romtreatment,


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=NEE & "OAER "EGInspection

Palpation

ROM

Goniometer

Muscle Strength

Nervous System

Special Tests


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INSPECTIONP!"P!TION

"ocate #ony lan$mar%s

Palpate

' Me$ial an$ "ateral -emoral Con$yles

' Patella an$ Patellar Ten$on' Ti#ial Tu#erosity

' Me$ical an$ "ateral Ti#ial Plateau

' Suprapatellar Pouch


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!ssess Range o( Motion +Goniometer,

' Test -le.ion o( the %nee +/61


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!ssess Muscle Strength

Numeric &Descriptive Grade

Description

1 NORM!" Complete Range o( Motion !G!INST gravity 8ith (ull ornormal resistance

) GOO: Complete Range o( Motion !G!INST gravity 8ith someresistance

6 -!IR Complete Range o( Motion !G!INST gravity

0 POOR Complete Range o( Motion 8ith Gravity Eliminate$

/ TR!CE Muscle Contraction 4ut no or very limite$ ;oin motion

7 !4SENT No evi$ence o( muscle (unction


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Evaluate the Nervous System

' Patellar Re(le.' -in$ the patella ten$on +in(erior to patella, an$ tap #ris%ly 8ith

re(le. hammer

' Sensory !reas +:ermatomesSharp:ull"ight

Touch,' Test "6 +me$ial upper leg a#ove the %nee,

' Test ") +me$ial to mi$line o( the patella,

' Test "1 +lateral cal( #elo8 the %nee,

' Test S/ +lateral popliteal (ossa,

' Test S0 +me$ial popliteal (ossa,


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oPatellar Grin$ Test

o

Pivot Shi(t Test

oNo#le>s Test

oO#er>s Test

oAilson Test


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oPatellar Grin$ Test' Aith the patient supine an$ the leg e.ten$e$9

press $o8n on patella 8ith #oth thum#s line$ up

8ith the length o( the legD Then9 push the

patella into trochlear groove o( (emurD

' Pain is POSITIBE SIGN (or

patello(emoral ;oint $isor$erD


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oPivot Shi(t Test' Patient supine

' Grasp the lateral aspect o( the %nee9 8hile cupping the heel 8iththe other han$D

' Passively (le. the hip to 07


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oNo#le>s Test' Patient lies supine 8ith %nees (le.e$ at 7 $egrees accompanie$

8ith hip (le.ionD

' Pressure is applie$ to the lateral (emoral epicon$yles or /


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oO#er>s Test' Patient is in si$e lying position 8ith the

uninvolve$ leg (le.e$ at the hip an$ the

%nee (or sta#ilityD

' The e.aminer passively a#$ucts an$

e.ten$s the hip 8ith %nee (le.e$ at 7 $egreesD

' E.aminer uses pro.imal han$ to sta#iliFe hip to prevent pelvis (romanteriorly tiltingD

' The e.aminer slo8ly lo8ers the (emurD

' I( the hip remains a#$ucte$ an$ $oes not a$$uct past anatomicalneutral this is a positive sign (or contracture o( the ilioti#ial #an$ ortensor (asciae lataeD


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oAilson Test' The patient is sitting upright on a ta#le 8ith legs $angling over the

e$ge at 7 $egreesD

' Grasp patient>s (oot an$ internally rotate ti#iaD

' Instruct patient to slo8ly e.ten$ leg until pain is (eltD' Test is positive (or Osteochon$ritis :issecans o( the %nee 8hen

patient reports pain at a#out 67 $egrees (rom (ull e.tension an$ #y$isappearance o( pain 8hen ti#ia

is e.ternally rotate$ #ac% to

normal positionD


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=NEE PRO4"EMS &

=NEE :ISE!SE/D !nterior Cruciate "igament tear +!C",

0D Me$ial Collateral "igament In;ury

6D Meniscal Tear


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!nterior Cruciate "igament tear +!C",

Clinical Mani(estations

' Imme$iate e((usion is note$

' 3Pop5 soun$ is hear$ at time o( in;ury

' Per(orm patellar #allottement< assess (or e((usion

' :ecrease$ ROM may result (rom e((usion or ;oint line

ten$erness secon$ary to meniscus tear


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:iagnosis +Special Tests,

' "achman9 anterior $ra8er9 an$ pivot shi(t tests

' Posterior $ra8er test (or PC" in;ury

' McMurray Test +Meniscus Tear,

' :ial Test evaluate posterolateral corner in;ury +P"C,

' Balgus & Barus stress test evaluate MC" an$ "C"

' Patella apprehension test patella $islocation

:iagnosis +Imaging,'


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Initial Management

' Patient E$ucationRevie8 T options inclu$ing ris%s an$ #ene(its

!utogra(t < pre(erra#le (or surgical reconstruction

Hamstring Ten$ons4one Patella Ten$on 4one +4PT4, gra(t

' Initial Treatment Rest9 ice9 compression9 elevation

!spiration may #e per(orme$ to $ecrease e((usion

Maintain ROM< $o not place ptD in a %nee immo#iliFer

Treatment Options

Nonoperative

Operative


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' -ollo8


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!rthritis o( the =nee

' Clinical Mani(estationso *oint s8elling9 sti((ness9 perio$ic (lares9 night pain & pain at rest

8ith severe O!9 catching an$ loc%ing o( %nees9 common in ol$er

patients

o O#servations Gait an$ use o( assistive $evice9 ua$riceps atrophy9

e((usion

o Palpation E((usion9 crepitus9 ten$erness

o ROM o(ten $ecrease$J may lac% (ull e.tension


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' :iagnosiso Ra$iographs

o Common ra$iographic changes seen in O! inclu$e $ecrease$ ;oint

space9 osteophyte (ormation9 su#chon$ral sclerosis9 cyst (ormation9

(lattening o( the (emoral con$yles

oMRI


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' Initial Management

Nonoperative Managemento!ctivity Mo$i(ication

o Ice or Heat

o!cetaminophen or NS!I:s

o Orthotics 3unloa$er5 or 3support5 #races

o

Corticosteroi$ In;ectionso Glucosamine & Chon$roitin sul(ate

o E.ercise


o!rthroscopic :e#ri$ement

o High Ti#ial Osteotomy

o nicon$ylar Replacement

o Total =nee Replacement

-ollo8


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4ursitis

' Clinical Mani(estation' Prepatellar #ursitis

' !nterior %nee pain an$ s8elling

' :i((iculty %neeling

' 4allota#le collection o( (lui$ over the patella 8ith or 8ithout erythema

an$ 8armth

' Ten$erness over the #ursal sac

' Chronic #ursitis is characteriFe$ #y palpa#le su#cutaneous co##lestone

Documents

Hip-Knee Presentation