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Hip Impingement Syndrome

 
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Hip Impingement Syndrome - April 8, 2005 7:11:00 PM   
srcase

 

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Is there such a thing as hip impingement, similar to shoulder impingement with tightness in the posterior capsule/rotator muscles, and anterior hip pain? Has anyone treated this and if so, what were the signs and symptoms, and what worked? Any thoughts?
Sarah
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Re: Hip Impingement Syndrome - April 8, 2005 7:48:00 PM   
jma

 

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I believe there is and there may be an association between it and the development of osteoarthritis in the hip. Forgot exactly where I read it from but an author named Ganz, et al was involved with the 2004 article.

JMA

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Re: Hip Impingement Syndrome - April 8, 2005 9:40:00 PM   
PTupdate.com


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Weird timing Sarah...I just recently abstracted an article on my site about this:

SURGICAL TREATMENT OF FEMOROACETABULAR IMPINGEMENT: EVALUATION OR THE EFFECT OF THE SIZE OF THE RESECTION. Journal of Bone and Joint Surgery, Vol. 87-A, No. 2, February 2005.

Also, you might find this article interesting:

THE WATERSHED LABRAL LESION: ITS RELATIONSHIP WITH EARLY ARTHRITIS OF THE HIP. The Journal of Arthroplasty, Vol. 16, No.8, Suppl. 1, December 2001.

Best,

John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]

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John M. Duffy, PT
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www.PTupdate.com

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Re: Hip Impingement Syndrome - April 8, 2005 11:26:00 PM   
jbeneciuk

 

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The anterior capsule can become impinged at times when the hip joint mobility is assessed if proper care is not taken in returning to the resting position...I was taught that an isometric contraction of the rectus femoris will prevent this from occuring...to be used as a treatment approach, I have never experienced this or had a chance to use it...just my 2 cents

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Re: Hip Impingement Syndrome - April 10, 2005 2:48:00 AM   
Alex Brenner PT MPT OCS

 

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How does the patient respond to hip joint mobilizations?

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Re: Hip Impingement Syndrome - April 10, 2005 11:40:00 AM   
srcase

 

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Alex,
It was a hypothetical question, and the "patient" in question is actually myself. I was seeing a physical therapist at work for right hip and low back pain, and passive flexion of the hip caused sharp pain in front at end range, similar to what jbeneciuk mentioned, but it did not resolve with contraction of the rectus femoris. The treating therapist also thought there was a positive scour test, but it reproduced the sharp pain in the front of the hip, so I felt it was still impingeing the labrum or rectus femoris tendon. The therapy was focused mainly on radicular pain (lumbar) and he did a lot of trigger point release in my hip (gluteus medius and piriformis) and stretching of the iliopsoas/rectus femoris (which was and is very tight). Unfortunately, my insurance ran out and the other PT went on vacation for 2 weeks, and the hip pain has worsened. That's why I am trying to figure out what is going on. I continue to be uncomfortable lying on the right hip and my latest symptom is large "pops" when I move the hip first thing in the morning. I wouldn't say it is "stiff" however. And the popping doesn't really hurt. Any suggestions?
Sarah

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Re: Hip Impingement Syndrome - April 10, 2005 8:27:00 PM   
PTupdate.com


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You might want to investigate both snapping hip syndrome, and also make sure you don't have an pelvic rotation

Duffy

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Re: Hip Impingement Syndrome - April 11, 2005 12:58:00 PM   
Shill

 

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Sarah,
When you say pain at end-range flexion, what do you mean? Are you cramming it down, as in knee to chest hip flexion? Or, are we talking premature end-range hip flexion. Put one finger on the top(anterior) of your ASIS as you do the hip flexion, and get an idea of the compressive forces between the femur and the ASIS as you do a single knee to chest in supine. For some patients, this is the reason for the "end-range pain", simply approximating the ASIS with the femur, and squishing the bejeezus out of the stuff in between. If the pain resolves with slight abduction and ER, yet still moving through full flexion, then there you have it.
How else does your hip pain behave?

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Re: Hip Impingement Syndrome - April 11, 2005 1:01:00 PM   
JLS_PT_OCS

 

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We do a lot of the hip labral repairs and debridements lately in this part of the military system.
We see so-so results.

