Young Adult Hip Pathology and FAI: Physical Therapy Management for Non-Operative and Post-Operative Patients Jill Monson, PT, OCS Monson Orthopaedic Consulting, LLC BASIC SCIENCE My “A-Ha” Moment • Closely observing dynamic squatting in patients with primary c/o knee pain • Knee squatters • Cued to sit into hip flexionàCOULD NOT • Put them on plinth for ROM and “A-Ha” • Have you ever had groin pain or clicking at your hip? © Monson Orthopaedic Consulting, LLC 3 2012 Poor, Lost Souls • Young adult hip patients – Saw an average of 4.2± 2.9 health care providers before a definitive diagnosis was made – Experienced symptoms for a mean of 3.1 years prior to obtaining a definitive diagnosis • Clohisy JC. Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement. Clin Orthop Relat Res 2009. © Monson Orthopaedic Consulting, LLC 4 2012 Anatomy Exploration • Bony Construct • Articular Surface • Hip Capsule/Ligaments • Musculotendinous Structures • Neurovascular Structures © Monson Orthopaedic Consulting, LLC 5 2012 Bony Anatomy of the Hip: Normal • Acetabulum: – Ilium – Ischium – Pubis • Femur: – Femoral head • Fovea Capitus – Femoral Neck – Greater Trochanter – Lesser Trochanter © Monson Orthopaedic Consulting, LLC 6 2012 Anatomy: Acetabulum • Develops as early as 8 wks of gestation • Fully formed by 11 weeks gestation – Watanabe R. Clin Orthop 1974 • Acetabular formation in response to presence of contact w/femoral head © Monson Orthopaedic Consulting, LLC 7 2012 Acetabulum • Triradiate cartilage at the confluence of ilium, ischium, pubis – Fuses fully by 16-18 y/o (**May be late) • Ponseti J. Bone Joint Surg Am 1978 • Vascular Supply to Acetabulum: – Internal Iliac a. © Monson Orthopaedic Consulting, LLC 8 2012 Femoral Head & Neck • Vascular Supply Femoral Head – Medial femoral circumflex © Monson Orthopaedic Consulting, LLC 9 2012 Avascular Necrosis (AVN) • Traumac AVN via dislocaons – Medial circumflex artery is torn • Non-traumac AVN Associaons – ETOH – Steroid use – Chemotherapy © Monson Orthopaedic Consulting, LLC 10 2012 Fibrocartilage: Acetabular Labrum • Consists of both Thickest @ anterosuperior rim fibrocartilage and dense (greatest loads here) connective tissue – Peterson W. Arch Orthop Trauma Surg 2003 • Creates a circumferential seal around the hip joint • Nerve endings indicate nociceptive and proprioceptive capabilities @ labrum • Kim YT. Clinic Orthop 1995 © Monson Orthopaedic Consulting, LLC 11 2012 Acetabular Labrum Circumferential Seal of the Labrum • Enhances joint stability through a suction effect and contributes to a fluid-enhanced force distribution • Contributes to homeostasis at joint for lubrication, nutrition and load sharing with articular cartilage © Monson Orthopaedic Consulting, LLC 12 2012 Labrum, Cont. • Blood supply via the obturator a., superior and inferior gluteal aa., medial femoral circumflex a. • Blood vessels only detected in the peripheral 1/3 of the labrum; internal portion avascular – Peterson et al. immunostaining study; Arch Orthop Trauma Surg 2003 • Some capacity for labral healing has been observed in basic science and ovine experimental studies – Seldes et al. Clin Orthop 2001 – Philippon Arthroscopy 2007 – Miozzari H Osteoarthritis and Cartilage 2004 © Monson Orthopaedic Consulting, LLC 13 2012 Capsular Anatomy • Extends from acetabular rim to anterior intertrochanteric line at anterior aspect of proximal femur © Monson Orthopaedic Consulting, LLC 14 2012 Capsular Anatomy: Ligamentous 3 Extra-articular ligaments • All taut in extension • All lax in flexion © Monson Orthopaedic Consulting, LLC 15 2012 Extra-capsular Ligaments • Iliofemoral (strongest, thickest) – AIIS to anterior intertrochanteric line – Tight in ER and ADD • Pubofemoral – Superior pubic ramus to inferior femoral neck – Tight in ER and ABD • Ischiofemoral (weakest, thinnest) – Ischium to posterior inferior femoral neck – Tight in IR and ABD © Monson Orthopaedic Consulting, LLC 16 2012 Extracapsular Ligaments Anterior View Posterior View © Monson Orthopaedic Consulting, LLC 17 2012 Intra-capsular: Ligamentum Teres • Acetabular notch to fovus capitis (fovea) of femur – Tight in ADD, Flex, ER © Monson Orthopaedic Consulting, LLC 18 2012 Other Ligamentous Structures • Inguinal Ligamant © Monson Orthopaedic Consulting, LLC 19 2012 Bursae • Trochanteric (“Gluteal”): – Between tendon of G. Max and greater trochanter • Synovial lined, several layers b/tw tendon layers of G. Med & Min • Ischiogluteal: – Under G. Max just posterior to Ischial Tuberosity • IliopecHneal: – Between Psoas Major tendon and IliopecHneal eminence © Monson Orthopaedic Consulting, LLC 20 2012 Dermatomes -Hip Joint is an L3 structure -Consider: Traveling/sweeping pain vs. Contained/localized pain © Monson Orthopaedic Consulting, LLC 