Hip

Post syndromes related to the hip joint here.

=__Hip Labral Tear__= A tearing injury to the soft elastic tissue (labrum) that follows the outside rim of the acetabulum. The labrum is a ring of fibrocartilage and dense connective tissue. It serves to deepen the acetabulum, increase surface area, enhance hip stability, and aid in dispersing load. - Hip or groin pain - Clicking, locking, catching, instability - Slight loss of ROM, typically rotation - Positive impingement sign - Gait abnormalities - Pain with provocative maneuvers A hip labral tear can be difficult to diagnose and patients will typically have a long duration of symptoms before being diagnosed, often up to two years. Signs and symptoms are non-specific and clinical assessment may not allow for a confident diagnosis. MRI is often used in assessing a labral tear. Arthroscopy is the gold standard for a definitive diagnosis. - Trauma - Dysplasia - Degeneration - Capsular laxity - Impingement - MVA - Falling with or without dislocation - Sports with frequent external rotation such as soccer, golf, hockey - Running and sprinting - Torsional or twisting movements - Hyperabduction - Hyperextension with or without external rotation
 * Definition**
 * Signs and Symptoms**
 * Mechanism of Injury**

Radial flap tear – most common, disruption of the free margin of the labrum Radial fibrillation – fraying of the free margin, associated with degenerative joint disease Abnormally mobile – result from a detached labrum Longitudinal peripheral – least common Limited weight bearing and NSAIDS “Physical Therapy should focus on reducing anteriorly directed forces on the hip by addressing the patterns of recruitment of muscles that control hip motion, by correcting movement patterns during exercise such as hip extension and during gait, and by instruction in the avoidance of pivoting motions in which the acetabulum rotates on the femur, particularly under load.” - Lewis - Standing alignment - Femoral motions accompanying knee extension in sitting - Precision of both active hip flexion and passive hip flexion - In prone, pattern of hip extension as an indication of the relative participation of the hamstring and gluteus maximus - Strength of hip abductors, gluteus maximus, iliopsoas, and deep external rotators of the femur - Muscle length and stiffness of the hamstrings - Gait assessment – knee hyperextension causes hip hyperextension - Train not to rotate the acetabulum on the femur - Sitting positions to avoid: knees lower than hips, legs crossed, on the edge of the seat contracting hip flexors, with pressure on the femur instead of the ischial tuberosity - Avoid Post Operative - Same guidelines - Avoid - No exercises should cause pain and functional activities should be corrected so they do not cause pain
 * 4 types of tears**
 * Treatment**
 * excessive hip hyperextension that may result from walking on a treadmill
 * weight training of quadriceps and hamstrings
 * exercises that cause hip hyperextension
 * active straight leg raises
 * sit ups
 * hip extension past neutral
 * References**
 * 1.** Haviv, B., J. O’Donnell. (2011). Arthroscopic treatment for acetabular labral tears of the hip without bony dysmorphism. //The American Journal of Sports Medicine//. Pg. 79s-84s.
 * 1) Rakhra, K. (2011). Magnetic resonance imaging of acetabular labral tears. //The Journal of bone and joint surgery. American volume.// Vol. 93 Suppl 2. Pg. 28-34.
 * 2) Smith, M., H. Panchal, R. Ruberte, Thiele et al. (2011). Effect of acetabular labrum tears on hip stability and labral strain in a joint compression model. //The American journal of sports medicine//. Vol. 39 Suppl. Pg. 103S-10S.
 * 3) Trapuzzano, T. (2006). Acetabular Labral Tears of the Hip: Examination and Diagnostic Challenges. //Journal of Orthopaedic and Sports Physical Therapy//.
 * 4) Lewis, Cara L. and Shirley A. Sahrmann. (2006). Acetabular Labral Tears. //Journal of the American Physical Therapy Asssociation//. Vol. 86. Pg. 110-121.

Stress fractures of the femoral neck occur when chronic, repetitive stresses act on the hip1. Two classifications:
 * Femoral Neck Stress Fracture **
 * __ Definition: __**
 * Fatigue fractures
 * Insufficiency fractures

Fatigue and insufficiency fractures are broken up into three additional categories4:
 * Compression – occurs on underside of femoral neck.
 * Tension – occurs on upper side of the neck.
 * Displaced – the femoral neck cracks all the way through causing the head and the rest of the femur to no longer line up correctly.


