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INSPECTIONP!"P!TION
"ocate #ony lan$mar%s
Anterior Surface of the Hip
' Iliac Crest at the "evel o( ")
' Iliac Tu#ercle'!nterior Superior Iliac Spine
' Greater Trochanter
' Pu#ic Symphysis
Posterior Surface of the Hip' Posterior Superior Iliac Spine
' Greater Trochanter
' Ischial Tu#erosity
' Sacroiliac *oint
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!ssess Range o( Motion +Goniometer,
' Test -le.ion o( the hip +/012,' 34en$ your %nee to your chest an$pull it againstyour a#$omen5
' Test E.tension o( the hip +672,' 3"ie (ace $o8n9 then #en$ your %nee an$ liftit up5
' Test !#$uction o( the hip +)12,' 3"ying (lat 9move your lo8er leg away fromthe mi$line5
' Test !$$uction o( the hip +)12,' 3"ying (lat9 #en$ your %nee an$ move your lo8er leg towardthe mi$line5
' Test E.ternal Rotation o( the hip +)12,' 3"ying (lat9 #en$ your %nee an$ turn your lo8er leg an$ (oot acrossthe
mi$line5
' Internal Rotation o( the hip +)12,' 3"ying (lat9 #en$ your %nee an$ turn your lo8er leg an$ (oot away from
the mi$line5
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Evaluate the Nervous System
' Peripheral Nerve o( the Hip
' O#turator Nerve' Hip !$$uction
' Sensory !rea +Me$ial !spect o( Mi$
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Per(orm an$ Interpret Special Tests
oThomas Test
oTren$elen#urg Test
o-a#er Test
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Per(orm an$ Interpret Special TestsoTren$elen#urg Test
Tests stren#th of #luteus medius muscle
'!s% the patient to stan$ on / leg
' I( pelvis stays at levelNormal strength' I( contralateral si$e o( pelvis $rops +or asymmetric iliac crest, Aea%
gluteus me$ius
' Aea%ness in contralateral si$e that patient is stan$ing on
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Per(orm an$ Interpret Special Tests
o-a#er Test +$le.ion Ab$uction %.ternal otation,Tests for Hip and S' patholo#y
' Press $o8n on patients %nee 8ith leg crosse$ an$ an%le
on opposite %nee +-igure ),
' POSITIBE RES"T elicits pain
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HIP PRO4"EMS &
HIP :ISE!SE/D Osteoarthritis o( Hip0D -emoral Nec% Stress -racture
6D Trochanteric 4ursitis
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Hip :islocation
' Clinical Mani(estation' Present o(ten in athletes
' Pain aroun$ hip an$ pro.imal thigh
' Superiorly $isplace$ $islocations present 8ith the a((ecte$ hip
e.ten$e$ an$ e.ternally rotate$' The in(erior type o( anterior $islocations present 8ith the a((ecte$
hip (le.e$9 a#$ucte$9 an$ e.ternally rotate$
' The posterior type o( $islocation most commonly appears 8ith a
shortene$9 internally rotate$9 an$ a$$ucte$ lim#
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Hip :islocation
' :iagnosis
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Hip :islocation
' Treatment OptionsPost
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-emoral Sha(t -racture
' Clinical Mani(estation' !cute9 severe pain 8ith movement o( lim# or
palpation o( lim#
' Possi#le $e(ormity in the thigh
' Possi#le leg shortening o( the a((ecte$ si$e
' Ecchymosis evi$entD
' 4ruits9 hematomas9 or lac% o( $istal pulses can in$icate vascular
in;ury
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-emoral Sha(t -racture
' :iagnosis
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-emoral Sha(t -racture
' -ollo8 p' Patient 8ill nee$ crutches an$ have to remain non
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Pelvic -racture
' Clinical Mani(estation' History o( high velocity trauma or
lo8
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Pro.imal -emur -racture
' Treatment OptionsNonoperative ManagementImpacte$ or non$isplace$ (ractures
Mo#iliFe patient
Control painOperative Management
Surgery shoul$i$eally occur 8ithin )K hours o( hospital a$mission
Pro.imal (emur may #e supplemente$ 8ith har$8are9 may #e replace$
8ith a prosthesis9 or the entire hip ;oint may have to #e replace$
' -ollo8 pMo#iliFe patient !S!P9 as tolerate$ +8ith use o( supportive $evices
at (irst,
PT (ocus on strengthening e.ercises an$ ROM
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In(lammatory !rthritis o( Hip
' Clinical Mani(estation
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In(lammatory !rthritis o( Hip
' :iagnosis