I have just read a portion of Shirley Sahrmann's book on this, and it has totally changed my approach.
I had a lot of these folks who weren't getting anywhere with hip mobs, and / or the mobs were too painful to tolerate.
Her book really explains things in a different way and talks about using motor control and retraining to correct the problelm, diagnosed by movement impairment classification instead of what's anatomically wrong (such as a hip labral tear).

I think a lot of these labral tear people have the sort of muscle and movement imbalance she is talking about, and the surgery is a temporary fix only.

I have used her stuff on my own hip problem "labral tear" and it is getting better slowly and without the offered surgery.

I really can't explain it too well, because her book is kind of over my head at times, but it is really helping me look at things in a whole new way.

Highly recommended.
J

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Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

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Re: Hip Impingement Syndrome - April 11, 2005 8:54:00 PM   
PTupdate.com


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And Jason, this is a really good way to think. This has been my treatment approach for years. I don't get too hung up on what "tissue" is damanged. Instead, I look at a particular joint and everything that crosses/influences it. If tight, I stretch it, if weak, I strengthen it, if imbalance, I balance it, and if displaying abnormal mechanics, I restore them. 99% of the time, the problem goes away, without me really knowing what tissue was causing the "pain" or problem in the first place. Makes my life soooooooooo much easier.

John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]

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www.PTupdate.com

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Re: Hip Impingement Syndrome - April 11, 2005 9:55:00 PM   
srcase

 

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The hip pain began after changing jobs and communting 25 - 30 minutes in stop-and-go traffic. I had also started learning to use the pedal on the piano and had been practicing 30 minutes a day. I thought maybe it was rectus femoris tedonitis or iliopsoas bursitis. Palpation of the rectus femoris origin at the AIIS was very tender, severe pain with resisted hip flexion, and it hurt quite a bit to stretch it too. When my coworker was scouring the hip, he reproduced the sharp pain near end range flexion with internal rotation, it was better with external rotation, so yes I think the affected tissue was getting "squished" and was inflammed, thus it hurt.

We treated it with ultrasound and cross-friction massage and stretching, also strengthened the internal rotators which were weak. Interestingly, I was getting treated for a lumbar radic/sciatic problem at the same time, and the anerior hip pain was reproduced with a standing straight-leg raise test. I had mechanical traction, joint mobilizations and did core strengthening. Both problems got better with 2 months of PT, but I stopped PT about a month ago (continued exercises) and most of the symptoms have returned. I certainly think the hip and back are related. I also think there is a biomechanical link. I just can't figure out exactly what that is. And yes, John I have pelvic assymetries (right iliac crest is higher in standing) but have been through PT with a therapist who did muscle energy and it was never consistent (L on R one day, R on R the next, lumbar rotations, ilial rotations...never any consistent pattern). I feel like a fool that I can't figure out my own problem. I have had back pain/sciatic nerve problems for 4-5 years now, and have been looked at by countless PT's. The hip problem is recent (last 6 months) Lumbar x-rays (4 years ago) and EMG (2 months ago) were negative.

I think the Sahrmann approach makes the most sense in my case, instead of chasing the symptoms around and around, fix the underlying imbalances.

Sarah

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Re: Hip Impingement Syndrome - April 12, 2005 10:13:00 AM   
spfister

 

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HI,
What about trying a heel lift on the left? Is right leg possibly long?
I agree with the basics of everthing said before. I would focus on ROM, Strength, and normalizing movement and not worry about the anatomy of the problem so much. Have someone analyze your gait, my experience is that people with long standing problems such as yours usually have a gait compensation (decreased weight bearing, toeing out) that tends to perpetuate the problem. Other than that my
basic ideas Neutral spine stabilization exercises, hip strengthening and stretching, I would also add the pelvic floor muscles into the equation given what seemed to be the ever changing pelvic findings. Go to the basics and be patient.
Steve

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Re: Hip Impingement Syndrome - April 12, 2005 11:35:00 AM   
JLS_PT_OCS

 

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Sarah,
Buy Shirley Sahrmann's book.
You have an impairment called 'Femoral Anterior Glide with Medial Rotation'.
You will get better if you treat it her way, trust me. Your descriptions, including the differential dx, is EXACTLY what she is talking about.
Good luck.
ISBN# 0-8016-7205-8

Jason.

