Greater thoracic pain syndrome
greater trochanteric bursitis (GTB)
● manual therapy/ mobilization techniques
● Common in arthritic conditions, with
fibromyalgia, and with leg length
discrepancies.
● Common in females than in males
(2-4:1 ratio), with a peak incidence
occurring between 40 and 60 years of
age.
● In athletes, may result from a fall onto a
hard surface (traumatic GTB) or friction
of the ITB over the greater trochanter
during repetitive flexion/ extension
motion of the hip, such as occurs in
running (similar to ITB friction
syndrome at the knee).
● With friction-related GTB often have
tightness of the hip abductors/ ITB or
gluteus maximus or weakness of the
ipsilateral hip abductors.
● Characterized by an aching pain over
the lateral aspect of the hip accompanied
by distinct tenderness on palpation
around the greater trochanter.
● Intervention include modalities such as
therapeutic ultrasound/ phonophoresis,
iontophoresis, and nonsteroidal
anti-inflammatory drugs (NSAIDs) to
alleviate the inflammatory response;
however, treatment also should include
and therapeutic exercises to address
potential causative factors.
● In cases when symptoms are persistent
despite the appropriate nonoperative
management, a corticosteroid injection
into the bursa has been shown to provide
good pain relief, as stated earlier.
Surgical treatment is reserved for
refractory cases. Although originally
performed as an open procedure, most
surgeons currently prefer to treat GTB
through endoscopy (i.e., hip
arthroscopy).
Gluteus medius/ minimus tear/ tendinosis
● Tendinosis and strains (tears) of the
gluteus medius and gluteus minimus
 were a common finding in an MRI study
of patients presenting with buttock,
lateral hip, or groin pain.34 Khan et
al.35 has reported that most cases of
tendinopathy are, in fact, tendinosis, not
tendinitis.
● (+) Trendelenburg Sign
● Eccentric strengthening has been shown
to be an effective method of treating
tendinosis, probably because eccentric
muscle action stimulates
mechanoreceptors, which encourage
tendon cells to produce collagen.
● Twelve musculotendinous structures
(i.e., gluteus medius, gluteus minimus,
TFL, ITB, gluteus maximus, the six
short lateral rotators, and the vastus
lateralis muscles) attach to or cross over
the greater trochanter, making this
region the “Grand Central Station” of
the hip.
● The use of soft tissue mobilization
techniques for muscles attaching to the
greater trochanter is extremely
beneficial for restoring optimal hip joint
mechanics.
● Surgical treatment is very similar to that
of treating greater trochanter bursitis in
that many surgeons prefer to use
endoscopic techniques. Using a lateral
entry point, the peritrochanteric
compartment of the hip can be debrided.
After inspection of the gluteal
insertions, the decision can be made to
debride or repair the tissues depending
on the amount of tissue torn
● iliopsoas as it slides over the
Other type of bursitis
● Psoas bursitis
○ Pain is experienced in the groin
or anterior thigh and possibly
into the patellar area when there
is inflammation of the psoas
bursa. Activities requiring
excessive, repetitive hip flexion
aggravate the condition.
● Ischiogluteal bursitis (Tailor’s or
Weaver’s Bottom)
○ When there is inflammation of
the ischiogluteal bursa, pain is
experienced around the ischial
tuberosity, especially when
sitting. If the adjacent sciatic
nerve is irritated from the
swelling, symptoms of sciatica
may occur.
Snapping hip syndrome
● A phenomenon patients may experience
in which there is an audible snap or pop
as the hip moves through a ROM,
usually when the flexed hip is extended.
● Painless, but it can become symptomatic
in athletic individuals.
● Common in young athletic females.
● Can be intra-articular or extra-articular
● External snapping hip can be caused by
contracture or thickening of the ITB.
Often presenting as an audible or
palpable sound as the ITB, TFL, or
gluteus maximus slides over the greater
trochanter during movement, this can be
associated with or without pain.
● Internal snapping hip is caused by the
iliopectineal ridge or the anterior
capsulolabral complex and femoral
head.
● Treatment of both internal and external
snapping hips with NSAIDs and ice can
be helpful in the short term.
 ● Treatment can involve soft tissue
mobilization and stretching techniques
for myotendinous contractures,
correction of muscle imbalances,
Femoral neck stress
● Symptoms are often vague, and one
should have a high index of suspicion to
catch this diagnosis early and avoid
complications such as displacement or
avascular necrosis. If suspicion is
present,an MRI should be obtained
● Fractures on the tension side (lateral) are
less common and require immediate
surgical referral. Fractures on the
compression side (medial) are more
common. If the fracture line extends
more than 50% of the width of the
femoral neck, percutaneous fixation
should be considered because the
likelihood of displacement is higher.
When the fracture line is less than 50%
of the width of the femoral neck, strict
non–weight-bearing status is necessary
for about 4 to 6 weeks until the patient is
pain free.
​Avascular necrosis
● Avascular necrosis, also called
osteonecrosis, is the death of bone
resulting from a lack of blood supply
that can lead to microfractures and
eventually collapse of the bone.
● The femoral head is the most commonly
affected location. Disruption of the
normal blood supply to the femoral head
can be caused by various conditions
including trauma, high doses of
corticosteroids, alcohol abuse, and
systemic illness (such as diabetes, lupus,
and sickle cell anemia).
● In mild cases, the plain films can be
normal. MRI and CT can detect the
condition in its earlier stages.
● Conservative treatment might include
minimizing weight-bearing of the
affected joint and use of pain
medications. Once collapse occurs, joint
replacement surgery is indicated
Legg calve perthes disease (LCPD)
● Idiopathic osteonecrosis of the femoral
head in children
● Occurs most frequently in boys between
the ages of 4 and 8 years
● Limping gait and restriction in hip
motion, especially hip abduction.
● Complain of groin or thigh pain.
● Healing can occur in children with
revascularization of the femoral head
and remodeling of the bone. Prognosis is
better in younger children and those
with milder involvement. In children
under the age of 6 years, observation
and use of an abduction brace to
maintain the femoral head in a spherical
state is reasonable.
Slipped capital femoral epiphysis
● Most common hip disorder in
adolescents
● Injury to the epiphyseal plate of the
proximal femur with medial
displacement of the femoral head
relative to the femoral shaft can be due
to acute trauma or repetitive
microtrauma
● Rare in boys under age 11 years and
girls under age 9 years, and is more
common in overweight boys
● Associated with hypothyroidism and
renal osteodystrophy
● Usually bilateral about 50% of the time
 ● A mild slip can be treated ○ Pain on ambulation, resisted hip
conservatively, closed reduction can be flexion, passive hip extension
done. If this is unsuccessful, open ○ May walk with ​G.med lurch​/
reduction should be done inability to walk
Hip dislocation ● Diagnosis
● Dislocation of the femoral–acetabular ○ Plain film is suspect fracture
joint requires significant trauma. ● ​Treatment
● In children, hip dislocation is more ○ Rest, ice, compression
common than hip fractures. ○ PROM or AAROM
● In adults, fractures of the acetabulum ○ Stretching of muscles
often accompany hip dislocation ○ NSAIDS, local steroid and
● Most commonly, the head of the femur anesthetic injection
dislocated posteriorly relative to the ○ Hip pads
acetabulum
● Presents with severe hip pain and tends
to hold the hip in flexion, internal
rotation, and adduction. With the less
common anterior dislocations, the hip is
held in an extended, abducted, and
externally rotated position. ○
● Closed reduction as treatment. When
unsuccessful, surgery is indicated Sportsman’s hernia

