zhang hip exam - ucsf cme · sports medicine and hip arthroscopy ucsf department of orthopaedic...
TRANSCRIPT
11/20/2017
1
The Hip Exam for the Generalist
Alan Zhang MDAssistant ProfessorSports Medicine and Hip ArthroscopyUCSF Department of Orthopaedic Surgery
The Layers of the Hip
To treat hip pathology-
1st 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
11/20/2017
2
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
11/20/2017
3
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
11/20/2017
4
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
11/20/2017
5
TrendelenbergGait
FAI gait
FAI gait
• Loss of peak hip extension
Zhang et al AJSM 2016
• Increased hip joint loading in FAI patients
11/20/2017
6
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
11/20/2017
7
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
11/20/2017
8
Log Roll
Assess for intra-articular hip pathology
15
Flexion ADduction Internal Rotation
11/20/2017
9
FADIR for FAI
FABER Test
SI pathology
Sometimes anterior labral pathology
11/20/2017
10
Flexion ABduction External Rotation
Labral Testing/Scour Test
11/20/2017
11
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
11/20/2017
12
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)
11/20/2017
13
Lateral Exam
OBER test
• IT band tightness
Palpate Greater Trochanter
• Trochanteric bursitis
Gluteus Medius strength testing
Ober Test
26
11/20/2017
14
Gluteus Medius Strength Test
27
Prone exam
Hamstring exam
• Palpate for defects
• Evaluate for weakness
11/20/2017
15
Thank You
29