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In(lammatory !rthritis o( Hip
' Treatment OptionsNonoperative Management
Operative Management
' -ollo8 p
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"ateral -emoral Cutaneous Nerve Syn$rome
' Clinical Mani(estation
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"ateral -emoral Cutaneous Nerve Syn$rome
' :iagnosis
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"ateral -emoral Cutaneous Nerve Syn$rome
' Treatment OptionsNonoperative Management
Operative Management
' -ollo8 p
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Osteoarthritis o( Hip
' Clinical Mani(estation' !ntalgic gait an$or use o( assistive $evices +8al%er9 cane,
' "im# length $iscrepancy
' Positive Tren$elen#erg test
' Pain 8ith active an$ passive ROM
+especially 8ith hip (le.ion an$ internal rotation,D Positive heel tap
+8ith occult (racture,D
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Osteoarthritis o( Hip
' :iagnosis
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Osteoarthritis o( Hip
' Treatment OptionsOperative ManagementI( la#ral $amage present on MRI9
total hip arthroplasty nee$e$
+contrain$icate$ in patients 8ith a
4MI )7,D
I( la#ral $amage not present on MRI9 consi$er surgical $e#ri$ement o( the
(emoral hea$D
I( the (emoral hea$ has collapse$ (rom necrosis9 patient 8ill nee$ total hip arthroplasty
+seen in the picture,J i( it hasn>t collapse$ (ully consi$er core $ecompression an$ #one
gra(t to restore the #loo$ supply
' -ollo8 p6 months to assess e((ectiveness o( pain management +non
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Osteonecrosis o( Hip
' Clinical Mani(estation' !symptomatic in early stages
' Groin9 thigh9 or #uttoc% pain
' Can #e #ilateral
' May #e secon$ary to in;ury9 ;oint$islocation9 or pressure in ;oint
' Re$uce #loo$ supply to ;oint
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Osteonecrosis o( Hip
' :iagnosis
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Osteonecrosis o( Hip
' Treatment OptionsOperative ManagementCore $ecompression
Inner layer o( #one remove$
4one gra(tTransplant o( healthy #one to assist in #one gro8th
Osteotomy
Removes #one a#ove or #elo8 the ;oint to help shi(t 8eight o(( $amage$
#one
*oint replacement
se$ 8hen #one has collapse$se$ 8hen other treatments not 8or%ing
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Snapping Hip
' Clinical Mani(estation' "ateral hip pain associate$ 8ith an au$i#le 3clic%5
' -reuently seen in young9 (emale athletes
' Pain an$ clic% notice$ 8ith repetitive hip (le.ion9 e.tension9 an$
a#$uction' "ateral snapping may #e repro$uce$ an$ (elt 8ith (le.ion an$
e.tension o( a((ecte$ hip
' !nterior snapping may improve 8ith $irect pressure over the
iliopsoas ten$on at the level o( the (emoral hea$
' Pain or snapping 8ith internal or e.ternal rotation o( the a((ecte$hip may suggest an intra
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Snapping Hip
' :iagnosis4ase$ on physical e.am
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Snapping Hip
' Treatment OptionsNonoperative ManagementMay a$minister steroi$ inections to the greater trochanter #ursa or
intra
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Strain o( Hip
' Clinical Mani(estation
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Strain o( Hip
' Treatment OptionsNonoperative Management
Operative Management
' -ollo8 p
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Strain o( Thigh
' Clinical Mani(estation' !ntalgic gait
' Pain repro$uce$ 8ith active ROM o( the a((ecte$ muscle
' Ecchymosis evi$ent
' S8elling9 palpa#le mass9 or gap inmuscle note$
' Ten$erness to palpation note$ at
point o( in;ury
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Strain o( Thigh
' :iagnosisMainly #ase$ on history an$ clinical presentation
MRI can #e use$ to assess (or (lui$ collection or severity o( tear
' Initial ManagementConservative treatment(irst 1 $aysIce
Rest
Compression +thigh 8rapsleeve,
Elevation
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Strain o( Thigh
' Treatment OptionsOperative ManagementRarely nee$e$
' -ollo8 p' 6 8ee%s #egin active ROM
' 8ee%s increasing sport
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-emoral Nec% Stress -racture
' Clinical Mani(estation' sually seen in young athletes +speci(ically runners,9 or ol$er
