1

Hip and Knee: An update to Examination, Evaluation and Rehabilitation for Common Pathologies

Paul K. Canavan PhD, PT, DPT, ATC, CSCS

Allied Health Education

“Teaching you today what you need to know tomorrow”

Provider Disclaimer

• Allied Health Education and the presenter of this

webinar do not have any financial or other

associations with the manufacturers of any products or suppliers of commercial services that may be

discussed or displayed in this presentation.

• There was no commercial support for this

presentation.• The views expressed in this presentation are the

views and opinions of the presenter.

• Participants must use discretion when using the

information contained in this presentation.

1)Describe the Functional Anatomy of the Hip and

Knee Joint

2) Understand the Biomechanics/Arhrokinematics of

the Hip and Knee Joint

3) Femoral Acetabular Tears/FAI

4) Understand special tests for the Hip and Knee Joint

for common pathologies

Course Objectives

2

5) Select appropriate therapeutic exercises based

upon Examination Findings for common Hip and

Knee Joint pathologies including acetabular labral

tears, femoral acetabular impingement, anterior

cruciate ligament injury, and anterior knee pain.

6) Have information that could may improve your

ability to work clinically with patients

Course Objectives

Outline: Knee

1) Functional Anatomy/Biomechanics of the Knee Joint

2) Special Tests for the Knee

3) Anterior Knee Pain, OA, and Therapeutic Exercise Considerations

4) ACL Tear, pre-op and post op Ther Ex

5) Conclusion/Review

Importance of Continuing Education

Improve the utilization of the Knowledge of

Anatomy, Physiology, Motor Control,

Biomechanics (Kinesiology), Resistance

Training, Examination and Evaluation skills and

is able to develop an Individualized Program for

Patients.

3

Hip Joint

■ The hip joint is a multi-axial ball and socket synovial joint with the femur and the acetabulum. The bony structures provide inherent stability.

■ Mobility, Support & Weight Transfer.

■ The Biomechanics and Anatomical geometries of the femur and acetabulum are significant to joint preservation and stability of the acetabular labrum and articular cartilage.

Hip Joint

Femoral Acetabular Joint

1) Appropriate femoral head-neck angle;

2) Optimal acetabular anteversion;

3) Acetabular coverage of the femoral head

4

ANATOMY: Hip Muscles

Anterior• Psoas Major/Minor

• Iliacus

• Sartorius

• TFL

• Rectus Femoris

Lateral• Glut Med.

• Glut. Min.

• Glut. Min.

Posterior• Glut Max

• Biceps Femoris

• Semitendinosus

• Semimembranosus

• Ext. Rotators

Medial• Gracilis

• Adductor M., B., L.

• Pectineus

Anatomy: Muscles

■ Adductor Longus Strain

– Micro or Macro trauma

■ Tight Hip Flexors

– Rectus Femoris– Psoas

LOG posterior to hip joint

Bilateral L.E. Stance

Psoas Major tightness**

Iliacus tightness

5

Hip Ligaments

1) Iliofemoral

2) Ischiofemoral

3) Pubofemoral

4) Ligamentum obicularis

5) Ligamentum Teres

Hip Ligaments■ The hip capsule is a series of 5 primary ligaments;

iliofemoral ligament (medial and lateral arms), pubofemoral, ischiofemoral (superior & inferior portion), ligamentum teres femoris, and the ligamentum obicularis. The collagen structure of the hip is similar to that of the shoulder and elbow.

(Kaltsas DS Comparative study of the properties of the shoulder joint capsule with those of other joint capsules Clin Orthop 1983; 173; 20-26)

Ligaments

■ Iliofemoral Ligament“Y” ligament it is more triangular shaped AIIS -intertrochanteric line

■ Pubofemoral Ligament– Obturator crest upper

ramus of the pubis

Ischiofemoral Ligament

Back of capsule, Base of Ischiumapex of the trochanteric fossa

6

Hip Capsule; Ligaments

The ligaments, iliofemoral, ischiofemoral, and pubofemoralare connected to each other by the circular ligamentum obicularis, which circumvents the femoral neck and is located posteriorly and inferiorly.

(Stewart et. Al., 2002)

The ligamentum teres femoris originates at the acetabular notch form the transverse ligament and inserts to the fovea of the femoral head.

Hip Ligaments

■ Ligament pathology may be contributing to patient’s c/o

e.g. Abnormal functioning of the iliofemoralligament has been identified as a cause for coxa sultans.

Howse AJ Orthopaedists aid ballet Clin Orthop 1972; 89: 52-63

Hip Motions: Ligaments

• Hip Extension is restricted by the Medial arm of iliofemoral Ligament

• Hip Flexion is restricted by the inferior ischiofemoral ligament

• Hip Abduction is restricted by the Pubofemoral ligament

• Hip Adduction is restricted by the Posterior Coxal ligaments and the

superior ischiofemoral ligament

• Hip Internal Rotation is restricted by the Superior ischiofemoral

ligament

• Hip External Rotation is restricted by the Lateral Iliofemoral ligament

(Fuss FK, Bacher A New aspects of the morphology and function of the human hip joint ligaments Amer J

Anat 1991; 192: 1-13)

7

Ligaments, cont.

