Hip and knee pathologies
Hip conditions
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Avascular necrosis
- Etiologies that result in impaired or loss of blood supply to the femoral head
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Symptoms
- Loss of range of motion in hip flexion, internal rotation, and abduction
- Pain in the groin and/or thigh
- Tenderness with palpation at the hip joint
- Antalgic gait
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Diagnosis
- Clinical presentation
- X-ray
- Bone scans
- CT or MRI imaging
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Medical management
- Surgical intervention for revascularization
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Physical therapy management
- Joint protection
- Functional mobility training
- Improve joint mechanics and mobility
- Improve strength/coordination
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Trochanteric bursitis
- Inflammation of the deep trochanteric bursa due to direct injury, irritation by the iliotibial band, or repetitive microtrauma
- Can be associated with rheumatoid arthritis
- Inflammation of the deep trochanteric bursa due to direct injury, irritation by the iliotibial band, or repetitive microtrauma
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Symptoms
- Sharp or dull ache on the outside of the hip
- Pain that radiates down the upper thigh
- Pain that worsens with activities that involve the hip, such as walking, running, or climbing stairs
- Tenderness at the lateral hip
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Diagnosis
- Clinical presentation
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Medical management
- Management of rheumatoid arthritis as indicated
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Physical therapy management
- Determine the phase (acute vs subacute vs chronic) and make an appropriate selection of interventions based on the phase of healing
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Iliotibial band tightness
- Tight iliotibial band, abnormal gait pattern
- Can lead to trochanteric bursitis
- Can lead to increased lateral tracking of the patella
- Tight iliotibial band, abnormal gait pattern
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Symptoms
- Pain that worsens with activity, especially running, cycling, or going up and down stairs
- Severe pain with knee flexion
- Swelling on the outside of the knee
- Tenderness to the touch on the outside of the knee
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Diagnosis
- Clinical presentation
- Special tests- Ober’s and Noble’s tests
- Clinical presentation
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Medical management
- Treatment of trochanteric bursitis as appropriate
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Physical therapy management
- Stretching of the IT band
- Gait training- appropriate running shoes, orthotics may be prescribed
- Reduction of pain/inflammation
- Soft tissue and manual techniques
- Joint mobility and functional training
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Coxa vara and coxa valga
- Caused by a defect in the ossification (formation) of the femoral head; it can also be a result of avascular necrosis due to septic arthritis
- The position of the knee will be the direct opposite of the hip
- Coxa vara- angle of femoral neck <115 degrees, knee in valgus
- Coxa valga- angle of femoral neck >125 degrees, knee in varus
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Symptoms
- Coxa vara
- Leg length discrepancy
- Pain in the hip and/or leg
- Stiffness with abduction
- Prominent greater trochanter
- Limited hip mobility
- Coxa valga
- Increased anterior pelvic tilt
- Coxa vara
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Diagnosis
- Clinical presentation
- X-ray
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Medical management
- Surgery (corrective osteotomy) if the deformity is severe or progressive (e.g., Hilgenreiner-epiphyseal angle >60 degrees in developmental coxa vara)
- Assistive devices as indicated
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Physical therapy management
- Improve joint mobility and mechanics
- Use of orthotics for leg length discrepancy
- Use of muscle energy techniques to correct pelvic tilt
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Piriformis syndrome
- Tightness or spasm of the piriformis can result in compression of the sciatic nerve
- Tightness can be a result of repetitive movement of the piriformis or overuse
- Compression of the sciatic nerve can cause radiation of pain down the leg
- Tightness or spasm of the piriformis can result in compression of the sciatic nerve
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Symptoms
- Restriction in internal rotation
- Pain with palpation of the piriformis muscle
- Referred pain to the lower posterior leg
- Weakness of external rotation
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Diagnosis
- Clinical presentation
- Special test- piriformis test
- Rule out lumbar spine involvement
- Electrodiagnostics of the sciatic nerve
- Clinical presentation
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Physical therapy management
- Pain management and reduction of pain from the posterior leg to only the piriformis (centralization of pain)
- Muscle mobility and strengthening
- Muscle balance restoration
- Correction of biomechanical faults with orthoses
Knee conditions
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Ligament sprains
- Can involve one (single plane) or multiple (rotary instability) ligaments of the knee
- Anterior cruciate ligament
- Posterior cruciate ligament
- Medial collateral ligament
- Lateral collateral ligament
- Classification of sprains
- First degree: minimal instability of the knee joint; ligament stretched but not torn
- Second degree: minimal- moderate instability of the knee joint; ligament is partially torn
- Third degree: extreme instability; ligament is completely torn and ruptured
- Can involve one (single plane) or multiple (rotary instability) ligaments of the knee
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Symptoms
- First degree: minimal pain and swelling
- Second degree: moderate pain, swelling, tenderness to the joint, and joint laxity noted with certain movements
- Third degree: significant pain, swelling, and instability due to a complete tear
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Diagnosis
- Clinical presentation
- Special tests based on ligament injury
- Anterior cruciate ligament - Lachman, anterior drawer
- Posterior cruciate ligament- posterior drawer test
- Medial collateral ligament- valgus knee test
- Lateral collateral ligament - varus knee test
- MRI
- Special tests based on ligament injury
- Clinical presentation
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Medical management
- Surgery is indicated if functional instability is present, which can be for grade two or three sprains
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Physical therapy management
- If surgery is performed, interventions will be based on protocols post-surgery
- Reduction of pain and inflammation
- Functional training
- Joint mobility
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Meniscus injuries
- A combination of flexion, compression, and rotary forces on the knee, causing abnormal stress to the knee
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Symptoms
- Pain increases with twisting or weight-bearing activities
- A sensation of the knee giving way or locking up, especially when squatting, standing up, or turning
- A feeling that the knee is not stable or may give out
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Diagnosis
- Clinical presentation
- Special tests- McMurray, Apley, Thessaly
- MRI
- Clinical presentation
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Medical management
- Surgery may be indicated
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Physical therapy management
- Reduction of pain and inflammation
- Functional training
- Joint mobility
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Patellofemoral pain syndrome
- Dysfunction of the knee due to trauma, muscle imbalance/tightness, improper loading of joints
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Symptoms
- Pain in the front of the knee, around or behind the kneecap
- Pain when going up or down stairs
- Pain when squatting or kneeling
- Pain after prolonged sitting with bent knees
- A grinding or catching sensation in the knee
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Diagnosis
- Clinical presentation- description of pain when increased load to the patella, such as stair climbing or squatting
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Physical therapy management
- Reduction of pain and inflammation
- Taping, mobilization of the patella
- Functional training
- Biofeedback for vastus medialis
- Prescription of orthotics as appropriate
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Patellar tendinopathy
- Degeneration of the patellar tendon due to overload and/or jumping-related activities
- Can be related to patellofemoral pain syndrome
- Degeneration of the patellar tendon due to overload and/or jumping-related activities
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Symptoms
- Pain that’s worse with activity, such as running, jumping, or walking
- Pain that’s worse when going downhill or descending stairs
- Pain that’s worse with knee flexion or extension
- Pain that’s worse when sitting for long periods or going up or down stairs
- Tenderness on the front of the knee
- Tenderness behind the lower part of the kneecap
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Diagnosis
- Clinical presentation
- Abnormal patella position
- Patella alta- patella tracks superiorly
- Patella baja- patella tracks inferiorly
- X-ray
- Abnormal patella position
- Clinical presentation
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Medical management
- Realignment of the patella if subluxation has occurred
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Physical therapy management
- Improve lower extremity strength- specifically quadriceps and hamstrings
- Functional training
- Joint mobility
- Patella taping or bracing