sleep on their backs with an abduction pillow in place to prevent passive adduction during sleep. A study by Slaven (2012) investigated whether predetermined variables could be used to identify patients who might have functional limitations at 6 months following THA. Demographics and baseline measures including age, sex, and preoperative LEFS score were assessed at 1 to 3 weeks prior to surgery, and an additional LEFS score was recorded at 6 weeks post- op. Walking speed and balance were assessed using the 10-meter walk test and TUG, and a functional reach test. Results demonstrated that body mass index (BMI) >34 kg/m2, female sex, and age above 68.5 years were found to be predictors to classify patients that did not reach successful outcome status. Similarly, another study by Nankaku et al. (2013) analyzed preoperative factors likely to estimate ambulatory status of patients undergoing THA at 6 months post-op. Findings of this sitting, with walking, or squatting. It is most commonly diagnosed in the middle-aged and geriatric population (OrthoInfo, n.d.a.) The bursa may be septic or aseptic, and the condition is thought to be secondary to overuse via friction of the gluteus maximus tendon at the iliotibial band insertion. Risk factors include pelvic asymmetry, repetitive running on a crowned road (the downhill side is most often affected), repetitive stair climbing or step aerobics, or weakness in the gluteus medius resulting in a Trendelenberg gait pattern. Gluteus medius tendinopathy Gluteus medius tendinopathy is an overuse injury of the gluteus medius tendon resulting in calcification in the tendon and is more commonly found in women. Compression of the gluteus medius tendon by the iliotibial band when the leg is adducted, particularly with external rotation of the hip, is a common mechanism of injury (Cook, 2012). This is associated with habitual positions such as leg crossing while seated, stair climbing by taking the stairs two at a time, and during ambulation when excessive relative adduction of the pelvis on femur occurs, as is commonly observed in the case of poor hip abductor strength lending to poor pelvic control in the single- limb stance phase of gait (Cook, 2012). Similar to greater trochanteric bursitis, it is necessary to rule out lumbar radiculopathy. Differential diagnosis for the implication of gluteus medius tendinosis includes pain with contraction of the gluteus medius muscle against resistance. The patient may report persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee, and occasionally below the knee and/or buttock (Williams, 2009).
study suggest that patients with a preoperative TUG score of <10 seconds are likely to walk without an assistive device at 6 months after THA. A study conducted in 2003 determined that treadmill training with partial body weight support (TT-BWS) following THA was more effective than conventional physical therapy alone for the purpose of restoring symmetrical independent walking after hip replacement surgery. The investigators conducted 10 days of treatment on patients randomized into either the conventional physical therapy group (control) or treadmill physical therapy group (experimental), and found that Harris Hip scores were 13.6 points higher in the treadmill group. Furthermore, hip extension was 6.8° greater, symmetry more significant, and hip abductor strength greater in the treadmill group as well, with results persisting at 12 months post-intervention (Hesse et al., 2003). This common diagnosis must be verified in the physical therapy clinic by examining the lumbar spine to rule out an L3 referral issue. Other differential diagnoses included tensor fascia latae strain, entrapment neuropathy, and femoral neck stress fracture. Thus, a proper evaluation including a neuromuscular screen and provocative hip tests is important. A recent systematic review on conservative management of trochanteric bursitis revealed a lack of high-quality research in this area (Barratt et al., 2017). While there is little evidence for the provision of exact physical therapy treatment protocols, it can be inferred that treatments to reduce pain including anti- inflammatory iontophoresis, as well as exercise to improve pelvic and hip strength, correction of gait deviations, and education in body mechanics to reduce continued strain are beneficial (Shbeeb & Matteson, 1996). Physical examination should include the following clinical tests (Grimaldi, 2015): ● FADER (Flexion Adduction with External Rotation) : To perform this test, have the patient positioned in supine on the treatment table. Place the patient into 90° hip flexion, and hip adduction coupled with external rotation, then ask the patient to actively resist external rotation. A report of pain provocation is considered positive. ● Modified Ober’s : To perform this test, have the patient positioned in side-lying position, with therapist behind the patient. The therapist will passively adduct the top hip and monitor for pain. Treatment should begin by strengthening of the gluteus medius eccentrically first, then concentrically. Exercises should be performed bilaterally to ensure muscle balance and to prevent subsequent injury to the contralateral side; core strengthening is recommended to promote pelvis and hip stability. radiograph film at the femoral neck. Pain during movement of the individual is often provoked with end ranges of hip flexion and adduction. When FAI is present, bony spurs develop around the femoral head or in the acetabulum and over time, this friction causes tearing and degeneration of the articular cartilage in the anterior aspect of the joint and can result in osteoarthritis (Powers, 2016). Patients with FAI will report pain or a dull ache in the groin or deep within the hip itself, popping, clicking, and a sense of the hip giving way (Thornborg, 2018). Pain is often aggravated with physical activity, including running, and may present with an audible click during flexion or extension of the hip (Loudon & Reiman, 2014). Examination should include an FAI-specific test. With the patient supine on a table, therapists should use a combined
Greater trochanteric bursitis (greater trochanter pain syndrome) Greater trochanteric bursitis is caused by friction or inflammation of the bursa lying lateral to the greater trochanter and medial to the iliotibial band (OrthoInfo, n.d.a.). Pain is reported to be sharp and located at the lateral aspect of the hip. The patient may report pain to be worse at night when lying on the painful side, or when attempting to rise from seated position after prolonged
Femoral acetabular impingement & acetabular labrum lesions The primary purpose of the acetabulum of the hip is to provide stability to the joint, and decrease forces transmitted to the articular cartilage. Stability of the joint is dependent on the depth of the acetabular recession and, thus, if the acetabulum is abnormally shallow, there will be increased stress on the labrum and joint capsule. Nerve endings within the capsule provide proprioceptive feedback; however, they can also be a source of pain if impinged upon (Martin et al., 2006).
Femoral acetabular impingement (FAI) is a disorder of the hip involving excessive friction between the femoral head and the acetabulum. The etiology differs by patient and continues to be studied (Van Klij, 2018). It is thought to occur as a result of abnormality in either the femur or acetabulum itself. Bony abnormality associated with FAI is commonly observed on
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