Hip (Orthopedic)

Posture, general appearance, ambulation
Special Tests
ROM (DF/PF, inversion/eversion, knee extension)
Strength (DF/PF, inversion/eversion, knee flexion/extension, hip ABD, hip extension)
Joint mobility 
Palpation
Muscle length testing (gastrocnemius/soleus)

Hip Osteoarthritis

Diagnosis:
CPR for hip OA (4/5 is very high probability, 3/5 is moderate probability)
-Self-reported squatting as aggravating activity
-Lateral pain with active hip flexion
-Passive hip IR </= 25 deg
-Pain with active hip extension
-Positive Scower test with adduction

Used for patients over age 50 (from the CPG)
Moderate anterior or lateral hip pain during weightbearing activities, morning stiffness less than 1 hour in duration after wakening, hip internal rotation range of motion less than 24° or internal rotation and hip flexion 15° less than the nonpainful side, and/or increased hip pain associated with passive hip internal rotation. (A)

When examining a patient with hip pain/hip osteoarthritis over an episode of care, clinicians should document the flexion, abduction, and external rotation (FABER or Patrick’s) test and passive hip range of motion and hip muscle strength, including internal rotation, external rotation, flexion, extension, abduction, and adduction. (A)

Outcome Measures:

To assess activity limitation, participation restrictions, and changes in the patient’s level of function over the episode of care, utilize: 6-minute walk test, 30-second chair stand, stair measure, timed up-and-go test, self-paced walk, timed single-leg stance, 4-square step test, and step test. (A)

Clinicians should measure balance performance and activities that predict the risk of falls in adults with hip osteoarthritis, especially those with decreased physical function or a high risk of falls because of past history. Recommended balance tests for patients with osteoarthritis include the Berg Balance Scale, 4-square step test, and timed single-leg stance test. (A)  

Interventions:

Clinicians should use individualized flexibility, strengthening, and endurance exercises to address impairments in hip range of motion, specific muscle weaknesses, and limited thigh (hip) muscle flexibility. (A)

Clinicians should use manual therapy for patients with mild to moderate hip osteoarthritis and impairment of joint mobility, flexibility, and/or pain. Manual therapy may include thrust, non-thrust, and soft tissue mobilization. Doses and duration may range from 1 to 3 times per week over 6 to 12 weeks in patients with mild to moderate hip osteoarthritis. As hip motion improves, clinicians should add exercises including stretching and strengthening to augment and sustain gains in the patient’s range of motion, flexibility, and strength. (A)

Hip FAI

Femoroacetabular impingement has been further classified into 3 categories, based on the specific osseous abnormality present. (1) Cam impingement is the result of asphericity of the femoral head, which is often related to a slipped capital femoral epiphysis or other epiphyseal injury or protrusion of the head-neck junction occurring at the proximal femur. (2) Pincer impingement is the result of acetabular abnormalities, such as general (protrusia) and localized anterosuperior acetabular over-coverage of the femur (acetabular retroversion). Excessive acetabular coverage anteriorly may result in premature abutment of the femoral neck on the anterior acetabular rim. (3) A combination of the cam and pincer impingement, which is likely the most common category.

Studies have suggested that the abnormal movement at the hip joint occurring secondary to femoral acetabular impingement may lead to labral lesions and cartilage damage.