patients 8ith meta#olic #one $isor$er
' "ocaliFe$ hip painprimary complaint
' Pain 8orsens 8ith activity an$ improves 8ith rest' Pain typically in the groin an$ possi#ly ra$iating into the thigh an$
%nee
' Possi#le report o( a ne8 activity or an increase in the intensity o(
an activity
' Night pain common' No a#normality on visual inspection
' No palpa#le ten$erness
' Possi#le pain 8ith ROM o( the hip
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-emoral Nec% Stress -racture
' :iagnosisMRI or #one scan nee$e$ to reveal
(racture +t al8ays sho8 it,
' Initial ManagementNon
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-emoral Nec% Stress -racture
' Treatment OptionsOperative ManagementOnly nee$e$ i( (racture progresses
' -ollo8 p' Every ) 8ee%s (or repeat imaging
stu$ies to ensure no change in
(racture pattern or symptoms9 an$ to
evaluate callus (ormation +sign o( healing,
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Transient Osteoporosis o( Hip
' Clinical Mani(estation
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Transient Osteoporosis o( Hip
' :iagnosis
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Transient Osteoporosis o( Hip
' Treatment OptionsNonoperative Management
Operative Management
' -ollo8 p
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Trochanteric 4ursitis
' Clinical Mani(estation' Commonly overuse in;ury
' Intermittent or constant lateral hip pain that
can ra$iate $o8n the lateral thigh +see picture,
' Pain 8hen lying on the a((ecte$ si$e' No o#vious s%in color changes or s8elling
' Ten$erness to palpation over the lateral or
posterior aspect o( the greater trochanter
' Pain 8ith e.treme hip a#$uction an$ e.ternal
rotation
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Trochanteric 4ursitis
' :iagnosis
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Trochanteric 4ursitis
' Treatment OptionsNonoperative ManagementPT re(erral may #e $one +8ill (ocus on
stretching o( the ilioti#ial #an$ an$ strengthening o( the muscles
surroun$ing the hip,
NS!I:s
Trochanteric #ursa corticosteroi$ in;ection
' -ollo8 p
' !s nee$e$ +have patient come #ac% i( no improvement seen (romtreatment,
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=NEE & "OAER "EGInspection
Palpation
ROM
Goniometer
Muscle Strength
Nervous System
Special Tests
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INSPECTIONP!"P!TION
"ocate #ony lan$mar%s
Palpate
' Me$ial an$ "ateral -emoral Con$yles
' Patella an$ Patellar Ten$on' Ti#ial Tu#erosity
' Me$ical an$ "ateral Ti#ial Plateau
' Suprapatellar Pouch
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!ssess Range o( Motion +Goniometer,
' Test -le.ion o( the %nee +/61
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!ssess Muscle Strength
Numeric &Descriptive Grade
Description
1 NORM!" Complete Range o( Motion !G!INST gravity 8ith (ull ornormal resistance
) GOO: Complete Range o( Motion !G!INST gravity 8ith someresistance
6 -!IR Complete Range o( Motion !G!INST gravity
0 POOR Complete Range o( Motion 8ith Gravity Eliminate$
/ TR!CE Muscle Contraction 4ut no or very limite$ ;oin motion
7 !4SENT No evi$ence o( muscle (unction
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Evaluate the Nervous System
' Patellar Re(le.' -in$ the patella ten$on +in(erior to patella, an$ tap #ris%ly 8ith
re(le. hammer
' Sensory !reas +:ermatomesSharp:ull"ight
Touch,' Test "6 +me$ial upper leg a#ove the %nee,
' Test ") +me$ial to mi$line o( the patella,
' Test "1 +lateral cal( #elo8 the %nee,
' Test S/ +lateral popliteal (ossa,
' Test S0 +me$ial popliteal (ossa,
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Per(orm an$ Interpret Special Tests
oPatellar Grin$ Test
o
Pivot Shi(t Test
oNo#le>s Test
oO#er>s Test
oAilson Test
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Per(orm an$ Interpret Special Tests
oPatellar Grin$ Test' Aith the patient supine an$ the leg e.ten$e$9
press $o8n on patella 8ith #oth thum#s line$ up
8ith the length o( the legD Then9 push the
patella into trochlear groove o( (emurD
' Pain is POSITIBE SIGN (or
patello(emoral ;oint $isor$erD
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Per(orm an$ Interpret Special Tests
oPivot Shi(t Test' Patient supine
' Grasp the lateral aspect o( the %nee9 8hile cupping the heel 8iththe other han$D