 * __ Mechanism of Injury __**
 * Fatigue Fractures (normal bone under abnormal stress)
 * Happen because of repetitive mechanical stress. Occurs in healthy young or middle aged individuals. This type of fracture is most common in military recruits, high-level athletes, and avid runners1,2.
 * Insufficiency fractures (abnormal bone under normal stress)
 * Most common in elderly people who have osteoporosis, osteomalacia, or other disease states. These conditions cause bone fatigue strength to decrease. Because of the decreased bone fatigue strength, any amount of repetitive stress can cause a stress fracture of the femoral neck1.


 * __ Signs and Symptoms __**
 * Deep aching pain in hip and groin – possibly radiating to the knee.
 * Present for several days, weeks, or months
 * Worsens after physical activity
 * Antalgic gait
 * ROM slightly decreased
 * Pain at end range with PROM, especially with internal and external rotation3

Initially, stretching must be done once the fracture is healed in order to increase ROM. Exercises then must be done to strengthen several muscles to ensure proper hip stability following a femoral neck stress fracture2:
 * __ Therapeutic Exercise __**
 * Gluteus medius – clams, bridges, lunges
 * Gluteus maximus – quadruped bent knee hip extension, lunges, step ups
 * Iliopsoas – Seated hip flexion with ankle weights
 * Adductor magnus, longus and brevis – Medicine ball squats, hip adduction with cable column, side-lying hip adduction
 * Quadriceps – Straight leg raise, short arc quad, step downs
 * Hamstrings – Resisted knee flexion, stiff-legged dead lift

Patients need to be educated on how their injury occurred and what can be done to prevent re-injury. For younger patients whose fracture occurred due to sports injuries, physical therapists need to educate them on the progression used to return to sport. In general, patients need to progress from short to long distances. If pain occurs when returning to sport, two days of rest is suggested2.
 * __ Patient Education __**

Patients who do not require surgery can use the assistance of a walker or crutches until they no longer have pain4. If surgery is required to fix the fracture, the use of assistive devices will be left to the discretion of the surgeon. Some will allow touch down weight bearing, while others will require a period of non-weight bearing2.
 * __ Assistance Equipment __**


 * __ Manual Therapy __**
 * Posterior Glide
 * Facilitates hip flexion and internal rotation5.
 * Anterior Glide
 * Facilitates hip extension and external rotation5.

Glides would be indicated only after fracture is completely healed and only minimal pain remains2.

Patients are given home exercise programs that include stretches and exercises that can be done in their home. These are done to help supplement and maintain the treatments that are done during physical therapy sessions.
 * __ Home Instruction __**

For pain control, adequate rest in the acute stage is essential. Modalities are used only in the acute phase. Cryotherapy such as ice packs and commercial cold packs are used to control swelling and help with pain. NSAIDs can also be taken by the patient as needed to control the pain and inflammation2. 1. Egol, K. A., Koval, K. J., Kummer, F., Frankel, V. H. (1998). Stress fractures of the femoral neck. //Clinical Orthopaedics and Related Research. 348,// 72-78. 2. Medscape Reference (2011). Orthopaedic: Examination, Evaluation, & Intervention. New York, NY: McGraw-Hill. 3. Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill. 4. Orthogate (2006). Stress Fracture of the Hip. Retrived from [] 5. Loudon, J., Swift, M., Bell, S. (2008). The Clinical Orthopedic Assessment Guide.
 * __ Pain Control/Modalities __**
 * References **


 * Trochanteric Bursitis **
 * Definition ** : Troachanteric Bursitis can be defined as inflammation in the bursae, small fluid fill sacs that provide cushion for the gluteus tendons, Iliotibial band and tensor fascia latae. Recent MRI studies have shown that it may not be the bursae that are implicated but rather deep to the bursae in the area of perceived pain there was abnormal signaling of the gluetus medius and gluteus minimus or a muscle- tendon junction tear rather than a bursal lesion. Also, a study in 2001 by Bierma-Zeinstra et al. showed that edema around the gluteus tendons could also be the cause. Thus, the syndrome is more accurately defined now as Greather Trochanteric Pain Syndrome (GTPS) since the bursae aren't always implicated or the cause of the pain.