Symptomology
Pain in the anterior hip/groin and/or lateral hip/trochanter region. Aching or sharp. Aggravated by sitting. Mechanical symptoms: popping, locking or snapping
Assessment
Reproduced with FADIR Test. 
Hip IR is less than 20 with the hip at 90 deg flexion. 
Hip flexion and abduction are also limited.
Interventions
-Patient should avoid activities and positions that create impingement effect. Activities that place the hip joint in end-range flexion, internal rotation, and in some cases abduction are of particular concern. 
-Assess to see if sitting, sit-to-stand, ambulation on level surfaces, stairs, and sleeping positions cause pain. If so, assess the movement pattern and alignment of the hip during these activities. For example, sitting in a low chair may exacerbate symptoms (FADIR).
-When used appropriately, an AD such as a cane, walker, or crutch can off-weight limb).
-Instructing patients in gait modification by emphasizing ankle and toe plantar flexion at the terminal stance and pre-swing phases of the gait cycle may be helpful.
-A patient with FAI may be instructed to use a higher seat position during work or fitness activities such as cycling. The higher seat position will result in the hips being positioned higher than the knees, and thus excessive hip flexion will be avoided.
-Indications for mobilization/manipulation of the hip joint include hip pain and decreased passive range of motion with a capsular end feel.
-Indications for mobilization of the pelvis and hip soft tissue, such as myofascia that may be limiting normal hip mobility, include decreased passive range of motion with an elastic end feel and immediate positive gains in mobility following application of procedures to inhibit or relax the targeted myofascia.
-Individuals with identified osseous abnormalities may be subject to specific concerns in regard to manual therapy.
-End-range physiologic techniques such as flexion and internal rotation should be avoided if the patient has cam or pincer impingement. Impingement may be suspected if a bony end feel is detected at the end of hip flexion and internal rotation.
-Patients who display a limited range of motion and a capsular end feel may benefit from stretching. ----NOTE: not indicated if bony end-feel such as the commonality of IR being limited and ER being increased with FAI. 
-Cibulka showed that those who have excessive hip external rotation range of motion when compared to internal rotation range of motion have weakness in their hip internal rotator muscles, whereas those who display excessive hip internal rotation range of motion compared to external rotation range of motion have weakness in the hip external rotator muscles. 
-Neuromuscular re-education, including proprioceptive/ perturbation training, has been previously defined as “movement training progressions that facilitate the development of multijoint neuromuscular engrams that combine joint stabilization, acceleration, deceleration, and kinesthesia through intermittent protocols that progress from low intensity movements focused in a single plane to multiplanar power training.” Neuromuscular re-education has had some success for other lower extremity disorders and may provide an effective intervention in nonarthritic hip pain. Kim and Azuma suggested that nerve endings located within the acetabular labrum potentially have an effect on proprioception. Individuals with a compromised labrum may benefit from training to increase the efficiency of the musculature to provide dynamic stabilization.

Structural Instability

Hip instability may be traumatic, atraumatic, or secondary to bony or soft tissue abnormality. Factors related to structural instability of the joint include a shallow acetabulum and an excessive femoral anteversion. Excessive acetabular anteversion or retroversion, inferior acetabulum insufficiency, and a neck shaft angle greater than 140° may also be a component of structural instability. A shallow acetabulum (acetabular dysplasia) has been associated with labral tears due to structural instability. Insufficient anterior coverage with anteversion or posterior coverage with retroversion can lead to labral stress. Structural instability due to dysplasia is thought to be more common in females. Adult individuals with hip pain can be anywhere from 5.4-32% and the studies found there to be no difference between genders in hip symptomatic populations.

Symptomology
Pain in the anterior goin, lateral hip, or generalized hip joint. Mechanical symptoms: popping locking, or snapping.
Assessment
Reproduced with FADIR or FABER
Positive hip apprehension sign
Hip IR is greater than 30 deg when hip is 90 deg flexed
Interventions
-Patient should avoid positions and activities that place the hip in forced extension or rotational loading.
-Assess to see if sitting, sit-to-stand, ambulation on level surfaces, stairs, and sleeping positions cause pain. If so, assess the movement pattern and alignment of the hip during these activities. 
-When used appropriately, an AD such as a cane, walker, or crutch can off-weight limb).
-Instructing patients in gait modification by emphasizing ankle and toe plantar flexion at the terminal stance and pre-swing phases of the gait cycle may be helpful.
-Indications for mobilization/manipulation of the hip joint include hip pain and decreased passive range of motion with a capsular end feel. Individuals with identified osseous abnormalities may be subject to specific concerns in regard to manual therapy. Joint mobilization, except for pain modulation, is contraindicated in individuals classified as hypermobility.
Stretching is contraindicated. 
-Cibulka showed that those who have excessive hip external rotation range of motion when compared to internal rotation range of motion have weakness in their hip internal rotator muscles, whereas those who display excessive hip internal rotation range of motion compared to external rotation range of motion have weakness in the hip external rotator muscles. 
-Particular attention should be placed on the strength of the hip abductors and hip rotators in patients with structural instability. It has been suggested that loss of rotational stability may be linked to acetabular labral tears. Sufficient strength may be a particular concern in this population, reducing the ability to control the excessive range of motion that occurs at the hip joint.
-Neuromuscular re-education, including proprioceptive/ perturbation training, has been previously defined as “movement training progressions that facilitate the development of multijoint neuromuscular engrams that combine joint stabilization, acceleration, deceleration, and kinesthesia through intermittent protocols that progress from low intensity movements focused in a single plane to multiplanar power training.” Neuromuscular re-education has had some success for other lower extremity disorders and may provide an effective intervention in nonarthritic hip pain. Kim and Azuma suggested that nerve endings located within the acetabular labrum potentially have an effect on proprioception. Individuals with a compromised labrum may benefit from training to increase the efficiency of the musculature to provide dynamic stabilization.