Internal Rotation in Flexion and Extension restricted by Ischiofemoral Ligament

External Rotation in Flexion and Internal and External Rotation in Hip Extension is restricted by the Lateral arm of the iliofemoral ligament

External rotation in Hip Extension also is restricted by the Pubofemoral ligament and also Medial arm of the iliofemoralligament

Hip Instability or Restriction

■ When abnormal muscle and osseous pathology can be eliminated as a cause of instability or restriction in motion, the understanding of the hip ligaments will aid in defining an accurate assessment

(Martin H et. al, 2008)

Biomechanics:Hip Joint Actions including Function

■ Hip adduction: Adductor longus was always active with hip adduction, but adductor magnus was only active with resistance.

■ Hip abduction: Glut. Medius

■ Internal rotation of the thigh both Adductor Longus and Magnus muscles are active

■ External rotation The adductor magnus upper fibers showed the greatest activity as well as the “Hip External Rotator” muscles

8

Biomechanics

■ Dynamic Movement is constrained by Osseous, Ligamentous, and Muscle Structure

■ Gravity, Ground Reaction Force, and Muscular Activation all contribute to hip joint forces

Moment arms of muscles vary with body position.(Hoy MG, Zajac FE, Gordon ME A musculoskeletal model of the human lower extremity: the effect of

muscle, tendon, and moment arm on the moment-angle relationship of musculotendon actuators at the hip, knee, and ankle J Biomech 1990; 23: 157-169)

(Murray WA, Delp SL, Buchanan TS Variation of muscle moment arms with elbow and forearm position J Biomech 1995; 28: 513-525)

(Zajac FE, Neptune RR, Kautz SA Biomechanics and muscle coordination of human walking Part I: introduction to concepts, power transfer, dynamics and simulations Gait and Posture 2002; 16: 215-232)

Biomechanics: Hip Muscles

■ Excessive Hip Flexion may exacerbate internal rotation of the hip as the trend for the majority of muscles of the hip switch from external rotation to internal rotation (15 of 18) as the hip is flexed.

■ For example, gluteus maximus and gluteus medius have several “compartments”. Glut. Med. Int and Ext Rot as well as Hip Abd

Biomechanics: Hip Muscles

■ Gluteus Medius action of the compartments changed drastically as hip is flexed from 0 to 90 deg. Hip flexion; At 0 deg, the anterior compartment has a small internal rotation moment arm, while the other 3 compartments has external moment arms.

■ Piriformis average external rotation moment arm of 29 mm with 0 deg hip flexion and at 90 deg hip flexion, it has an internal rotation moment arm of 14 mm.

9

Acetabular LabrumArthrokinematics

ANTERIOR

Gait 30 degrees flexion 10 degrees extension

5 degrees abduction 5 degrees adduction

5 degrees med rot 5 degrees lat rot

Sit-to-stand 130 degrees flexion

TAKE TO THE CLINIC INFORMATION

Arthrokinematics

Movements follow the concave/convex rule

Flexion/Extension is primarily spin

Functional Hip ROM

Pelvic Girdle The pelvic “girdle” is dependent upon the Lumbosacral joint

and the Hip joints for movement

Pelvis rotates to put the acetabulum in a favorable position for movements of the femur and for muscles

10

Hip Pathologies

■ Hip OA

■ Acetabular Labral Tears

■ FAI

Hip OsteoarthritisShallow Acetabulum (Elmslie BMJ, 1933)

Distinct group whom no discernible etiologic factors can be found

(Flores & Hochberg, 1998)

A/P Radiographs

Normal acetabular anteversion 0 Deg. Acetabular anteversion

11

Precursors to Hip OsteoArthritis(OA)

■ Acetabulum Version

■ Acetabular Depth

■ Acetabular Labral Tears

■ Femoral Version

■ Femoral Neck-Shaft Angle

Etiology of Acetabular Labral Tears

■ The actual mechanisms of hip injuries, including acetabular labral tears, are not well understood.

■ Common Diagnoses associated with Hip pain; – Hip OA, Lumbar Spine/Low Back Pain, RA, Bursitis, Overuse,

Inguinal Hernia, “Sports Hernia”, Soft tissue injury (non-specific)

(Byrd JW, Jones KS Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients Am J Sports Med 2004; 32: 1668-1674)

Acetabular Labrum

■ Fibrocartilaginous rim composed of longitudinally oriented type-I collagen fibers. The labrum attaches to the hyaline cartilage of the acetabulum through a transition zone of 1-2mm calcified cartilage.

(Seldes R.M., Tan V., Hunt J., Katz M., Winiarsky R., Fitzgerald R.H. Anatomy, histological features and vascularity of the adult acetabular labrum Clin Orthop 2001; 382: 232-240)

12

Acetabular LabrumArthrokinematics

ANTERIOR

Physical Examination: Misdiagnosis

■ Often pain from the intra-articular hip may be misdiagnosed as extra-articular pathology such as bursitis and tendonitis. Only 40% of intra-articular hip pain cases were accurately diagnosed after initial evaluation.