Pelvic and Hip orthopedic conditions

Hip pointer
● Corked ​hip
● Subcutaneous contusion ​of the iliac
from a different blow
● Common in ​contact and collision
sports
● History
● Athletic pubalgia or Gilmore’s groin
○ Direct blow to the iliac crest
● Result from ​weakening ​of the
○ Immediate debilitation due to
abdominal muscles
pain rather than tissue damage
● Refers to a spectrum of disorders that
● Observation:
cause pain in the lower abdomen and
○ Swelling
groin
○ Ecchymosis
● characterized by ​insidious onset,
○ Muscle spasm
gradually worsening and disabling lower
● Findings
abdominal and ​deep groin pain on
○ Severe, localized pain with pop
exertion
or click
● Presentation
○ Tenderness over iliac crest
 ○ Unilateral ​groin pain ● Usually acute with a sudden sharp pain
○ Proximal adductor pain that the hip and groin region occurring
worsens with sudden during sprinting
movements ● Involves over contraction of the muscles
○ May be sharp often ​centered at attached to each bony prominence.
the inguinal canal, ​near the
insertion of the rectus ASIS apophyseal injuries
abdominis ● MOI
○ May ​radiate to the adductor ○ Forced overpull contraction of
region ​or the testicle sartorius ​when hip is in
○ Revealed in resisted hip extension ​with knee ​flexion
adduction ● Paresthesia on
○ Symptoms ​may abate with rest anterolateral
but recur ​with attempt to thigh
sporting activities. ● Pain with hip
● Treatment abduction and
○ Initial attempt at conservative flexion
therapy
■ 2-3 month PT program
■ Focus on dynamic
pelvic stability
○ Surgery
■ If the patient is a
high-level athlete in
whom the diagnosis AIIS apophyseal injuries
appears clear and other ● MOI
pathology has been ○ Forceful contraction of
ruled out rectus femoris ​when
■ Initial surgical referral hip is in ​extension ​with
is appropriate. knee ​flexion
● Symptoms:
Tendinitis, apophysitis, strain, and sprain pain and
swelling at the
site of injury
● Painful active
hip flexion
● Antalgic gait