Intra-Articular Injury (Labral Tear, Osteochondral Lesion, Loose Bodies, and Ligamentum Teres Rupture)

Labral Tears
Labral tears have recently been identified as a potential source of hip pain and a possible precursor to hip OA. A study looking at 70 young asymptomatic individuals (mean age of 26), 38.6% had labral tears. In a different study with individuals with hip or groin pain, prevalence of labral tears were as high as 22% to 55%. Tears have been observed in up to 96% of older individuals.123,172 In another study, 88% of patients older than 30 years were found to have labral detachment from the articular cartilage.
Acetabular labral tears may occur as the result of acute trauma or of insidious onset. Common traumatic mechanisms involve rapid twisting, pivoting, or falling motions. Groh and Herrera found that up to 74% of labral tears are not associated with any specific event. Narvani found acetabular labral tears to be the cause of symptoms in 20% of athletes presenting with groin pain.
Ligamentum Teres
Plays a role in stabilization, especially when the hip is externally rotated in flexion or internally rotated in extension. Tears of the ligamentum teres are generally considered rare. A prevalence of less than 8% seen in arthroscopic surgeries. The correlation between injuries to the ligamentum teres and clinical presentation is not well understood. A tear of the ligamentum teres can create microinstability. In the presence of recreational and sports activities, this may result in damage to the labrum or cartilage. 
Chondral Lesions
73% of patients with fraying or tearing of the labrum also had chondral damage. Anterior-superior cartilage lesions have been associated with dysplasia, anterior joint laxity, and the presence of femoroacetabular impingement. Chondral lesions have been reported in younger, more active individuals as a source of hip pain. A traumatic injury pattern involving acute overloading through impact sustained by a blow to the greater trochanteric region has been described. This clinical hypothesis has been supported by arthroscopic findings.
Loose Bodies
The presence of loose bodies (small fragments of bone or cartilage within the joint) has been implicated as a disrupter of joint function in individuals presenting with hip pain. Numerous underlying mechanisms have been described. Though the specific mechanisms underlying their presence may vary, their potential for being a cause of pain and/or mechanical disruption should be considered. Loose bodies, ossified and nonossified, may be present in the joint secondary to a number of factors. Single fragments typically occur in the case of dislocation or osteochondritis dissecans. Multiple fragments are more common in conditions such as synovial chondromatosis.