■ ITB syndrome, Snapping Psoas Syndrome, Inguinal or Femoral Hernia, Hip Stress Fracture

(Byrd J.W.T., Jones K.S. Hip arthroscopy in athletes Clin Sports Med 2001; 20: 749-761)

Proper Intervention

• In order to provide the most appropriate intervention for patients with anterior hip or groin pain, physical therapists should be knowledgeable about all the possible causes and sources of pain, including tears to the acetabular labrum.

(Lewis C.L., Sahrmann S.A. Acetabular labral tears Phys Ther 2006; 86 (1): 110-121)

13

Acetabular Labral Tears

• What segment of the population gets acetabular labral tears?

• Recreational athletes, dancers, ballet, karate, and ice hockey players

(Repeated cutting and twisting)

(Mason J.B. Acetabular labral tears in the athlete Clin Sports Med 20 (4): 779-789; Narvani A.A., Tsiridis E., Tai C.C., Thomas P. Acetabular labrum and it’s tears Br J Sports Med 2003, 37: 207-211.)

Etiology of Acetabular Tears

■ The actual mechanisms of hip injuries, including acetabular labral tears are not well understood.

■ 25-50% of patients report an acute provoking event, which could be minor or major.

■ Many patients will not have the diagnosis of Acetabular labral tear until approx. 2 years following their initial complaints of pain.

■ Hip OA, Lumbar Spine/Low Back Pain, RA, Bursitis, Overuse, Inguinal Hernia, Soft tissue injury (non-specific)

(Byrd JW, Jones KS Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients Am J Sports Med 2004; 32: 1668-1674)

Acetabular Labral Tear Classification (Etiology & Morphology)

EtiologyDegenerative, 48.6%

Idiopathic, 27.1%Traumatic, 18.9%Congenital, 5.4%

MorphologyRadial flap, 56.8%;

Radial fibrillated, 21.6%; Longitudinal peripheral, 16.2%;

Unstable, 5.4%(Lage LA, Patel JV, Villar RN The acetabular labral tear: An arthroscopic classification Arthroscopy: The Journal of Arthroscopic and Related Surgery 1996; 12 (3): 269-272)

14

Force on the Acetabulum: Gait

■ Force from weight bearing in the acetabulum occurs with peaks in force at heel strike and toe off. With areas of contact on the posterior and anterior rims. TWISTING

Trunk and Pelvic Rotation

Coxa Valgus/Normal/Coxa Varus

1) appropriate femoral head-neck offset angle;

2) optimal acetabular anteversion;

3) and appropriate acetabular coverage of the femoral

head

15

One StrideStance and Swing

I cdnuolt blveiee that I cluoud aulacltyuesdnatnrd what I was rdanieg. The phaonmneal pweor of the hmuan mnid!!

It deosn’t mttaer in what oredr the ltteers in a word are, the olny iprmoatnttihng is that the frist and lsat letteer be in th rghit pclae. The rset can be a taotlmses and you can still raed it wouthit a porbelm.

16

~20o anteversion

head exposed superior

& anterior in standing

Acetabululm

A/P Radiographs Acetabulum

Normal acetabular anteversion 0 Deg. Acetabular anteversion

Acetabular Tear Location

Anterior (most common)

Superior

Posterior

Santori N. & Villar R.N. Acetabular labral tears: results of arthroscopic limbectomy. Arthroscopy 2000; 16:11-15

17

Acetabular Labrum

ANTERIOR

Labral Tear: Exam Findings Pain Location

■ Patient will present with groin pain or will have a “C-sign” and have a presence of a click or pop. “C-sign” is when the patient holds their hand in the shape of a C and places it above the greater trochanter with the thumb positioned posterior and the fingers extending towards the groin.

■ Lateral based pain may be intra and/or extraarticular in origin

■ Groin pain is more a suspicion of intraarticular pain

(Byrd JWT Physical Examination. IN: Byrd JWT, ed. Operative Hip Arthroscopy 2nd ed. New York, Springer; 2005: 36-50)

Hip Dysplasia and Acetabular Tears

■ Patients with acetabular dysplasia had a higher incidence of anterior labral tearing than those without dysplasia.

Lage L.A., Patel J.V., Villar R.N. The acetabular labral tear: An arthroscopic classification. Arthroscopuy 1996; 12:269-272)

18

Acetabular Dysplasia and Labral Tear and Development of Hip DJD

■ Patients with acetabular dysplasia had a higher incidence of anterior labral tearing than those without dysplasia.(Lage L.A., Patel J.V., Villar R.N. The acetabular labral tear: An arthroscopic classification. Arthroscopuy 1996; 12:269-272)

■ McCarthy et al. found that of 436 patients with mechanical hip symptoms…

■ …73% of patients had associated chondral damage. – 94% of them had labral and chondral damage in the same

quadrant.

McCarthy J., Noble P.C., Schuck M.R., Wright J., Lee J. The role of labral lesions to development of early degenerative hip disease Clin Orthop 2001; 393: 25-37

Diagnostic Tests

■ MRI arthrography using gadolinium increases the sensitivity of dection of capsulo-labral pathology (Sensitivity 95% and Accuracy 65%).(Kelly B.T., Williams R.J., Philippon M.J. Hip arthroscopy: current indications, treatment options, and management issues. Am J Sports Med 2003: 31 (6): 403-408)

■ Small pixel size non-contrast MRI also resulted in similar accuracy in detecting labral lesions as MRI artrhography.

