Femoral neck stress fracture Femoral neck stress fractures comprise 2% to 7% of all stress fractures, and are commonly identified in runners (Lamonthe, 2018). Early diagnosis is difficult, as symptoms tend to be non-specific with insidious onset, and pain is generalized to the anterior thigh and groin. The patient may report difficulty performing sit to stand tasks, pain while running or ambulating, and pain in single limb stance. Objective findings include pain and spasms with palpation of soft tissue over femoral neck such as psoas and hip adductors. Additionally, findings may reveal a patient report of pain in the hip at end range in all directions during range of motion testing. Manual muscle testing often demonstrates weakness in hip flexors and adductors. If a femoral neck stress fracture is suspected, a referral back to a physician is warranted, where the physician may order MRI imaging to make a definitive diagnosis (Lamothe, 2018). Recommended treatment is partial weight bearing for up to 12 weeks, with significant activity modification. Specific return to sport rehabilitation may be prescribed to prepare athletes for safe return and prevent future injury. Female athletes presenting with a stress fracture may benefit from hormonal testing and CT scan to identify possible osteoporosis or presence of relative energy deficiency syndrome (RED-S). Nutritional counseling from a licensed professional may also be indicated for female athletes to promote health and prevent future injury (Statuta, 2017). Legg-Calve-Perthes disease Legg-Calve-Perthes disease (also referred to as Perthes disease) is a disorder of the hip presumed to consist of a disorder of the epiphyseal cartilage at the proximal femur. This results in poor blood supply, possible avascular necrosis, and disturbance of the physeal plates, which may manifest as a shortened femoral neck and trochanteric overgrowth, among other femoral head deformities. It is most commonly diagnosed in boys aged 4 to 10, and the first sign is generally a limp. Some patients with Perthes disease experience bone remodeling typical of natural development and, therefore, experience reduced symptoms without additional treatment. Those without natural bone remodeling and subsequent femoral neck and head deformity are known to experience degenerative joint disease in long-term retrospective studies. The most important prognostic factor in outcome is residual deformity of the femoral head and resulting hip joint incongruity (Dorman, 2016). Recommended physical therapy treatment for youth aged 3 to 12 with identified Perthes disease includes balance activity, gait training, lower extremity strengthening exercises, and range of Slipped capital femoral epiphysis (SCFE) is a disorder in which the capital femoral epiphysis is displaced through the physeal plate. It occurs more often in children and adolescents age 10 and older, and more commonly in males than females. Endocrine abnormalities, such as hypothyroidism and treatment with growth hormones, have a tendency to weaken the physis thereby increasing the frequency of SCFE (Dorman, 2016). This impairment is classified into three categories based upon patient presentation and radiographic findings: mild, moderate, and severe (Dorman, 2016). The slip may also be classified as stable or non-stable. Acute slips are those that are found within 2 weeks of symptom onset. The pain experienced from the acute slip is usually enough to prevent weight bearing, and if the patient can walk, it is generally with a limp. Patients with chronic- slipped capital femoral epiphysis often present with a history of knee or lower thigh pain first, with symptoms progressing to the groin or medial thigh pain over a span of months to years (Dorman, 2016). motion exercises (Karkenny, 2018). Slipped capital femoral epiphysis
full weightbearing when the patient has been cleared by the physician. Intertrochanteric hip fracture By definition, intertrochanteric fractures occur between the greater trochanter and lesser trochanter. Patients often undergo surgical repair consisting of open reduction internal fixation (ORIF; Kellam, 2020). Patients are often instructed by their orthopedist to weight bear as tolerated and may be prescribed use of an assistive device such as a front-wheel walker for initial ambulation. Physical therapy treatment following intertrochanteric fracture consists of aerobic reconditioning, lower-extremity strengthening, functional training, and stretching of the lower extremity (Heiberg, 2017). Subtrochanteric hip fracture A subtrochanteric fracture is a fracture occurring within 5 cm below the lesser trochanter and comprises 10% to 30% of all hip fractures (Lee, 2020). This fracture type is most commonly seen in two very different populations: geriatric osteoporotic patients sustaining low-energy falls directly onto the hip, and young athletes sustaining high-impact trauma (Lee, 2020). During the past few years, another population has been identified as at-risk for this type of fracture: patients taking bisphosphonate medications. A careful screen of patient medications may be helpful in identifying patients taking bisphosphonates who may be at risk for osteoporosis (Lee, 2020).
COMMON CHILDHOOD HIP DISORDERS AND TREATMENT
Developmental and congenital hip impairments require understanding signs and symptoms, as well as screening to catch them as early as possible. Screening is often performed by a pediatrician or primary care provider, however some physical therapists may be the first point of contact for evaluating the hip of a child. Developmental hip dysplasia and dislocation Developmental Hip Dysplasia (DDH) is a diagnostic term for a spectrum of hip diseases ranging from a hip which is poorly centered within the acetabulum, to a hip that is completely dislocated. DDH affects predominantly females (80%) and is usually detected at infancy (International Hip Dysplasia Institute, n.d.). The etiology of DDH is both genetic and developmental due to position in utero (for example, breech position) or positioning/carrying during infancy. Diagnosis is usually made by a pediatrician during the first few weeks of life (Dorman, 2016). It is commonly treated with a Pavlik harness, a bracing system that is worn for approximately three months. This bracing system provides a 95% chance of normal hip formation if used diligently. If this hip impairment goes undiagnosed, or the Pavlik harness is not worn appropriately, the femoral head and acetabulum may not develop properly and surgery may be required. Improper development of the acetabulum may result in the growth of a false acetabulum with subsequent dislocation of one or both hips, leading to degenerative disease later in life (Dorman, 2016). Treatment of patients presenting with developmental dislocation of the hip begins with reduction of the hip as early as possible in hopes of providing stimulus for resumption of normal hip joint growth and development. A further concern for missed opportunity at reduction is the development of avascular necrosis and degeneration of the joint surfaces (Dorman, 2016). Physical therapy treatment for non-infant patients with developmental hip dysplasia consists of gentle movement and stretching to promote lubrication of the joint surfaces. Hip abductor and external rotation strengthening exercises should be administered as well, with education about a home exercise program. Gait training and balance exercises should also be provided. Patients with limb length discrepancy will benefit from a heel lift or in-shoe orthotic to balance the pelvis and promote efficient ambulation (International Hip Dysplasia Institute, n.d.).
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