Symptomology
Pain in the anterior goin or generalized hip joint. Mechanical symptoms: popping locking, or snapping. May report feelings of instability (ligamentum teres) and the sensation of instability when squatting.
Assessment
Reproduced with FADIR or FABER
Interventions
-When used appropriately, an AD such as a cane, walker, or crutch can off-weight limb).
-Instructing patients in gait modification by emphasizing ankle and toe plantar flexion at the terminal stance and pre-swing phases of the gait cycle may be helpful.
-Utilization of manual therapy in an attempt to improve the rate of nutrient imbibition for the articular cartilage has been suggested
-Indications for mobilization/manipulation of the hip joint include hip pain and decreased passive range of motion with a capsular end feel.
-Indications for mobilization of the pelvis and hip soft tissue, such as myofascia that may be limiting normal hip mobility, include decreased passive range of motion with an elastic end feel and immediate positive gains in mobility following application of procedures to inhibit or relax the targeted myofascia.
-Individuals with identified osseous abnormalities may be subject to specific concerns in regard to manual therapy.
-Patients who display a limited range of motion and a capsular end feel may benefit from stretching.
-Particular attention should be placed on the strength of the hip abductors and hip rotators in patients with structural instability. It has been suggested that loss of rotational stability may be linked to acetabular labral tears. Sufficient strength may be a particular concern in this population, reducing the ability to control the excessive range of motion that occurs at the hip joint.
-The most common shortened muscles around the hip include the 2-joint muscles, iliopsoas, rectus femoris, hamstrings, and tensor fascia latae-iliotibial band.
-Neuromuscular re-education, including proprioceptive/ perturbation training, has been previously defined as “movement training progressions that facilitate the development of multijoint neuromuscular engrams that combine joint stabilization, acceleration, deceleration, and kinesthesia through intermittent protocols that progress from low intensity movements focused in a single plane to multiplanar power training.” Neuromuscular re-education has had some success for other lower extremity disorders and may provide an effective intervention in nonarthritic hip pain. Kim and Azuma suggested that nerve endings located within the acetabular labrum potentially have an effect on proprioception. Individuals with a compromised labrum may benefit from training to increase the efficiency of the musculature to provide dynamic stabilization.

Hip Arthroplasty

Performed on patients with labral tear and acetabular impingement/FAI. Repair and debridement of the labrum, removal of lose bodies, penser bone removal, removal of bone cam lesion, etc. In regard to rehab, main goal is protection of the labrum. Follow tissue healing principles in regard to protocol. Utilize the protocol from the surgeon.

Week 1-4 (Inflammation Phase)
Focus on healing labrum, ROM, decrease inflammation and pain, patient education.
-Education regarding precautions. Typically weight bearing is </=50% with crutches, no hip extension past neutral, no ER, hip flexion limited to 120 deg, and abduction limited to 45.  for approx. 3 weeks. Some patients will be prescribed a hip brace to limit motions.
-ROM. Some patients will have been issued a continuous passive motion machine for home use. Perform active ROM and stretching. Low grade joint mobilization and soft tissue mobilization. You can use a rolling stool for IR <> neutral with knee placed on stool in standing. Stationary bike without resistance for ROM can be performed.
-Resisted exercise. Isometrics of the hip and abdominals can be performed. Example is isometric hooklying glute squeezes (part of a bridge progression for later)
-Modalities for inflammation and pain can be utilized.
-Home program. Patient should be instructed to lay prone 1-2 hours per day and avoid SLR. Avoid sidelying hip abduction, as it can increase acetabular forces. Instead, utilize standing hip abduction with IR.
-Progress to next phase if: minimal pain with all exercises, full weight bearing allowed and tolerated, minimal c/o pinching in the hip before 100 degrees of flexion, and adequate muscle firing (especially of gluteus medius).

Week 5-7 (Reparative Phase)
During this phase the wounds are closed, revascularization of underlying tissue is occurring, femoral head and acetabulum will have callus forming to convert soft callus to hard callus, and the fibrous connective tissue of the labrum is being replaced with collagen.
-If patient ambulates safely and good form, discharge the crutches.
-ROM. Continue ROM exercises until patient can demo full ER and extension. Can utilize manual therapy to aid in ROM.
-Resistance exercises. Can now increase resistance on bicycle. Progress resisted exercise to include balance, proprioception, and functional movement. Bridge progression exercise as an example. Bridge progression to isotonic. Progress to single leg bridging.
-To progress to next phase, patient should have normalized pain-free gait, full ROM, no pain, and able to perform intermediate strengthening with good mechanics.