(Mintz D.N., Hooper T., Connell D., Buly R., Padgett D.E., Potter H.G. Magnetic resonance imaging of the hip: Detection of labral and chondral abnormalities using noncontrast imaging. Arthroscopy 2005: 21: 385-393)

Femoracetabular Impingement

■ For some FAI deformites the etiologies are not known.

■ Osseous deformities seen on the acetabulum (Pincer) or the Femoral side (Cam) side of the hip leading to characteristic alterations of the acetabulum rim.

■ CAM FAI is commonly found in 20-30 year old athletic men, revealing deep cartilage avulsions from the acetabular rim while the labrum is frequently left intact.

■ In pincer FAI, commonly found in 30-40 year old women, the labrum is frequently destroyed with only minor damage to the acetabular rim.

■ Understanding the etiologies of the FAI and it’s role in the development of hip OA might reduce the prevalence of so called “primary OA”.

(Leuning M., Ganz R. FAI Concept and Etiology Orthoapde 2009; 38: 394-401)

19

CAM and Pincer

CAM Impingement is primarily an abnormality of the femoral head-neck junction, whereas

Pincer abnormality of the acetabulum causes impingement of against the femoral neck.

Lequesne M., Morvan G. Description of the potential of an arthrometer for standard and reduced radiographs suitable to meaurements of angles and segments of hip, knee, foot and joint space widths Joint Bone Spine 2002: 69 (3): 282-289

Ganz R., Leunig M., Leunig-Ganz K, Harris WH The Etiology of the osteoarthrits of the hip: an integrated mechanical concept

J Clin Orthop Rel Res 2008; (2): 1528-1532

Surgery Pincer

Abnormality lies with the acetabulum then a resection osteoplasty of the excessive acetabular rim may be undertaken or the retroverted acetabulum may be reorientated by periacetabular osteotomy.(Sienbenrock K.A., Schoeniger R., Ganz R. Anterior femoroacetabular impingement due to acetabular retroversion with periacetabular osteotomy J Bone Joint Surg Am 2003; 85-A (2): 278-286)

Potential Side Effects of Open Surgical Dislocations:• Post-operative stiffness, Heterorophic ossification, and

sciatic nerve neuropraxia

(Eijer H, Myers SR, Ganz R Anterior femoroacetabular impingement after femoral neck fractures J OrthopTrauma 2001; 15 (7): 475-481)

Anterior Impingement and Posterior-Inferior

Anterior impingement is the most common pathology, however, pincer impingement is also often found and the combination of anterior (CAM) and posteriorinferior (pincer) is also often reported.

(Beck M., Kalhor M., Leuning M., et al. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip J Bone Joint Surg Br. 2005; 87 (7): 1012-1018)

20

Outcome: Post Op

■ Post Op Significant improvement in the first month with a plataeu by the third month.

(Byrd J.W.T., Jones K.S. Hip arthroscopy in athletes Clin Sports Med 2001; 20: 749-761)

(Byrd J.W.T., Jones K.S. Prospective analysis of hip arthroscopy with 2 year follow-up. Arthroscopy 2000; 16: 578-587)

■ Poor results after arthroscopic surgery seemed to be associated with concomitant factors such as arthritis.

Post operative Rehabilitation: Labral Tear Debridement

■ Non-weight bearing 5 days

■ Upper extremity and abdominal exercises

■ Day 10 cycling without resistance, pool exercises

■ Gradual progression with rehabilitation with running and some plyometrics starting at 5 weeks post.

Rehabilitation following Hip Surgery

■ Considerations

1) Soft Tissue Healing Constraints

2) Control of Swelling & Pain to limit muscular inhibition and atrophy

3) Early ROM

4) Early Initiation of Muscle Activity and Neuromuscular Control

5) Limitation on Weight Bearing

6) Cardiovascular Training

7) Progressive Lower Extremity Strengthening & Proprioceptive Retraining

8) Sport and/or Function Specific Training

(Stalzer S., Wahoff M., Scanlan M. Rehabilitation following Hip Arthroscopy Clin Sport Med 2006; 25 (2): 337-357)

21

Need and Importance

■ Rehabilitation protocols related to hip arthroscopy have remained rooted in THR paradigms. Rehabilitation protocols should have a scientific foundation for rehabilitation success and to help prevent re-injury.

■ Rehabilitation exercises may included Common hip stretches at end range may be harmful for individuals with hip pathology

Rehabilitation following Hip Surgery

Phase I Goals– Protect Integrity of repaired tissue– Restore ROM within restrictions– Diminish pain and inflammation– Prevent muscular inhibition

– Precautions: 1) Do not push through Hip Flexor pain; 2) Specify ROM restrictions; 3) Weight Bearing Restrictions; 4) Avoid weight bearing with twisting

Modified and Adapted from(Stalzer S., Wahoff M., Scanlan M. Rehabilitation following Hip Arthroscopy Clin Sport Med 2006; 25 (2): 337-357)

Phase I Exercise ExamplesAquatic Walking with buoyancy vest

■ Isometric sub-max, gluts, hams, quads, hip add, hip abd, prone hip int & ext rot./3 way leg raises