21 2012 Hip Musculature • Tremendous functional cross-over at the hip musculature • Function contingent on: – Hip joint position – Trunk position – CKC/OKC function • Tremendous interplay with proximal and distal segments – Pelvis, L-spine, Knee joint © Monson Orthopaedic Consulting, LLC 22 2012 Musculature: Flexors • Psoas Major & Iliacus (Iliopsoas) – Flex, ADD, ER • Tensor Fascia Latae – Flex, ABD, IR – Rectus Femoris © Monson Orthopaedic Consulting, LLC 23 2012 Muscles: Extensors • Gluteus Maximus – ABD, Ext, ER • Hamstrings Musculature: Abductors – Gluteus Maximus • ABD, Ext, ER – Gluteus Medius • Anterior Fibers – ABD, Flex, IR • Posterior Fibers – ABD, Ext, ER – Gluteus Minimus • ABD, IR – TFL • ABD, Flex, IR © Monson Orthopaedic Consulting, LLC 25 2012 Musculature: Adductors – Adductor Magnus – Adductor Longus • ADD, Flex, ER – Adductor Brevis • ADD, Flex, ER – Gracilis • ADD, Ext, IR – Pectineus • ADD, Flex, ER © Monson Orthopaedic Consulting, LLC 26 2012 Musculature • Adductor Magnus – Pubic ramusàLinea Aspera • Flex, ADD, ER – Isch TubàADD tubercle • Ext, ADD, IR Musculature: Deep External Rotators • Obturator internus • Obturator externus • Superior gemellus • Inferior gemellus • Piriformis • Quadratus femoris *All but Piriformis ADD hip *Think rotator cuff © Monson Orthopaedic Consulting, LLC 28 2012 Musculature: Deep Internal Rotators • Gluteus Medius – Anterior fibers • Gluteus Minimus © Monson Orthopaedic Consulting, LLC 29 2012 Palpaon: Anterior Pelvis • ASIS – TFL origin – Sartorius origin – Inguinal ligament • AIIS – Rectus Femoris origin *Note* • Rectus Femoris – Appreciate the proximity of its origin at the AIIS to the anterosuperior aspect of the acetabulum Palpaon: Posterior Pelvis • Sacral border – Gluteus maximus origin • Iliac Wing – Gluteus medius origin – Gluteus minimus origin © Monson Orthopaedic Consulting, LLC 32 2012 Gluteus Maximus • Origin – Sacrum, dorsal sacroiliac ligaments, small area of ilium near PSIS, sacrotuberous ligament • InserHon – Upper ½ @ lateral porHon of TFL, ITB – Lower ½ @ divided inserHon into ITB and deeper fibers at the gluteal tuberosity (lateral extension of linea aspera) • Bursa between tendon and GT © Monson Orthopaedic Consulting, LLC 33 2012 Gluteus Medius • Origin – Mostly lies under the glut max, but anterior fibers are not covered – Upper lateral surface of the iliac wing (b/tw A/P gluteal lines) & anteriorly at the fascia • InserHon – Greater trochanter © Monson Orthopaedic Consulting, LLC 34 2012 Gluteus Minimus • Origin – Lower part of lateral surface of wing of ilium (b/tw anterior and inferior gluteal lines) • InserHon – Greater Trochanter © Monson Orthopaedic Consulting, LLC 35 2012 Piriformis • Origin – Pelvic surface of sacrum • InserHon – Inner surface of upper part of GT – Fills the sciac foramen © Monson Orthopaedic Consulting, LLC 36 2012 Palpaon: Posterior Pelvis • Ischial Tuberosity – Semitendinosis • Near sacrotuberous lig. InserHon – Biceps Femoris • Most lateral – Adductor Magnus • Most medial Palpaon: Pubic Region • Pubic Tubercle (anterosuperior surface of pubic body) – Rectus abdominus (Superiorly) – Inguinal ligament (Laterally) – Adductor longus (Inferiorly) • Superior Pubic Ramus – Pecneus • Inferior Pubic Ramus – Gracilis – Adductor Magnus (at bony segway to ischial ramus) © Monson Orthopaedic Consulting, LLC 38 2012 Palpaon: Proximal Femur • Greater trochanter (superior & posterior aspect) – Gluteus medius inserHon – Gluteus minimus inseron • Just anterior to medius • Gluteal Tubercle (just distal to greater trochanter) – Gluteus maximus inserHon Palpaon: Proximal Femur • Posterior trochanteric facet – Deep hip rotators inserHon point • Lesser Trochanter – Iliopsoas LAB: Palpa*on • ASIS • Ischial Tuberosity – Resisted hip flexion + IR – Resisted knee flexion (TFL) (Hamstring) • AIIS • Greater Trochanter – Resisted hip flexion – Resisted hip ABD (Rectus Femoris) • Proximal:Gluteus medius • Pubic Bone • Distal: Gluteus maximus – Resisted hip ADD (ADD • Iliac Crest longus, Pecneus, – Resisted hip ABD Gracilis) (Gluteus medius, minimus) © Monson Orthopaedic Consulting, LLC 41 2012 Biomechanics vs. Kinematics • Biomechanics – “I see dead people”/anesthetized • Biomechanical laboratory studies – Dissected cadaver Hips: Hemi-pelvis, transected femurs • Kinematics – “I see living people” • Motion analysis laboratory kinematic studies – Real, moving humans with completely intact proximal and distal anatomy and active musculoskeletal interactions © Monson Orthopaedic Consulting, LLC 42 2012 Surgery vs. Rehabilitation • What can a surgeon change with their tool set? – Bony anatomy – Ligamentous, Fibrocartilage fixation • What can a physical therapist change? – Dynamic muscular control • Strength, proprioception – Static Tissue