ASIS and AIIS apophyseal injuries

 Lesser trochanter apophyseal injury ● Complaints
● Common in sports involving ○ Localized pain in
sprinting, jumping and kicking the lateral aspect
● Due to powerful contraction of of the knee (lateral
Iliopsoas​ against resistance epicondyle of the
● Signs and symptoms femur)
○ Anterior hip pain ○ Pain increases
○ Radiating pain to the with knee flexion
groin and flank to extension
○ Pain with active hip ● Treatment
flexion ○ Ice, ​US, ​phonophoresis
○ Passive extension and ITb stretching, strengthening,
ER is painful endurance, coordination
○ Antalgic gait ○ Evaluate biomechanical faults

Apophyseal injuries
● Diagnostic imaging
○ Xray to confirm
● Treatment
○ Usually non-operative
○ Ice and rest
○ Stretching, strengthening, and
proprioception
○ Return to sport only when full
strength and function returns.
Adductor strains
Iliotibial band syndrome ● Groin strain
● MOI
○ Hyperabduction or forceful
abduction of thigh during
adduction
○ Repetitive, high-velocity limb
movements that usually involve
a change in movement
● Complaints:
○ Limp and pain ​during
● Cause abduction or hip flexion with
○ Irritation of the ITB from resistance
repetitive activity ○ Sharp pain in groin with
acceleration
 ● Treatment ​Quadriceps strain
○ NSAIDs ● May be elicited by
○ PRICE, US extreme knee flexion
○ Hip spica and by resisted knee
○ Strengthening, flexibility, and extension
endurance ● Neurologic finding is
○ Return to sports: ​70% of the normal except for
strength and pain-free full strength testing
ROM which may be
limited by pain
Hamstring strains Quadriceps tendon rupture
● Two joint muscle functioning to ● Rectus femoris
eccentrically ​control ​knee extension ○ Most vulnerable
and ​hip flexion ○ Most commonly affected
● The ​biceps femoris ​muscle tends to be ● Site
the most commonly injured component ○ Tendon insertion at the superior
● Causes pole of the patella
○ Sports involving high speed
movements ● Degree
○ Dancers doing prolonged ○ 1st (mild)
end-ranged stretch positions ■ Overstretch;
○ Eccentric control of hip flexion microscopic disruption
in sports ○ 2nd (moderate)
● Complaints ■ Actual (incomplete) tear
○ Immediate pain, tenderness, ■ (+) IM bleeding and
warmth hematoma
○ “Pop” often heard at the time of ○ 3rd (severe)
injury ■ Complete rupture
○ Loss of function ● Treatment
○ Pain with SLR and palpation ○ Incomplete tears
● Treatment ■ Splinting
○ PRICE, NSAID ■ Crutch walking
○ Crutch walking, gentle ○ Complete tears
stretching ■ Surgery
● Avoid SLR ​in early rehabilitation
Bursitis
● Caused by overuse and
friction
● Major sites
○ Psoas bursa
○ Greater trochanter
○ Bursa
○ Ischial bursa
Greater trochanteric bursitis
● Causes;
○ Direct blow
○ Irritation by ITB
○ biomechanical/
gait abnormality causing
repetitive microtrauma
● Common on patients with
RA
● Complaints
○ Burning or ​deep
ache on greater trochanter,
lateral thigh pain with ​walking
○ Pain during transitions ​from
standing to lying down to
standing
○ Avoid toe clips during cycling
to avoid increase in hamstring
activation
Femoroacetabular impingement
● Bones of the hip are ​abnormally
shaped; ​decreased ​ joint clearance
● Sharp ​anterior groin pain
● Types
○ Cam
○ Pincer