Progress to….– Double leg bridges, Leg press limited range and

limited weight, short range hip flexion

– Typical ROM restrictions

– Hip Flexion 0 to 90 deg ; Hip Abd 0-25 deg; Hip Add 0-20 deg; Hip Int & Ext Rot 0-25 deg

– Weight Bearing restrictions dependent upon Surgery and Individual

22

Phase II Intermediate Phase

Phase II Goals

■ Restore Full ROM

■ Restore Normal Gait Pattern

■ Gradually Increase Strength

Criteria for progression to Phase II

■ When full weight bearing is allowed

■ ROM is >= 75% of the involved side

■ Minimal Pain

■ Proper muscle firing during exercises

Phase II Rehabilitation

Precautions:

– No ballistic or Forced Stretching– No Treadmill use– Avoid Hip Flexor Joint Inflammation

Exercise Examples

Quadraped Rocking

Increased appropriate Cardiovascular Training

Gait Training Level Ground

Single Leg Balance Ex (avoiding twisting)

Stationary Cycle and/or U & LE cycle ergometers

Gradual Increase with Resistance Exercise and Aquatics and/or use of Unweighting Device

Phase III Post Op Rehabilitation

Criteria for Progression to Phase III

Full Range of Motion

Painfree/Normal Gait Pattern

Hip Flexor Strength > 60% of uninvolved side

Hip Abd/Add/IR/ER strength >70% of uninvolved side

Precautions

Avoid Ballistic type exercises and Forced end of range ROM exercise

23

Phase III Exercise Examples

Single leg stance

Single leg stance on Rocker Board and/or Firm Foam

Single leg ½ range trunk rotations

Backwards and Side-step resistance with Cable Column

Increased ROM and Resistance with Leg Press

Increase Cardiovascular exercises and time

Phase IV Rehabilitation Return to Play or Return to Physical Work

Criteria for Progression

-Hip Flexion > = 70 % Hip Flexor Strength from uninvolved side

-Hip Add/Abd/IR/ER >= 80% from uninvolved side

Gradual Progression to Sport or Job Specific Exercises

Criteria for Return to Competition

- Full Painfree ROM

- Hip Strength >= 85% from uninvolved side

- Ability to perform Sport or Job Specific Skills

- Psychologically Ready – Plan for Gradual Progression

Rehabilitation plan Surgical and Non-Surgical

Maintaining appropriate femoral head position within the joint capsule and labral complex is paramount to normal hip function and to the health of the acetabular labrum and cartilage. This hip congruency, is not solely dependent upon the femoral-head acetabular bony constituents for hip stabilization. (Neuromuscular factors, flexibility, training, strength, intrinsic and extrinsic factors)

24

Straight Leg Raise

SLR

Abdominals work

Under tremendous torque

Compressive forces are very high

Examination Goals

1) Define the Problem

2) Identify the Tissues Involve

3) Identify possible etiological factors

4) Physiological and Biomechanical demands upon the athlete, sport andposition.

5) Screen each individual athlete

6) Develop an individualized action plan/intervention as needed

7) Communication, Comfort, Confidence, Compliance (Canavan, 1998)

Hip Examination A consistent hip examination is conducted to screen the hip, back,

abdominal, neurovascular, and neurologic systems and to find co-morbidities that could also exist with hip pathology. Differential Diagnosis: infection, abscess tumors, etc. could also be present.

One of the most important aspects of the evaluation is the manner and order of the eval in order for interobserverconsistency

(Byrd JWT Physical Examination. IN: Byrd JWT, ed. Operative Hip Arthroscopy 2nd ed. New York, Springer; 2005: 36-50)

Exam Patient Position Order

The most efficient order of examination is having the patient in:

1) Standing;

2) Sitting;

3) Supine;

4) Side-lying;

5) Prone(Braly BA, Beall DP, Martin HD Clinical examination of the athletic hip Clin Sports Med 2006; 25: 199-210, vii.)

25

Clinical Examination of Experts Pattern and Technique of the Clinical Evaluation of the Adult Hip 6

Hip Specialists

-11 subjects

All examiners were blinded to subject’s diagnoses and to their radiographs

There were 18 common tests (11 supine, 3 standing, 3 lateral and 1 prone)

Supine (Flexion, Int. Rot, Ext. Rot., supine rotation test, flexion/adduction/internal rotation**, flexion/abduction/external rotation, SLR vs resistance,, Standing (Gait and Single leg )

(Martin HD, Kelly BT, Leunig M., Philippon MJ, Clohisy JC, Martin RL, Sekiya JK, Pietrobon R, Mohtadi NG, Sampson TG, Safran MR The pattern and technique in the clinical evaluation of the adult hip: the common physical examination tests of hip specialists Arthroscopy: The Journal of Arthroscopic and Related Surgery 2010; 26 (2): 161-172)

History: Hip Symptoms Associated with Labral Tears

66 hips

Onset of Symptoms

Insidious (61%)

Acute (30%)

Trauma (9%)

Severity of Symptoms

Mod-Severe Symptoms (86%)

Location of pain

Groin (92%)

Lateral Hip (59%)

Ant. Thigh/Knee (52%)

Buttock (38%)

(Burnett RS, Della Rocca GJ, Prather H, Curry M, Maloney WJ, Clohisy JC Clinical presentation of patients with tears of the acetabular labrum J Bone Joint Surg Am 2006;88-A (7): 1448-1457)

History

Femoracetabular Impingement presents in young and middle-aged adults, typically men, with insidious onset groin pain which may be preceded by minor trauma or no reported history of specific precipitating factors. The pain may be brought on by prolonged sitting.