GTPS definition: chonic pain syndrome with chronic pain overlying the lateral aspect of the hip at or around the Greater Trochanter. It mimics pain generated from other sources, including, but not limited to myofascial pain, DJD, and spinal pathology. **MOI:** Risk Factors: age, female gender, ipsilateral ITB pain, knee OA, obesity, LBP

GTPS is a chronic intermittent or continuous pain syndrome that is thought to be due to overuse, chronic microtrauma, regional muscle dysfunction, inflammation and tears of glut med or min muscles or tendinous insertions, acute injury such as a fall, bone spurs, or calcium deposits. However, many of these predisposing factors have not been proven, and leg length discrepancy has recently been disconfirmed.


 * Signs/symptoms: ** A patient that has GTPS will most commonly report pain in the lateral hip, with or without buttock pain, around the greater trochanter that may radiate down the thigh or even past the knee in some patients. This pain is exacerbated by physical activity (walking, running, climbing stairs), when lying on their side, prolonged standing or moving to a standing position, sitting with the affected leg crossed, climbing stairs, or running or other high impact sports. The patient will have point tenderness in the posterolateral area of the greater trochanter upon palpation.

Physical examination will be key in differentiating between GTPS and many other idiopathies that cause hip pain and/or what is causing the pain
 * A study by Lequesne et al. demonstrated that single leg stance and re sisted external rotation have good specificity and sensitivity in diagnosing tendinous lesions and bursitis.
 * Pain with resisted abduction and internal rotation are also __helping__ in diagnosing GTPS, whereas pain with resisted flexion and extension of the hip is usually an indication of intraarticular disease.
 * ITB syndrome can also cause lateral hip pain so this is ruled out by a positive Ober's test.
 * Another regional pain syndrome called meralgia paresthetica can cause lateral hip pain but this can be differentiated from GTPS because the patient will have sensory deficits.
 * To diagnois tendon teat: Trendelenburg's test can be used with a positive test indicating a tendon tear.

• Femoral neck stressfracture: The hop test on one leg will cause pain in the ipsilateral groin region in case of a femoral neck stressfracture. • Lumbar spine disease and ipsilateral hip pain : Differentiated with the [|FABER_Test]


 * Therapeutic Exercises ** - depends on the cause of hip pain
 * correction of __training__ errors or biomechanics
 * progressive slow repetitive exercise: piriformis stretch, iliotibial band (ITB) stretch standing, straight leg raise, wall squat with ball, gluteal strengthening, etc.
 * stretching: Tensor fasciae latae and the Iliotibial band because these aspects are often shortened and causes an increased friction with the bursa

- One study found that they are better in short term pain relief at 1 month as compared to conservative treatment but no difference seen in the long term (1 year out) - study found decreased pain at rest and during activity at 3 month follow up, but at 1 year follow up no difference seen between the group with injections and group with "normal" intervention - study showed home exercise and radio shockwave therapy were more beneficial in the long term (years) than corticosteroid injections (injections only superior intervention at 1 month follow up) - some studies still find that injections are the superior treatment, but can be more effective when used with imaging -It will be important to have this conversation with the patient so that they understand that corticosteroids are mostly for temporary relief and that they aren't proven to be more beneficial in pain relief than conservative/traditional treatment (rest, ice, NSAIDS, physical therapy)
 * Home Instruction ** -
 * rest and activity modification
 * NSAIDS
 * ice
 * some patients report difficulty sleeping since lying on side can exacerbate symptoms: instruct/help them find a new sleeping position.
 * Pain control/modalities **
 * radial shockwave therapy- specifically if the underlying condition is gluteal tendinopathy since SWT is beneficial in tendinopathies
 * US
 * moist heat
 * massage
 * Patient __Education__ **
 * anatomy review: what/where bursae are/what is causing the pain
 * Corticosteroids: There is ongoing research about corticosteroids injections used as __treatment__.
 * Surgery (If all other treatments have failed): bursectomy, iliotibial band release, osteotomy, gluteal tendon repairs
 * Assistive Equipment ** -
 * nothing in the research
 * assistive devices for safer/efficient ambulation (cane, walker, etc.)
 * Manual Therapy ** -
 * nothing in the research
 * distraction of hip-Grade 1 or 2 for pain relief