Week 8-12(Remodeling Phase)
During this phase, bone is remodeling into hard lamellar bone and bonds between labral collagen fibers to bone are strengthening.
-No pain, full ROM.
-Strengthening. Include multiplanar movements, balance and proprioception, and functional activity. Example of multiplanar exercise would be lunges with trunk rotation at bottom of movement which also challenges proprioception. Progress with weighted ball.
-Work/Sport specific training including plyometrics. Progress to running and agility drills. Sports specific: sprinting, cutting, and hills. Agility exercises should include lateral and diagonal movements.
-Can implement Functional Sports Test to return to practice (not competition, but preparation for competition). 
-Validated hip tests: Single leg stance test, deep squat test, single leg squat test, star excursion balance test (SEBT).

ACL Reconstruction

Usually younger athletes. Allows for return to previous activities. Tear usually from rapid deceleration with knee in valgus position usually from cutting or landing maneuvers. Also can be from contact injury forcing knee in valgus position. Allograph: cadaver, autograph: from patient's body. A bone patellar tendon bone autograph can be up to 168% the strength compared to original ACL.

Week 1-4 (Inflammation Phase)
Usually seen after first week of surgery. Focus on protecting graft, controlling pain and inflammation, full knee extension, begin quadriceps strengthening. Typically patient will have crutches and a hinged knee brace locked at 0 deg. Variability regarding surgeon use of CPM machine.
-Education. Patient should avoid using a pillow under their knee while lying supine to promote full knee extension. If only ACL surgery was performed, they will be WBAT.
Removal of brace occurs as patient demonstrates normal gait pattern, SLR without a lag, and has around 100 deg of flexion.
-ROM initiated immediately with prolonged stretching and manual therapy techniques including joint and soft tissue mobilization. Superior patellar glides of  can be beneficial in restoring knee extension. Mobilization of tibiofemoral joint can help improve ROM. Stretches, AROM, and PROM can aid in improving ROM. Include HEP. One exercise for AROM is supine with swiss ball under feet promoting flexion/extension.
-NMES may be beneficial for extension. 
-Strengthening with isometrics and isotonics.

Week 4-16 (Reparative Phase)
During this phase, the graft is still in a reparative and proliferative phase. Focus on increasing LE strength, impro ving neuromuscular control, and pre-running training. Patient should have normal, pain-free gait mechanics at this stage.
-ROM. Since full extension ROM has been achieved at previous stage, focus on end range flexion. You may utilize joint and soft tissue techniques to regain motion.
-Resistive exercises with open and closed chain exercises.
-As long as proximal control, advance balance and proprioceptive exercises.
-Start incorporating sport and job specific exercises. Plyometrics can be added toward end of this phase. Progress from double to single leg exercises. Patient should maintain good mechanics through all exercises with no medial collapse occurring. If they don't have the proximal control, focus on the glutes and abdominals. The graft is actually at the weakest point at this phase, so mechanics are important.

Week 16 to 6 months (Remodeling Phase)
Graft maturity occurs 12-16 months following reconstruction. Focus on building muscle, endurance, power, agility, improving biomechanics, and running. 
-For return to running, patient should have good quad and glute control, with no evidence of giving way. Quad strength should be at least 70% of uninvolved leg. Patient should be able to perform repetitive single leg exercises without valgus collapse. Quad strength can be determined by isokinetic testing, hop test, or percentage of 1-rep max compared to opposite leg. The final test for return to running would be assessment of running on a treadmill.
-Progress balance and proprioception with unstable surfaces and incorporating reaction time.
-Progress plyometric and agility training with hopping and cutting.
-Return to sport assessment: hop test, Cincinnati Knee Rating, isokinetic testing, KT-2000 Testing

Physical Impairment Measures
Trendelenburg Sign: ability for patient to hike hip for 30 seconds. 
FADIR. If not provocative, take them into maximal hip flexion.
FABER. If not provocative, place pressure at knee for increasing range.
Log-Roll Test. Determines ligament laxity. With patient supine and 0 deg knee and hip extension, IR and ER hip. If greater hip ER compared to uninvolved hip, positive for ligamentous laxity.
Questionnaire
LEFS (Lower Extremity Functional Scale)
PSFS

Protocols: https://medicine.osu.edu/departments/sports-medicine/education/medical-professionals/rehabilitation-protocols