26

History of “Snapping”:Intra & Extraarticular Snapping Hip

Snapping hips can have a intra-articular or extra-articular origin. Intraarticular origin could be from acetabular labral tear, cartilage defects (Byrd JW Labral lesions: an elusive source of hip pain case reports and literature review Arthroscopy 1996; 12 (5): 603-612)

Patients with Intraarticular pathologies related to snapping are more likely to describe Catching, locking, painful clicking or sharp stabbing sensations.

(Gruen GS, Scioscia TN, Lowenstein JF The surgical treatment of internal snapping hip Am J Sports Med 2002; 30 (4): 607-613)

Externally, Lateral Region; snapping over the greater trochanter usually ITB

History and Observation: Functional Limitations Associated with Acetabular Tears

Limp with walking at any time during symptoms (89%)

Use of Assistive device (9%)

Limitation in walking distance (36%)

Require use of banister when walking stairs (67%)

Increased pain with sitting less than 30 minutes (26%)

Difficulty with donning shoes and socks (32%)

(Burnett RS, Della Rocca GJ, Prather H, Curry M, Maloney WJ, Clohisy JC Clinical presentation of patients with tears of the acetabular labrum J Bone Joint Surg Am 2006;88-A (7): 1448-1457)

Hip Range of Motion Exam

Check Hip Internal and External Rotation Range of Motion, Supine Hips flexed at 45 degrees and 90 degrees and in Prone.

In a study of 189 Osteoarthritic hips, with the hip at 45 degrees, the average hip internal rotation range of motion was 17 degrees

Current Concepts Review Acetabular and Femoral Anteversion:

Relationship with Osteoarthritis of the Hip*

BY D. TÖNNIS, M.D.†, A. HEINECKE, GERMANY JBJS 81: 1747-1770, 1999

27

Hip ROM

EXAM : Pain on Internal Rotation

The pain exhibited on hip internal rotation with hip flexion in due to the abutment and impingement of the femoral neck against the acetabular labrum, most often in sports like ice hockey, martial arts, tennis, soccer as well as horse riding and weight lifting.

Bizzini et al. reported loss of ROM in Hip INTERNAL ROTATION was the main performance limiting factor for athletes in high demand sports.

Bizzini M., Notzli H.P., Maffiuletti N.A. Femoroacetabular impingement in professional ice hockey players: a case series of 5 athletes after open surgical decompression of the hip Am J Sports Med 2007; 35 (11): 1955-1959

Strength Testing

28

Hand held dynamometer for Strength Testing

All Adductor strains occurred during games. Players that sustained a adductor strain, the side that was injured had the lower adductor/abductor strength ratio

(Tyler et al., Am J Sports Med, 2001)

Hip Abduction/Adduction Strength

100 uninjured professional rugby league players were evaluated and followed over a 2 year period. Tested on a Cybex isokinetic dynamometer. Multi-variate predictive model. Eight variables including hip abduction/adduction peak torque ratio, angle of peak torque abduction/adduction, bilateral differences in knee extension peak torque, Strength ratio of hip muscle groups were able to correctly classify 91.7% of the non-injured players and 90.5% of the injured players (Groin Injuries). Hip Abduction/Adduction and Knee Flexion and Extension.

(O’Connor, J Sports Science, 2004)

Special Tests

1) FABER (Flexion/ABduction/EXt. Rot)

2) FADIR (Flexion/Adduction/Int. Rot)

3) Thomas Test

4) Modified Thomas Test

5) Duncan-Ely Test

6) OBER

7) Single Leg Stance

(VIDE0 DEMONSTRATION)

29

FABER Test (Impingement)

Impingement test was positive in 99% with FAI (sole clinical finding of the CAM type of Impingement) of athletes and a positive test in 97% with the FABER test.

(Philippon M.J., Maxwell R.B., Johnston T.L. et al. Clinical presentation of femoroacetabular impingement Knee Surg Sports Traumol Arthrosc 2007; 15 (8): 1041-1047)

FABER (Flexion/Abduction/Ext. Rot)

Hip Examination Findings: Acetabular Labral Tears

Anterior Labral Tears: Loss of Internal Rotation ROM/Positive Flexion-Adduction-Internal Rot (pain)/Dynamic Internal Rotatory Impingement Test

30

FADIR (Flexion/Adduction/Int. Rot)

THOMAS TEST

MODIFIED THOMAS TEST

31

DUNCAN ELY TEST

OBER TEST

SINGLE LEG BALANCE TWIST

32

Duncan-Ely Test

Clinical Test for Rectus Femoris Flexibility

Patient prone, rapid passive knee flexion

+ test occurs if the patient displays hip flexion and the examiner feels a “catch”/resistance to further flexion

Special Tests for the Knee

1) Patella Apprehension Mobility/Stability

2) Lachman Test for ACL Integrity at 25 deg. Flex

3) Sag Sign for PCL Injury

4) Varus/Valgus for LCL and MCL Laxity

Patella Apprehension/Mobility Tests

33

Patella Apprehension/Mobility Tests

Sag Sign

Valgus and Knee Varus Test for Ligament Laxity

34

FABER

MODIFIED

THOMAS TEST

OBER and

MODIFIED OBER

PRONE KNEE

FLEXION (R.F.)PRONE HIP

EXTENSION TEST

End of Hip Joint

THANK YOU!!