Ischial bursitis
● Also known as ​ischiogluteal bursitis,
Tailor’s ​or ​weaver’s ​bottom

Femoroacetabular
impingement - pincer

● MOI
○ Direct trauma
○ Prolonged sitting in hard
surfaces
● Complaints
○ Aggravated during ​uphill
running
● Treatment
○ Rest, NSAID, corticosteroid
injection
○ Hamstring stretching
● Management
○ Decrease frequency and
duration of running
Management hip pain ​with ​clicking ​with
● Reduce anteriorly directed forces on the passive ​hip flexion, adduction,
joint and IR
● Develop a length/strength balance in the ● Anterior-superior tear
muscle of the hip ○ Flexion, adduction, and IR
● Conservative treatment involves ○ Most common site of tear
modification of activity to avoid the ● Posterior tear
impingement positions and NSAIDs ○ Passive hyperextension
abduction and ER
Acetabular labral tear ● Anterior tear
● MOI ○ Acute hip flexion with ER and
○ Young: ER in hyperextended full abduction, followed by
hip extension, abduction,and IR
○ Elderly: person with
hip/acetabular dysplasia, or
result of repeated twisting
● Pivoting and twisting movements

● Management
○ Bed rest
○ Develop length/ strength
balance in the muscle of the hip
○ Avoid
● Dx ■ Sitting with knees
○ Arthrography above hip
○ MRI ■ Hip hyperextension
○ Arthroscopy exercises
● Signs and symptoms ■ Pivoting on affected
○ Pain in the ​anterior hip/groin limb
or ​buttocks Osteonecrosis
○ locking , buckling, clicking, ● Death of the bone
giving away at the hip, and cells
restricted ROM ● Etiology
○ It is suspected when ○ Traumatic
radiograph are normal ​and ○ Non-traumatic
patient complains of ​anterior
Diagnosis of aseptic necrosis ○ Pain provoked by ​active
● X-rays adduction or sit ups
● MRI scanning ○ Popping in the pubic region
● Nuclear bone scanning with ambulation
○ Pain on the scrotum
○ Pain is described as “groin
burning
● Diagnosis:
○ Plain films
○ MRI bone scans
○ Hop test
● Treatment
○ Adductor stretching and
strengthening
○ Abdominal and core mm
strengthening
Hip dislocation
Osteonecrosis of the femoral head
● Clinical features
○ Limp and hip spasm (children)
○ Pain in the groin (adults)
○ Pain referred to thigh and knee
○ LOM in ​flexion, IR, and
abduction
○ Coxalgic gait
● Treatment
○ Conservative (children)
○ Surgical (adult)
Osteitis pubis
Types of hip dislocations
● Most common ​inflammatory disorder
● There are three main types of hip
affecting pubic symphysis
dislocations:
● Causes:
○ Traumatic dislocation of a
○ Overuse
normal hip
○ Trauma
■ Anterior, posterior,
○ Pelvic surgery
central
○ Childbirth
■ Developmental
● Self limiting
dysplasia of the hip
● Symptoms
■ Dislocation of a
○ Exercise induced
prosthetic hip
pain in the lower
​Causes of hip dislocation
abdomen and medial thigh
● MVA: major cause of traumatic
○ Tenderness over the ​pubic
dislocation
symphysis
○ Posterior hip dislocation
 ● Falls from a great height Central hip dislocation
○ Central fracture/ dislocations ● Falls from a great height or lateral
● Athletic activities impact on the hip
○ Common in children

Posterior hip dislocation

● Most common
● MOI
○ Force ​to flexed knee ​in an
adducted position. IR ​at hip

● Treatment
○ Closed reduction
○ Non-weight bearing ->
protected weight bearing
○ Progressive rehabilitation starts
a few days or week after
reduction

