Hip Syndromes - Shirley Sahrman

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Diagnosis and Treatment of Femoral Syndromes:A Movement System Impairment Approach

Who Am I?

Jill McVey, DPT, ATCPhysical Therapist at Movement Systems

Physical Therapy in SeattleAthletic Trainer at University of Puget Sound in

TacomaEx-softball player, aspiring roller derby athlete, handbell ringer, Red Sox fanatic, LP collector...

Who Am I?

*Lead Author, The Experience of Deep Brain Stimulation for Individuals with Parkinson's Disease Submitted to JNPT 2010*Lead Author, The Foot and Ankle chapter of Therapeutic Exercise: Moving Toward Function 3rdEdition*Teacher, Foundations in Movement System Balance

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Who Am I Referencing?

Shirley Sahrmann, PhD, PT, FAPTAProfessor, Physical Therapy, Cell Biology & Physiology

Associate Professor, NeurologyDirector, Program in Movement Science

Washington University School of Medicine

Author, Researcher, Teacher, Mentor, Comedienne

Reference Texts

The Movement System

Movement is the action of a physiologic system that produces motion of the whole body or of its component parts. It is the functional interaction of structures that

contribute to the act of moving. The movement system is in balance when the

elements interact appropriately, producing variety in specific joint movements and

postures, which allows for movement to be precise, which leads to good

musculoskeletal health.

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The Movement System

Component Parts Base: Musculoskeletal elements. The foundation on

which movement is based Modulator: Neurological. Regulates movement by

controlling the patterns and characteristics of muscle activation

Biomechanical: Statics and dynamics Support: Cardiopulmonary and metabolic systems

SO WHAT????

The Kinesiopathologic Model

One or more of the elements is dysfunctionalImpaired interaction of the structuresMovement is nonideal ...and the dysfunction is associated with pain.

As opposed to the pathokinesiologic model -abnormality of movement is the result of

pathological conditions

MSI Paradigm AssumptionsRepeated movements and prolonged

postures induce tissue changes contributing to...

-Development of relative flexibility: the body takes the path of least resistance for movements

-Development of a joint's directional susceptibility to movement (DSM)

The direction susceptible to movement (DSM) is associated with an accessory motion hypermobility, the cause of tissue injury and degeneration.

Musculoskeletal pain is a progressive condition, associated with degenerative changes and is affected by lifestyle.

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Key Concepts

It's all relative...stiffness/flexibilityYou get what you train

The presence of a muscle does not mean that is is being appropriately used.

There is no magic in an exercise except if the desired motion is evident

The way everyday activities are performed is the critical issue

Hypermobility is the loss of precise motion--the loss of normal accessory motion. Hypermobility

leads to degeneration and pain.

Cause vs. Source

Cause: the mechanical factor (movement) that results in tissue pathology (hip anterior glide syndrome)

Source: the tissue/structure that is symptomatic (labral tear). You can't treat a labral tear, but you can fix the underlying mechanical CAUSE of the labral tear.

Goals of the MSI Exam

Identify the primary dysfunction: the compensatory movement that is associated with the athlete's symptoms

...from history, signs, symptoms, examinations, and tests

Identify factors that are contributing to the primary dysfunction

The syndrome is therefore named for the principle impairmentthe movement direction

most consistently affecting the symptoms.Correction of the dysfunction decreases or

eliminates the symptoms.

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Contributing Factors

**The WAY movement is performed**The type of activity

FrequencyDuration/intensity

Tissue characteristics (collagen laxity), anatomical variations

Body proportions (height, weight, anthropometics)

Path of Instantaneous Center of Rotation-- PICR

SO WHAT?The majority of syndromes affecting the hip arise

from impairments in the muscles (recruitment, length, performance) attaching close to the

proximal femur that control the alignment and motion of the femur in the acetabulum. This results

in a deviation of the PICR.

The the point around which a rigid body rotates at a given

instant of time...a critical concept for assessing

aberrant femoral mechanics

Hip Articulation AnatomyAcetabular Labrum:fibrocartilaginous ring

that deepens boney acetabulum.