Paul K. Canavan PhD, PT, DPT, ATC, CSCS

The Human Knee

Paul K. Canavan Ph.D., P.T., A.T.,C., C.S.C.S.

35

KNEE PATHOLOGIES

1) “PATELLO-FEMORAL PAIN”

2) KNEE OSTEOARTHRITIS

3) Anterior Cruciate Ligament Tear

Functional Anatomy

Knee Joint

- Femoral-Tibial

- Femoral- Fibular

(Modified Hinge)

Patello-Femoral

(Synovial-Sellar)

Gliding Joint

MOTIONS:

1) Knee Flexion/Extension• Flexion: Femur lat rot, abducts &

translation

• Extension: opposite

2) Tibial & Femoral Rotation

3) Knee Valgus & Varus

4) Patella Motions

Muscles About the Hip and Knee Joint

36

Anterior Cruciate Ligament

Anterior medial tibia to posterior lateral

femur

Prevent anterior tibial displacement on

femur

Secondarily, prevents hyperextension, varus,

valgus and tibial internal rotation stresses

ACL, PCL, LCL

MRI: Normal & ACL Tear

37

Lachman Test for ACL Injury

Anterior Drawer TestPosterior Sag Sign

(+) Test is increased anterior tibial translation over 6 mm

(+) test indicates: • ACL (anteromedial

bundle)

• posterior lateral capsule

• posterior medial capsule

• MCL (deep fibers)

• ITB

• Arcuate complex

False (-) if only ACL is torn

Menisci

38

Meniscal Functions

Deepens the articulation

Primary Functions– Load distribution

– Joint Stability

– Shock Absorption

Secondary Functions– Joint Lubrication

– Articular Cartilage Nutrition

– Proprioceptive Feedback

Knee Joint” Tibio-Femoral Joint

Normal ROM– Flexion 135-140 degrees– Extension 0 degrees

Closed Pack Position– Full extension with ER

Loose Packed Position– 25 degrees of flexion

39

Knee is Capable of Rotation and

Translation about Three Axes

and Therefore has 6 degrees of

Freedom

Knee Flexion/Extension

Femoral Rotation

Tibial Rotation

Knee Valgus/Varus

Patella: Facets (Medial, Lateral, & Odd)

Patella-Femoral Joint (PFJ): Tilt, Rotation, & “Flexion/Ext”

40

Patella Position with motion

When the Knee is

Extended the

patella is almost

parallel to the

Femur

Patella: Apprehension and Laxity Testing

Patellofemoral Joint (PFJ)

PFJ Loading

Walking • 0.3 x body weight

Ascending Stairs• 2.5 x body weight

Descending Stairs• 3.5 x body weight

Squatting• 7 x body weight

41

Patello-Femoral Pain ETIOLOGY

Intrinsic Factors– Shortened

Quadriceps(Duncan-Ely Test) and Gastrocnemius

– Reflex response time VMO

– Hypermobile patella

– Psychological Parameter: seeking social support

(Witvrouw, Am J Sport Med, 2000)

Extrinsic Factors– Shoe wear/

Orthotics

(effect on force & area)

– Surface

– Training Errors

– Collisions/Falls

One of the Quadriceps Muscles, Rectus Femoris

PF Joint Reaction Force:Open vs Closed Chain

42

Valgus/Varus Stress: Joint Compression/Ligament Distraction

MCL

LCL

Valgus Stress Test

Assesses medial instability

Must be tested in 0° and 25° (+) Test in 0°

– MCL (superficial and deep)– Posterior oblique ligament– Posterior medial capsule– ACL/PCL

(+) Test in 25°– MCL (superficial)– Posterior oblique ligament– PCL– Posterior medial capsule

MCL Sprains

Typically due to valgus forces in CKC

– Foot typically in neutral or externally rotated

Most frequently injured ligament in the knee

Usually no joint effusion unless deep portion affected since primarily located outside the joint capsule

43

Convex-Concave Rule

WHEN THE CONVEX SURFACE IS FIXED AND THE CONCAVE SURFACE MOVES ON IT, THE CONCAVE SURFACE ROLLS AND GLIDES IN THE SAME DIRECTION.

WHEN THE CONCAVE SURFACE IS FIXED AND THE CONVEX SURFACE MOVES ON IT, THE CONVEX SURFACE ROLLS AND GLIDES IN OPPOSITE

Knee: Rule vs Reality

Origins of the Convex/Concave “Rule”

MacConaill MA, Basmajian JV. Muscles and Movements: A Basis for Human Kinesiology. Baltimore, Md: Williams & Wilkins; 1969.