' Passively (le. the hip to 07
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Per(orm an$ Interpret Special Tests
oNo#le>s Test' Patient lies supine 8ith %nees (le.e$ at 7 $egrees accompanie$
8ith hip (le.ionD
' Pressure is applie$ to the lateral (emoral epicon$yles or /
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Per(orm an$ Interpret Special Tests
oO#er>s Test' Patient is in si$e lying position 8ith the
uninvolve$ leg (le.e$ at the hip an$ the
%nee (or sta#ilityD
' The e.aminer passively a#$ucts an$
e.ten$s the hip 8ith %nee (le.e$ at 7 $egreesD
' E.aminer uses pro.imal han$ to sta#iliFe hip to prevent pelvis (romanteriorly tiltingD
' The e.aminer slo8ly lo8ers the (emurD
' I( the hip remains a#$ucte$ an$ $oes not a$$uct past anatomicalneutral this is a positive sign (or contracture o( the ilioti#ial #an$ ortensor (asciae lataeD
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Per(orm an$ Interpret Special Tests
oAilson Test' The patient is sitting upright on a ta#le 8ith legs $angling over the
e$ge at 7 $egreesD
' Grasp patient>s (oot an$ internally rotate ti#iaD
' Instruct patient to slo8ly e.ten$ leg until pain is (eltD' Test is positive (or Osteochon$ritis :issecans o( the %nee 8hen
patient reports pain at a#out 67 $egrees (rom (ull e.tension an$ #y$isappearance o( pain 8hen ti#ia
is e.ternally rotate$ #ac% to
normal positionD
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=NEE PRO4"EMS &
=NEE :ISE!SE/D !nterior Cruciate "igament tear +!C",
0D Me$ial Collateral "igament In;ury
6D Meniscal Tear
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!nterior Cruciate "igament tear +!C",
Clinical Mani(estations
' Imme$iate e((usion is note$
' 3Pop5 soun$ is hear$ at time o( in;ury
' Per(orm patellar #allottement< assess (or e((usion
' :ecrease$ ROM may result (rom e((usion or ;oint line
ten$erness secon$ary to meniscus tear
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!nterior Cruciate "igament tear +!C",
:iagnosis +Special Tests,
' "achman9 anterior $ra8er9 an$ pivot shi(t tests
' Posterior $ra8er test (or PC" in;ury
' McMurray Test +Meniscus Tear,
' :ial Test evaluate posterolateral corner in;ury +P"C,
' Balgus & Barus stress test evaluate MC" an$ "C"
' Patella apprehension test patella $islocation
:iagnosis +Imaging,'
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!nterior Cruciate "igament tear +!C",
Initial Management
' Patient E$ucationRevie8 T options inclu$ing ris%s an$ #ene(its
!utogra(t < pre(erra#le (or surgical reconstruction
Hamstring Ten$ons4one Patella Ten$on 4one +4PT4, gra(t
' Initial Treatment Rest9 ice9 compression9 elevation
!spiration may #e per(orme$ to $ecrease e((usion
Maintain ROM< $o not place ptD in a %nee immo#iliFer
Treatment Options
Nonoperative
Operative
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!nterior Cruciate "igament tear +!C",
' -ollo8
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!rthritis o( the =nee
' Clinical Mani(estationso *oint s8elling9 sti((ness9 perio$ic (lares9 night pain & pain at rest
8ith severe O!9 catching an$ loc%ing o( %nees9 common in ol$er
patients
o O#servations Gait an$ use o( assistive $evice9 ua$riceps atrophy9
e((usion
o Palpation E((usion9 crepitus9 ten$erness
o ROM o(ten $ecrease$J may lac% (ull e.tension
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!rthritis o( the =nee
' :iagnosiso Ra$iographs
o Common ra$iographic changes seen in O! inclu$e $ecrease$ ;oint
space9 osteophyte (ormation9 su#chon$ral sclerosis9 cyst (ormation9
(lattening o( the (emoral con$yles
oMRI
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!rthritis o( the =nee
' Initial Management
Nonoperative Managemento!ctivity Mo$i(ication
o Ice or Heat
o!cetaminophen or NS!I:s
o Orthotics 3unloa$er5 or 3support5 #races
o
Corticosteroi$ In;ectionso Glucosamine & Chon$roitin sul(ate
o E.ercise
Operative Management
o!rthroscopic :e#ri$ement
o High Ti#ial Osteotomy
o nicon$ylar Replacement
o Total =nee Replacement
-ollo8
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4ursitis
' Clinical Mani(estation' Prepatellar #ursitis
' !nterior %nee pain an$ s8elling
' :i((iculty %neeling
' 4allota#le collection o( (lui$ over the patella 8ith or 8ithout erythema
an$ 8armth
' Ten$erness over the #ursal sac
' Chronic #ursitis is characteriFe$ #y palpa#le su#cutaneous co##lestone