__ References __ Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill. Prentice, W. E., Quillen, W. S., & Underwood, F. (2011). Therapeutic modalities in rehabilitation. New York, NY: McGraw-Hill. [|__Rompe__], Segal, [|__Cacchio__]  , Furia, Morral, Maffulli (2009).Home Training, Local Corticosteroid Injection, or Radial Shock Wave Therapy for Greater Trochanter Pain Syndrome. American Journal of Sports Med //icine.// 37 (10) 1981-1990. Williams, B.S Cohen, S.P. (2009). Greater Trochanteric Pain Syndrome: A Review of Anatomy, Diagnosis and Treatment. //Anasthesia and Analgesia//. 108 (5) 1662-1670. Brinks, M. van Rijn, Willemsen, Bohnen, Verhaar, Koes, Bierma-Zeinstra. (2011) Corticosteroid Injections for Greater Trochanteric Pain Syndrome: A Randomized Controlled Trial in Primary Care. //Annals of Family Medicine.// 9 (3) : 226–234. Denman, M. (2011). ACP Journal Club. Corticosteroid injections improved short-term but not long-term recovery and pain in the greater trochanteric pain syndrome. //Annals of Internal Medicine//. 155(8):JC4-9. [|__Del Buono__], [|__Papalia__] , [|__Khanduja__] , [|__Denaro__] , [|__Maffulli__]. (2011). Management of the greater trochanteric pain syndrome: a systematic review. British Medical Bulletin. [|__Lustenberger DP__], [|__Ng VY__] , [|__Best TM__] , [|__Ellis TJ__]. (2011). Efficacy of treatment of trochanteric bursitis: a systematic review. // [|__Clinical Journal of Sports Medicine.__] // 21(5):447-53. Furia, Rompe, Muffalli. (2009). Low-Energy Extracorporeal Shock Wave Therapy as a Treatment for Greater Trochanteric Pain Syndrome. //American Journal of Sports Medicine//. 37(9) 1806-1813. Trochanteric Bursitis. Retrieved from: Physio-pedia.org.

__Hamstring Strain __ The hamstrings are composed of the biceps femoris, semimembranosus, and semitendinosus. A hamstring strain occurs when there is an excessive stretching or tearing of the muscle or tendon. The site of the strain can occur at any point along the muscle or occur at the attachment site of the muscle.
 * Definition: **

A hamstring strain can be classified as a 1st, 2nd, or 3rd, degree strain depending on the severity. A first degree strain occurs when there is excessive stretching or only a small part of the muscle/tendon is torn (less than 25%). A second degree strain occurs when there is moderate tearing of the muscle/tendon (25-75%). A third degree strain occurs when there is severe tearing of the muscle/tendon (75% or more) or there is a complete tear3.

•Patients often report hearing a “pop” or feel a tearing sensation when injury occurs •Sudden onset of posterior thigh pain that results from performing a specific activity •Pain at the site of the ischial tuberosity when sitting•Tenderness when passively stretching the hamstrings •Tenderness when palpating the origin, insertion, or belly of the muscle
 * Signs and Symptoms: **

•Person will have normal gait •Pain will occur at the extreme range with a straight leg raise •Antalgic gait or have an increase in knee flexion during ambulation •Resisted knee flexion and hip extension promotes a painful and weak response •Hard to ambulate and person will usually need crutches •Bruising, hemorrhage, and muscle defect may be visible1,5
 * //1st Degree //**
 * //<span style="font-family: "Arial","sans-serif";">2nd Degree //**
 * //<span style="font-family: "Arial","sans-serif";">3rd Degree //**