• Glenohumeral Arthrokinematicso He stated that when a convex surface moves on a

concave surface,"the direction of the slide that accompanies a roll is opposite to that of the roll”

o No Direct Measurements were used.

Kaltenborn used MacConaill's descriptions to propose an "indirect method" for determining the appropriate direction to apply a gliding mobilization technique that he called

“the concave-convex rule”

44

Review paper

Biomechanical considerations for rehabilitation of the knee

Gerald McGinty a, James J. Irrgang a,b,*, Dave Pezzullo Clinical Biomechanics 15 (2000) 160±166

These findings indicate that squatting, which produces a

substantial compressive joint force, does not necessarily

protect the anterior cruciate ligament more than active

flexion-extension of the leg.

The Strain Behavior of the Anterior Cruciate Ligament During Squatting

and Active Flexion-Extension; A Comparison of an Open and a Closed Kinetic Chain Exercise Beynnon et al. AJSM December 1997

On the basis of our review, both OKC and CKC

exercises can be modified and implemented for quadriceps strengthening after ACL reconstruction

without causing excessive ACL strain or patellofemoral joint stress.

When improvement in quadriceps femoris muscle function

is an essential treatment goal, therapists may need to combine OKC exercises with CKC exercises to provide

optimal training stimuli. (Open Versus Closed Kinetic Chain Exercise: Issues in

Rehabilitation After Anterior Cruciate Ligament Reconstructive Surgery Fitzgerald Phys Ther 1997)

ACL Tears

Non-Contact: – Most common– Due to sudden deceleration– Sudden landing, cutting, or pivoting

Most common mechanisms– Contact:

o Foot Fixedo Foot planted knee near full extensiono direct hit on the posterior tibia

■ Patient will report hearing or feeling a “Pop”

45

Pre-Op ACL Reconstruction 2/3 of primarily conservative treated pt.’s opt for

ACL reconstruction after Rehab.

(Strehl A., Eggli S. The value of conservative treatment in ruptures of the anterior cruciate ligament J Trauma 2007, (7): 1159-1162)

Prior to surgery the goals should be for minimal pain, full ROM, optimization of neuromuscular control and improved gait pattern. The Dutch Physician Standard advocates ACL Reconstruction should not be timed within 6 weeks after trauma.

(Plas C., Dingjan R., Hamel A. et al. Nederlands Huisartsen Genootschapstandaard traumatische knieproblemen 1998)

Evidence-Based Rehabilitation following ACL Reconstruction

van Grinsven S., van Clingel R.E.H., Holla C.J.M., van Loon C.J.M. Evidence-based rehabilitation following anterior cruciate ligament reconstruction Knee SurgSports Traumatol Arthrosc 2010 (18): 1128-1144 (Systematic Review using Cochrane Library checklist to exclude “poor” studies”)

Wright R.W. et al. A systematic review of ACL Reconstruction Rehabilitation J Knee Surg 2008 (21): 225-234

Post-Op ACL Rehabilitation

■ “Accerated”(RTS 6 months) post op ACL protocol without post-operative bracing has advantages over “Conservative” protocols and does not lead to stability problems.

■ Clear Patient Education and Instruction with Exercises, Crutch Ambulation and Rehab. Program to patients increases self-efficacy during rehab., stimulates early recovery of knee function, decreases post-surgical pain and creates a realistic view of the rehabilitation process.(Cascio B., Culp L., Cosgarea A Return to play after ACL reconstruction ClinSports Med 2004 (23): 395-408)

46

Post Operative ACL Reconstruction

Phase 1 (0-2 wks) Without endangering the ACL graft muscle control should be initiated with the use of Isometrics, Closed Chain (0-60 deg) Open Chain (95-45 deg knee ext. without weight), SLR, Heel Slides, Only mini-squats (0-25 deg), Weight Shifts, Open Chain Hamstring Ex.

Patients should be FWB without crutches within 10 days post-op.

Post Op ACL Rehabilitation

Early Weight Bearing may decrease PF Pain

Early Motion to decrease the chance of arthrofibrosis

CPM not needed; Post Op P.T. needed

Neuromuscular E-stim if necessary with high intensity should be utilized early in Rehab.

Reducing Pain, Inflammation and regaining Neuromuscular Control are very Important.

Gait Training & Proprioception Ex. Is beneficial

“Acclerated” (RTP @ 6 months) appears to be safe

Patient Education from a P.T. is important

Female Bilateral Static Stance1 foot on a different platform

47

Keys to Rehabilitation Success1) Define the Problem

2) Perform an appropriate examination

3) Identify the Anatomical Tissues Involved

4) Identify all possible Etiological factors

5) Understanding of anatomy, physiology, and biomechanics

6) Understand the individual’s functional demands

7) Develop an individualized therapeutic exercise and rehabilitation (manual, modalities, pt. education, etc.) plan

Communication, Comfort, Confidence, Compliance(Canavan)

Summary

1) Present the Importance and Need for clinical application of EVIDENCE AND EXPERIENCED CONTINUING EDUCATION

2) Review Functional Anatomy

3) Analyze Kinematics & Kinetics

4) Provide an Evidence Based Approach

THANK YOU!!

Paul K. Canavan PhD, PT, DPT, ATC, CSCS

pkc@earthlink.net