Maintains negative intra-articular pressure

*Free nerve endings (nociception, proprioception)

Highly vascularlized Thinner anteriorly; absent

over inferior acetabulum

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Ligamentous Support

Anterior Posterior

Femoral Head, Structural Variations

Angle of inclination: angle between the femoral shaft and femoral neck (normal = 125 degrees)

Coxa vara (seen with genu valgum): 125. Increases the subluxation risk; requires really strong abductors. The athlete will want to accommodate their typically longer hip abductors by standing in adduction.

Femoral Head, Structural Variations

Angle of declination: angle of femoral head in the transverse plane (normal = 12-15 degrees)

Excessive anteversion directs the femoral head towards the anterior aspect of the acetabulum when the femoral condyles are aligned in their normal orientation. This allows for a greater excursion of femoral MR relative to LR. Be careful interpreting MR/LR ratio as indication of anteversion or retroversion.

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Acetabular variationsFemoral head-neck proportions

Cam impingement: abnormal femoral head-neck junction is driven into the acetabulum during flexion/MR

Pincer impingement: normal femoral neck impinges against an overhanging anterosuperior acetabulum

Muscular Control of the Hip

Flexors:TFLSartoriusRectus femoris Iliopsoas**


Extensors: Gluteus maximus, medius,

minimusPiriformis (weak)HamstringsLateral rotators:Gemilli, obturators,

piriformis, quadratus femoris, portions of gluteals (posterior medius)

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Abductors:Gluteus medius, minimus,

upper fibers of maximus

Adductors:magnus, longus, brevis,

pectineus, gracilis

Lateral rotators: gemilli, obturators,

piriformis, quadratus, portions of gluteals (posterior medius)

Medial rotators: TFL, anterior gluteus

medius, minimus.

And your point is?

Femoral SyndromesFemoral syndromes arise from pain directly related to

the hip joint, characterized by a movement impairments of an accessory motion of the femur.

Anterior glideAnterior glide with medial rotationAnterior glide with lateral rotationPosterior glide with medial rotationMultidirectional Accessory Hypermobility (MAH)MAH with knee movementHypomobility

While these syndromes typically produce pain local to the hip joint, they may also

manifest as LBP or SIJ pain...

Cause vs. Source

Femoral anterior glide

Hypermobility

Posterior glide/anterior glide with lateral rotation

Iliopsoas tendinopathy/bursitis

Adductor strainLabral tearLabral tearEarly degenerationPiriformis syndrome

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Femoral Anterior GlidePrimary dysfunction: inadequate posterior glide

of the femoral head during hip flexionSymptoms: Pain in the groin with hip flexion or

standing; may experience generalized hip painSource: Iliopsoas tendon/bursa/anterior

capsule/labrumCause: pressure of femoral head on the anterior

capsulePrimary contributing factor: postural hip

extension

Femoral Anterior Glide with Medial Rotation

Primary dysfunction: inadequate posterior glide and excessive medial rotation of femoral head during hip flexion

Symptoms: groin pain during active hip flexion; may progress to aching pain of whole hip

Cause/Source often the same as anterior glidePrimary contributing factor: failure of the hip

flexor/lateral rotators to counteract the hip flexor/medial rotators

Femoral Anterior Glide with Lateral Rotation

Primary dysfunction: inadequate posterior glide with excessive lateral rotation of femoral head during hip flexion

Symptoms: groin pain with hip extension and lateral rotation, worse in weight bearing. Pain may be in the more medial aspect of the joint. Can feel similar to a groin strain.

Cause/Source often the same as with anterior glidePrimary contributing factor: sitting with involved limb's

foot resting on opposite thigh which increases stiffness of hip extensors/lateral rotators

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Anterior Glide +/- Rotation Key Examination Findings

POSTURE: hip extension (posterior pelvic tilt/knee extension) +MR: with MR / +LR: with LR

+ANTERIOR GLIDE SIGN: anterior PICR deviation (with or without MR/LR) with SLR, hip flexion/knee flexed, prone hip extension

ROM: limited hip flexion+MR: increased MR or limited LR+LR: increased hip LR or limited MR

STRENGTH: weak/painful iliopsoas+MR: weak iliopsoas and LRs

Pelvis appears higher on involved side during quadruped rocking

Anterior Glide Sign

Anterior Glide +/- RotationFocus of Treatment

Stop prolonged/excessive hip extension with standing and walking

Restore precise hip flexionQuad rocking, OP with hip flexion, stretch HS (seated knee

ext), strengthen iliopsoas*+MR: same as anterior glide plus:

Correct MR during hip motion and strengthen hip LRs. NO BACKWARD ROCKING

+LR: same as anterior glide plus: Correct LR and strengthen Mrs. Backward rocking ok.