<span style="font-family: "Arial","sans-serif";">•//Anterior pelvic tilt// - increases tension in the hamstrings which causes the hamstring muscles to lengthen putting stress on the origin and insertion points <span style="font-family: "Arial","sans-serif";">•//Leg length disparity// - can cause the shorter leg to have overly tight hamstrings <span style="font-family: "Arial","sans-serif";">•//Prior hamstring injury// – original injury causes loss of extensibility and loss of eccentric strength so increases likelihood of another strain <span style="font-family: "Arial","sans-serif";">•//Lumbar degenerative joint disease// – causes restricted range of motion and a decrease in the extensibility of hamstrings <span style="font-family: "Arial","sans-serif";">•//Biomechanical deficiencies// – such as wearing incorrect footwear, etc. <span style="font-family: "Arial","sans-serif";">•//Poor posture// <span style="font-family: "Arial","sans-serif";">•//Muscle imbalance// – quads can be stronger than hamstrings so when hamstrings fatigue earlier than quads can put them at risk for strains <span style="font-family: "Arial","sans-serif";">•//Decreased flexibility// <span style="font-family: "Arial","sans-serif";">•//Hamstring strength// –lacking eccentric strength in hamstrings might be a cause of strains <span style="font-family: "Arial","sans-serif";">•//Running & kicking// – knee is extended and hip is flexed which lengthens the hamstrings which puts them at risk for strains <span style="font-family: "Arial","sans-serif";">•//Inadequate warm-up// – tight muscles are more likely to be strained <span style="font-family: "Arial","sans-serif";">•//Fatigue// – Muscles susceptible to injury when fatigued. With fatigue there is an earlier activation of biceps femoris and semitendinosus causes muscle asynchrony <span style="font-family: "Arial","sans-serif";">•//Poor coordination// – during end of swing phase or a heel strike the hamstrings are working eccentrically to decelerate the leg <span style="font-family: "Arial","sans-serif";">•//Anatomical arrangement//1,3,6
 * <span style="font-family: "Arial","sans-serif"; font-size: 19px;">Mechanism of Injury ****<span style="font-family: "Arial","sans-serif";">: **

//<span style="font-family: "Arial","sans-serif";">Phase 1 (acute) 1-7 days // <span style="font-family: "Arial","sans-serif";">Excessive stretching of the hamstrings should be avoided so dense scar formation can be avoided and muscle can regenerate. Within a protected range of motion neuromuscular control can be focused on. Early motion exercise is helpful to prevent adhesion within the connective tissue. Patient can perform active knee flexion and extension. All movements and exercises need to be pain free to prevent further injury or irritate the injury.
 * <span style="font-family: "Arial","sans-serif"; font-size: 19px;">Treatment: **
 * <span style="font-family: "Arial","sans-serif";">Therapeutic Exercise: **

//<span style="font-family: "Arial","sans-serif";">Phase 2 (subacute) Day 3 to >3 weeks // <span style="font-family: "Arial","sans-serif";">The patient needs to work on muscle activity so muscle doesn’t atrophy and to help with healing. Once the patient has regained full range of motion, concentric exercises can begin. All motions and exercises need to be pain free.

//<span style="font-family: "Arial","sans-serif";">Phase 3 (remodeling) 1-6 weeks // <span style="font-family: "Arial","sans-serif";">The patient can begin stretching the hamstrings, and also eccentric strengthening can begin <span style="font-family: "Arial","sans-serif";">. //<span style="font-family: "Arial","sans-serif";">Phase 4 (functional) // <span style="font-family: "Arial","sans-serif";">The goal is to return to activity, so patient will need to further be increasing strength and flexibility in the hamstrings. Also, a progression from low-intensity jogging to sprinting can begin as long as it is pain free.

//<span style="font-family: "Arial","sans-serif";">Phase 5 (return to competition) // <span style="font-family: "Arial","sans-serif";">The patient needs to maintain stretching and strengthening exercises to help prevent reinjury of the hamstrings.1,3,4

<span style="font-family: "Arial","sans-serif";">The patient will need to be educated about their injury and informed about the anatomy concerning their injury. If the mechanism of injury is known the physical therapist can educate the patient on how to correct what caused the injury or how to avoid future injury. If the patient’s injury is severe enough the physical therapist will want to go over how to use crutches and their weight bearing status on their affected leg. The patient will also need to be educated about their home exercise program. Also, during the initial days after injury the patient will need to be educated about RICE (rest, ice, compression, elevation).
 * <span style="font-family: "Arial","sans-serif";">Education: **

<span style="font-family: "Arial","sans-serif";">During the acute phase crutches may be needed if injury is severe enough. The patient will need to be instructed to not hold the knee in flexion for long periods of time because it can cause tensile stress to be placed on the healing tissues3.
 * <span style="font-family: "Arial","sans-serif";">Assistive Equipment: **

<span style="font-family: "Arial","sans-serif";">Massage therapy can be performed to help decrease pain, stimulate circulation, facilitate healing, and increase flexibility2.
 * <span style="font-family: "Arial","sans-serif";">Manual Therapy: **