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Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

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Re: Hip Impingement Syndrome - April 12, 2005 12:28:00 PM   
SJBird55

 

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Ummm, can we diagnose over the internet or heck over the phone? LMAO Shh... better keep this a secret because exactly which practice act does one ever follow - the one where the patient exists or the one where the therapist exists? Maybe I should go into law? LOL

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Re: Hip Impingement Syndrome - April 12, 2005 3:36:00 PM   
JLS_PT_OCS

 

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What does LMAO mean?
The great part about describing impairments is that they can be found from a good history and exam (or report of an exam found in print).
My recommendation stands.
:)
J

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www.silvernailstudios.com
jasonsilvernail@gmail.com

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Re: Hip Impingement Syndrome - April 12, 2005 4:35:00 PM   
Synergy

 

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Jason,

LMAO = laughing my @ss off :)

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Re: Hip Impingement Syndrome - April 12, 2005 8:02:00 PM   
srcase

 

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Thanks for the replies Steve and Jason. My cowoker re-evaluated the hip again today, and noted tight adductors with internal rotation and extension, tight gluteals with full flexion, and tight iliopsoas and rectus. Also decreased posterior gliding. Pelvis and SI seem fine. Still have some weakness in gluteus medius and external rotators, but not as much. We are going to continue therapy on the hip, so I will try to be more patient. I agree with Jason's diagnosis, I have Sahrmann's book (read earlier posts) but haven't picked it up lately. I was thinking it was the femoral anterior glide with internal rotation, but I don't understand the book (tests and exercises for that particular impairment). I find her writing very convoluted sometimes. But I will pick it up again and try to figure it out. I think her brain must be way bigger than mine! Anyway, I know one can't diagnose over the internet, but I am a PT and Jason is a PT and I respect his opinion (as well as everyone else's) and I also applaud anyone confident enough to stick his/her neck out and voice an opinion (in any situation).
Sarah

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Re: Hip Impingement Syndrome - April 12, 2005 8:34:00 PM   
SJBird55

 

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I was just being facetious.

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Re: Hip Impingement Syndrome - April 13, 2005 12:30:00 AM   
nari

 

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Sarah

I stick my neck out all the time with neural approaches and Rx, and get it stomped on quite often - I don't mind! They work too well to worry about philistines!

I have to think along SJ's lines - we can't diagnose nonvisually with any accuracy, anyway, but here goes:

XR? To exclude changes in the HOF and acetabulum?
That would be the first thing from where I stand.
If that is all OK...then a look at function from an orthopaedic AND neural viewpoint.

Nari

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Re: Hip Impingement Syndrome - April 13, 2005 7:08:00 AM   
JLS_PT_OCS

 

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Yeah, SJ and I just like giving each other a hard time. It's all in fun. :) LMBO! (my butt off)

Sarah, also check your femoral torsion (I mean have someone else check it), as that can be a factor.
You want to do things that encourage the posterior glide, theoretically.

Exercise prescription sample:
1. Quadruped (always first and last)- rocking back toward your heels, focusing on hip flexion and not spinal flexion, stopping before pain comes. This is a self-mob into posterior glide.
2. Sidelying: Gluteus medius strength/retraining as needed
3. Prone: hip extension, focusing on Gluteal activation first. Activating the hams first to extend the hip may be encouraging the anterior glide. Start over pillow, and move the hip from about 20 deg flexion to neutral at first.
4. Sitting: passively flex the hip, this should not be painful at the groin, then try to hold the knee up. At this angle (and angles over 90) only the iliopsoas can hold the hip in flexion, so it cuts out the TFL and rectus fem. I would bet your iliopsoas is weak (mine is on my problem side) and you may be TFL dominant in hip flexion (god knows I am).
Functional: in standing, make sure you are not standing swaybacked (hips in front of line of gravity) and therefore standing in hip extension, eliminating postural use of gluteus. Anecdotally, that one correction has really helped anyone I have met with this problem, about 4 patient cases so far.

Use the case studies in her book as a guide for exercise prescription. I agree they are hard to follow, and I certainly don't claim to understand it yet, but I am digesting it in little chunks.

Let us know how it goes...
J

_____________________________

Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

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