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Case StudyCollegiate football player with six month history of

pelvic girdle pain. Diagnosed with osteitis pubis (visible on imaging studies)

Symptoms: pain with prolonged (>5') standing, sitting, running, walking. Anterior hips often feel tight.

Exam findings (B): hip abduction and hyperextension in standing, positionally weak/strained iliopsoas, significant TFL hypertrophy and dominance, +anterior glide sign with medial rotation with ASLR, knee to chest.+ ant glide sign with PSLR, limited hip flexion

Treatment: corrected standing and walking (no symptoms with corrections), quad rocking, heel slide initiation without TFL. Instructed to NOT stretch hip flexors.

Femoral Posterior Glide + MR

Primary dysfunction: imprecise spinning of the femoral head during hip flexion with excessive MR

Symptoms: deep hip pain, aching of whole joint, piriformis pain

Source: posterior hip capsule/ligaments, piriformis

Cause: pressure of femoral head on the posterior capsule

Primary contributing factor: overstretching of posterior hip structures

Femoral Posterior Glide +MR Key Examination Findings

POSTURE: Excessive femoral MR; Head of femur prominent in quadruped

- ANTERIOR GLIDE SIGNPelvis LOW on involved side or hip MRs during

quadruped rockingROM: Normal to increased hip flexion, increased

hip MRSTRENGTH: Weak LRs, glutealsRocking backward: greater trochanter medially

rotates, hip goes low

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Femoral Posterior Glide +MRFocus of Treatment

Avoid end range hip flexionStrengthen gluteals, LRsSitting: knee low relative to hip; towel roll just

anterior to ischial tuberosities; frequent standing breaks

STOP STRETCHING!!!!

Case Study

33 yo female elite fitness competitor with 6 month history of 8/10 posteromedial buttock pain and sciatica secondary to rear-end MVA. Affected limb's foot was resting on the dashboard

Symptoms: pain with prolonged sitting, esp. in car; pain with running, splits, deadlifts.

Exam findings: Trendelenburg gait, femoral MR in standing, posterior glide with quad rock, MR of femur with forward bend, hamstring>gluteals with prone SLR, very long and poorly recruited LRs

Treatment: No stretching, fill in well of car seat, strengthen LRs and gluteals, corrected mechanics with workout, core program; full resolution in 10 visits.

Multidirectional Accessory Hypermobility (MAH)

Primary dysfunction: increased accessory movement in a variety of directions

Symptoms: deep pain or groin pain with Wbing activities or sitting (soft surfaces worst)

Source: any region of or adjacent to hip capsuleCause: pressure of femoral head soft tissuesPrimary contributing factor: postural hip

extension, overstretching*Theory: hip joint hypermobile, passive stretch

of rectus femoris increases compression into joint

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MAH Key Findings+ ANTERIOR GLIDE+ POSTERIOR GLIDEMOVEMENT: posterior glide and/or MR with

knee extension. Prone active hip extension with LR, LR with faulty arc of movement

ROM: usually excessive; hip rotation painful. LR associated with PKB

STRENGTH: Weak iliopsoas, PGM, LRs, glut max

Pelvis LOW on involved side or hip MRs with quad rock

MAH Focus of Treatment

Avoid (all) end rangesAttention to sitting posture (avoid MR), surfaceImprove muscle performance of iliopsoas, PGM,

LRs, and glut maxIn order to avoid excessive accessory motion during

exercise/basic activities

MAH with Knee MovementIncreased accessory movements associated with a variety of hip movements AND knee movements.History of athletics/ weight trainingSame signs as MAH plus:

PKB and seated knee extension-symptoms improve with distraction

Treatment: same as MAH plus:Decrease use of thigh musculature to control hip motionDistractionModify weight training program

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Case Study32 yo lawyer with 20 year hx/o dance and ballet with

lumbar disc herniation.Symptoms: L perisacral/posterior buttock pain and

associated L thigh symptoms, pain 6/10. Unable to sit L, positive ASLR, PSLR, seated knee extension, intrapelvic torsion

Case Study

Goal of initial treatment: resolve impairments related to lumbar disc pathology.PPUs, seated L knee extension without lumbopelvic

rotation, lumbopelvic inner core isometrics-->formal program, neurodynamic mobilizations. Sitting tolerance 60' with significant decrease in pain intensity and irritability in 2 visits.