<span style="font-family: "Arial","sans-serif";">The patient should initially start by doing RICE. Then the patient will want to continue with stretching, working on flexibility, and strengthening as advised by the physical therapist. Based on the severity of the strain, the exercises will have to be progressed differently.
 * <span style="font-family: "Arial","sans-serif";">Home Exercise Program: **

<span style="font-family: "Arial","sans-serif";">Ibuprofen and NSAIDS can help with swelling and pain. Literature recommends only using up to 3 to 7 days after the injury occurs. //<span style="font-family: "Arial","sans-serif";">Initial acute (Injury-day 3) // <span style="font-family: "Arial","sans-serif";">•Cryotherapy, E-stim, Compression, Low power laser, Ultrasound, Rest
 * <span style="font-family: "Arial","sans-serif";">Modalities/Pain Control: **

<span style="font-family: "Arial","sans-serif";">//Inflammatory response (day 2-6)// <span style="font-family: "Arial","sans-serif";">•Cryotherapy, E-stim, Compression, Low power laser, Ultrasound

<span style="font-family: "Arial","sans-serif";">//Fibroblastic repair (day 4-10)// <span style="font-family: "Arial","sans-serif";">•Thermotherapy, E-stim, Compression, Low power laser, Ultrasound

<span style="font-family: "Arial","sans-serif";">//Maturation-Remodeling (day 7 to recovery)// <span style="font-family: "Arial","sans-serif";">•Ultrasound, E-stim, Low power laser, shortwave diathermy, microwave diathermy2,3,4

<span style="font-family: "Arial","sans-serif"; font-size: 16px;">References: <span style="font-family: "Arial","sans-serif"; font-size: 13px;">1 Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill. <span style="font-family: "Arial","sans-serif"; font-size: 13px;">2. Prentice, W. E., Quillen, W. S., & Underwood, F. (2011). Therapeutic modalities in rehabilitation. New York, NY:McGraw <span style="font-family: "Arial","sans-serif"; font-size: 13px;">3. "Hamstring Strain." Nicholas Institute Of Sports Medicine And Athletic Trauma, 8 Mar. 2007. Web. 2 Feb. 2012. <http://www.nismat.org/ptcor/ham>. <span style="font-family: "Arial","sans-serif"; font-size: 13px;">4 Worrell, Teddy W. "Factors Associated with Hamstring Injuries: an Approach to Treatment and Preventative Measures." //Sports Medicine// 17.5 (1994): 338-345. Web. 3 Jan. 2012. <span style="font-family: "Arial","sans-serif"; font-size: 13px;">5. Heiderscheit, Bryan C., Mark A. Sherry, Amy Silder, Elizabeth S. Chumanov, and Darryl G. Thelen. "Hamstring Strain Injuries: Recommendations for Diagnosis,." //Journal of Orthopaedic and Sports Physical Therapy// 40.2 (2012): 67-81. Web. 3 Feb. 2012. <span style="font-family: "Arial","sans-serif"; font-size: 13px;">6 O'Brien, Kathleen B. "Hamstring Strain." Children's Hospital Colorado, Mar. 2011. Web. 3 Feb. 2012. <http://www.childrenscolorado.org/wellness/info/teens/83136.aspx>.

=__SNAPPING HIP__=

__Definition__ Snapping hip, or coxa saltans, is a condition that causes a snapping sensation that is heard and/or felt in the hip during activities such as walking, running, getting up from a chair, etc. The actual “snapping” occurs when one structure in the hip passes over another structure. The most common definitions include two different types of snapping hip: 1- External- the iliotibial band passes over the greater trochanter of the femur 2- Internal- the iliopsoas tendon passes over the head of the femur

__Mechanism of Injury__ There are multiple suggested mechanisms of injury for snapping hip. First, it is thought to be associated with overuse. Snapping hip is often associated with ballet dancers, soccer players, or runners that are frequently using the associated muscles. Second, it is thought to develop secondary to an acute trauma. Patients will report that the snapping did not occur until after a certain trauma. In the case of external snapping hip, another possible cause is thickening of the posterior part of the iliotibial band.