Residual symptoms: return to yoga provokes pelvic girdle/SIJ pain, needs increased Wbing and sitting tolerance.

Case Study

Goals of second phase of treatment: stabilize pelvis, stabilize femurs.MET, advanced inner core stability training, deep hip

lateral rotators and iliopsoas strengthening; soft tissue work to L>R glut wall (found to be very stiff, hypertonic), education regarding hip protection/positioning, postural education. Referral to PT/yoga practitioner with MSI training to modify yoga program. Progressed to balance training, TFL downtraining, posterior hip muscle strengthening.

Full symptom resolution with significantly improved movement system balance in 18 visits.

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Hypomobility

Limited accessory motion in a variety of directions especially flexion; occurs with OA

Symptoms: deep hip or groin pain and stiffnessExam: loss of motion in capsular pattern; short

iliopsoasTreatment: Improve ROM; increased muscle

performance of gluteals

Exam Demonstration

Summary / Key PointsVariety in movement strategies maintains movement

system balance and long term musculoskeletal health

Hypermobility (loss of precise motion/normal accessory motion) leads to degeneration and pain

Hip syndromes arise from impairments in muscles attaching close to the proximal femur that control

alignment and motion.

Precise observation of movement strategies will elucidate compensatory movements associated with pain; correction decreases/resolves pain.

Examination findings dictate effective treatment

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Questions?

References

All material and pictures of anterior glide sign from: 1. Sahrmann SA. Diagnosis and Treatment of Movement

Impairment Syndromes. St. Louis, MO: Mosby; 2002.2. Course Notes, Diagnosis and Treatment of Movement

Impairment Syndromes: Lower Quarter Advanced Application. Presented by Shirley Sahrmann and faculty of Washington

University in St. Louis, October 1-4, 2011.

Picture References1. Nolan Ryan Pitching: Accessed from http://www.totalprosports.com/wp-

content/uploads/2011/08/nolan-ryan.jpg on Februrary 1, 2012.2. Knee PICR: Accessed from http://ars.sciencedirect.com/content/image/1-

s2.0-S0966636206000919-gr2.gif on February 1, 2012

3. Pelvis boney anatomy. Accessed from http://etc.usf.edu/clipart/36800/36869/_36869_lg.gif on February 1, 2012.

4. Anterior hip ligaments. Accessed from http://etc.usf.edu/clipart/36800/36869/_36869_lg.gif on February 12, 2012/

5. Posterior hip ligaments. Accessed from http://etc.usf.edu/clipart/53500/53523/53523_hip_lg.gif on Febraury 5, 2012.

6. Angle of inclination. Accessed from http://www.studydroid.com/imageCards/0b/gr/card-12087065-front.jpgon February 5. 2012.

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Picture References7. Angle of declination. Accessed from

http://www.pt.ntu.edu.tw/hmchai/kinesiology/KINlower/Hip.files/HipStructure.htm on February 23, 2012.

8. Cam/pincer. Accessed from: http://www.kevinneeld.com/wp-content/uploads/2011/07/Hockey-Training-Femoroacetabular-Impingement-1024x798.jpg on Februrary 21, 2012.

9. Anterior hip musculature. Accessed from: http://www.coachr.org/tfl.jpg on February 21, 2012

10. Posterior hip musculature. Accessed from:http://etc.usf.edu/clipart/38800/38868/hip_joint_38868_lg.gif on February 5, 2012.

11. Stop Stretching. Accessed from: http://yoga.prevention.com/slideshows/uploads/1/7.3_pigeon_fold.jpg on February 21, 2012.

12. Rat City Roller Girls. Accessed from: http://www.westseattleherald.com/sites/robinsonpapers.com/files/imagecache/3col/images/wwwwestseattleheraldcom/2012/01/rat-roller-1.jpg on March 1, 2012.

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Hip Syndromes - Shirley Sahrman