__Signs/Symptoms__ - a snapping sound or sensation with hip movement - pain in the anterior hip, often described as “deep” in the hip (internal) - pain on the lateral portion of the hip (external)

Upon examination, there can be several possible signs of snapping hip: - tightness in the IT band (a positive Ober test) - leg length differences (the affected side is often longer) - weakness in hip abductors and external rotators - poor lumbopelvic stability - over pronation of the foot that leads to increased internal rotation of the femur

The snapping sensation can often be reproduced: - External snapping often occurs with passive hip flexion/extension or IR/ER - Internal snapping often occurs with extension of a flexed, abducted, and ER leg

__Treatment Strategies__

//Modalities/Pain management:// In the acute stages, pain and inflammation management would be the focus. Oral NSAIDs are often used for this purpose. Other treatment options would be cryotherapy or non-thermal ultrasound. Rest should also be used to help with pain. Once past the acute stage, vigorous ultrasound might be an option to increase tissue extensibility in combination with stretching.

//Manual Therapy:// The main form of manual therapy that would be used for snapping hip is massage. Myofascial release or active release technique are good options to work on tight muscles. It can also help remove any fibrosis buildup that has formed from repeated use and friction. This would be used on areas such as the IT band, the tensor fascia lata, the gluteus maximus, or the iliopsoas.

//Education:// The patient should be educated on what is causing the snapping by use of anatomical models or pictures. It should be stressed that the patient needs to rest and avoid activities that cause pain in the hip. The patient should also be educated on the plan of care, including the reasoning and importance of the modalities and exercises that will be used.

//Assistive Devices// In most cases, assistive devices will not be necessary. In the case of extreme pain, the patient may want to consider using crutches or a walker until the pain is under control.

//Therapeutic Exercise// Stretching and strengthening exercises will both be important in the management of snapping hip. While it is especially important to stretch the IT band for external snapping hip and the iliopsoas for internal snapping hip, it is also a good idea to stretch the muscle groups surrounding the hip joint. Strengthening exercises should also be done surrounding the hip. Examples might be prone hip extensions, straight leg raises, and side lying abduction. It is also important to address any lumbopelvic instability with core strengthening. Examples of this might be bridging or quadraped alternating arm and leg extensions.

//Home Exercise Program// Stretching and strengthening exercises that are done in therapy are also good to do at home. However, patient compliance must be taken into account. If the patient does not have time for a large set of exercises, it might be best to emphasize stretching of the IT band or iliopsoas (based on which is affected). Also, if there is a lot of fibrosis in the IT band, it could be beneficial to instruct the patient on self release with the use of a foam roll or similar object. If conservative treatment of snapping hip does not resolve the symptoms, several surgical techniques are available for consideration.

Byrd, T. J. W. (2005). Snapping Hip. //Operative Techniques in Sports Medicine.// 13(1):46-54. Garry, J. P. (2010). Snapping Hip Syndrome. Retrieved February 5, 2012 from [] Prentice, W. E., Quillen, W. S., & Underwood, F. (2011). Therapeutic modalities in rehabilitation. New York, NY: McGraw-Hill. Spina, A. A. (2007). External coxa saltans (snapping hip) treated with active release techniques: a case report. //The Journal of the Canadian Chiropractic Association.// 51(1):23-29.
 * Resources:**

=__**Osteoarthritis of the Hip**__= Osteoarthritis also known as degenerative joint disease or age-related arthritis About 1 in 4 Americans can expect to develop osteoarthritis of the hip during their lifetime. Currently, about 10 million Americans report having been diagnosed with osteoarthritis.

[]

__**Definition**__
Osteoarthritis occurs when a joint experiences inflammation and injury or wear-and-tear, which causes breakdown or deterioration of cartilage tissue. Pain, swelling, and deformity result from the breakdown of cartilage tissue. Cartilage is a firm, rubbery material primarily made up of water and proteins that covers the ends of bones in normal joints. Cartilage helps to reduce friction in the joints and serve as a "shock absorber." Normal cartilage has a shock-absorbing quality because of its ability to change shape when compressed. The water content in cartilage allows it to undergo this change. When damaged, cartilage may undergo some repair, however, the body does not grow new cartilage after it is injured. Osteoarthritis usually occurs slowly over many years. Two main types of osteoarthritis: Primary: more generalized osteoarthritis, affects the fingers, thumbs, spine, hips, and knees Secondary: osteoarthritis that occurs after injury or inflammation in a joint

__**Mechanism of Injury**__
Causes of hip osteoarthritis are not entirely known. There are several reasons that hip osteoarthritis can develop. Contributing factors to hip osteoarthritis may include being overweight, increasing age, joint injury (previous hip injury/hip fracture), improper formation of the joints, genetic (inherited) defects in the cartilage, congenital and developmental hip disease, subchondral bone that is too soft or too hard, avascular necrosis, and/or activities that involve putting extra stress on the hip.

__**Signs / Symptoms**__
Patients with hip osteoarthritis, may experience discomfort and localized pain, swelling, or tenderness to the groin area, buttock, and the front or side of the thigh (many times when you first wake up). Morning stiffness, stiffness after sitting for a long period of time, limited hip range of motion, a "crunching" sound or feeling of bone rubbing against bone, and pain during motion may also accompany hip osteoarthritis. Pain typically flares up when active and gets better when at rest. Pain of the hip joint might come and go or worsen to the point where pain is constantly present. If hip osteoarthritis is left undiagnosed and untreated, the condition will continue to get worse until resting no longer relieves the pain. The hip joint may become stiff and inflamed and bone spurs can develop around the edges of the joint. Once the cartilage protecting the joint has worn away completely, the bones rub directly against eachother, creating bone on bone contact. This bone on bone contact can make it very difficult to move the hip joint. Loss in the ability to rotate, flex, or extend the hip may occur. To avoid pain, many patients with hip osteoarthritis become less active, which in turn causes the muscles controlling that joint to become weak. This may lead to a limp when walking.

**__Diagnosis__**
Osteoarthritis is not diagnosed performing a single test. Medical history, a physical examination, and hip function (including hip rotation, flexion, and extension to check for pain) will help determine if a patient has hip osteoarthritis. X-rays (to check hip joint space, see if any bone spurs have developed, or other abnormalities), MRIs, and even blood tests may be ordered by a doctor to rule in or rule out hip osteoarthritis. American College of Rheumatology classification criteria for hip osteoarthritis: hip pain must be present and at least 2 of the following 3 criteria: -erythrocyte sedimentation rate < 20 mm/hr -femoral or acetabular osteophytes seen on x-ray -joint space narrowing seen on x-ray

**__Treatment__**
The effects of hip osteoarthritis unfortunately cannot be reversed, however, pain, disability, and fast progression of the disease can help be avoided by many early nonsurgical treatments.

Pain Control / Modalities
Rest, avoid overuse of the hip joint. Pain relievers. Hot and/or cold therapies. TENS may be associated with some modest, short-term pain relief. Laser therapy may be associated with some pain relief. Topical capsaicin may help relief pain. No consistent evidence for diathermy or acupuncture interventions.

Manual Therapy
PROM stretching of the hip. Hip joint distractions. []

Assistive Device
The use of a cane, crutches, or walker can reduce stress on the joints and ease pain.

Education
Inform and educate patient with hip osteoarthritis to rest, get regular and routine sleep, manage a healthy weight or lose weight if necessary, take NSAIDS under the prescription of a doctor to relieve pain, and exercise.

Exercise
Perform exercises to increase flexibility and muscle strength.

Home Exercise Program
Perform exercises to increase flexibility and muscle strength.

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Surgical Treatment (can help if osteoarthritis condition is already severe)
Last resort treatment option, if all other more conservative treatment options have failed.

Surgical procedures: arthroscopy: articular cartilage condition is checked osteotomy: hip joint angle is realigned total hip replacement: new implanted femoral and acetabular components, two-piece ball and socket replacement

Hip replacement surgery can help to relieve pain and improve hip motion and the ability to walk. Post-surgery, assistive devices like crutches or a walker may need to be used for awhile. To restore the flexibility and muscle function of the hip, rehabilitation after surgery will be very important.

American Academy of Orthopaedic Surgeons. "Osteoarthritis of the Hip." Reviewed July 2007. Retrieved February 3, 2012. <[]>. Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill. Eustice, Carol. "Osteoarthritis." Updated September, 03, 2008. Retrieved February 3, 2012. <[]>. Loudon, J., Swift, M., Bell, S. (2008). The Clinical Orthopedic Assessment Guide. Prentice, W. E., Quillen, W. S., & Underwood, F. (2011). Therapeutic modalities in rehabilitation. New York, NY:McGraw. =Zelman, David. "Hip Osteoarthritis (Degenerative Arthritis of the Hip)." Reviewed February 28, 2011. Retrieved February 3, 2012. <[]>.=
 * References**