Fractures
anterior hip dislocation ● Clinical manifestation
● MOI ○ Pain and tenderness
○ superior/pubic ○ Increased pain on weight
■ Force to an extended bearing
and ER ○ Edema
○ inferior/obturator ○ Ecchymosis
■ Force to a flexed, ○ Loss of general function
abducted and ER ○ Loss of mobility
● Presentation ● Classification
○ Lower extremity is ​shortened, ○ Intracapsular
abducted ​and ​ER ■ Subcapital
■ Transcervical
■ Basicervical
○ Extracapsular
■ Intertrochanteric
■ Subtrochanteric
Femoral neck fracture
● Classification
○ Vague, non-specific description
and onset of pain
○ Unrelieved by rest
○ Aggravated at night by rolling
onto that side
○ (+) Trendelenburg’s sign
○ Positive percussion test;
symptoms reproduced with
hopping
● Positive test of femoral neck integrity
○ Pain as person tries to ER from
an IR position
○ Non-capsular position pattern
○ Localized tenderness at the
greater trochanter unrelieved by
treatment for bursitis
○ Pain may occur in the buttocks
and/or groin

Post-op management
● PT interventions
○ Bed mobility
○ Transitional movements
○ Ambulation
○ Return to premorbid ADL
Developmental Dysplasia of the hip (DDH) Shenton’s line
● Abnormality in the size, shape, ● From ​femoral diaphysis t​ o the
orientation, or organization the ​femoral inferior margin​ of the superior
head, acetabulum, ​or b ​ oth pubic ramus
● Can predispose a child to premature ● Break in the shenton’s line
degenerative changes and painful suggests displacement of the
arthritis femoral head from the
● Risk factors: acetabulum
○ First born babies
○ Family history of DDH Special test
○ Position of the baby in the ● Neonatal
uterus ○ Ortolani’s sign
● Manifestations ○ Barlow’s test
○ Affected leg: ○ Galeazzi sign
■ Shorter ● Infancy
■ ER ○ Abduction test
■ Folds in the skin of the ○ Galeazzi sign
thigh or buttock may ○ Telescoping sign
appear uneven
■ Space between legs may
look wider
○ Partially or
completely dislocated

○ Treatment options
■ Bracing
■ Traction and casting
■ Surgery and casting

● Dx
○ X-ray
○ Ultrasound
○ CT Scan
○ MR
Traction and casting
● Stretch the soft tissues around the hip
● Allow the femoral head to move back
into the hip socket
● 10-14 days
● Can either be set up at home or in the
hospital

Surgery
Pavlik harness ● Open reduction of the hip
● Upto to 6 months of age ○ Lengthening tendons about the
● Hold the hip in place, while allowing the hip
legs to move a little ○ Tightening the hip capsule once
● Full time for at least six weeks -> part reduction is obtained
time for six week ○ <18 months: medial adductor
approach, tenotomy of iliopsoas
○ 18 months - 2y/o: anterior
iliofemoral approach

Legg -calve Perthes disease

● Coxa plana
● Idiopathic form of osteonecrosis ​of
femoral head
 ● Self limiting
● Usually affects boys between 3-13
Feature:
● Psoatic limp
● LE moves in ​ER, flexion and
adduction
● Gradual onset of aching pain at hip,
thigh, and knee
● Atrophy of hip, thigh, and leg muscles
● AROM limited ​abduction, IR ​and ​ER
● Diagnosis tests:
○ MRI: (+) bony crescent sign
PT treatment
5 stages in Legg Calve Perthes
1. Necrosis
○ Characterized by vascular
damage
○ Small capital epiphysis
○ Increased radiodensity of the
femoral head
○ Appearance of osteopathic area
in the medial aspect of the
proximal femoral neck
2. Fragmentation
○ Fibrous tissue invades the
involved region and gradually
resorbs the necrotic neck
○ Enlargement of the femoral
neck
○ Severe deformity of the femoral
head
3. Revascularization
○ Begins after all necrotic tissue
has been resorbed
○ This gradual process is
complete when the entire region
has become re-ossified
4. Remodeling
○ Some resultant deformity may
resolve as the joint is subjected
to weight bearing and normal
joint forces
5. Healed
○ Only tissue is once again viable
and further resolution of the
deformity is minimal
○ enlarged /small femoral head
● Children 5 years of age or older usually
are placed in weight bearing abduction
braces and started in PT
● Surgery is reserved for those with
incongruity and loss of sphericity of the
femoral head
● Braces or plaster casts
 ○ Canadian hip orthosis ● Etiology
○ Scottish rite orthosis ○ Unknown
○ Toronto brace ● Pathology
○ Trilateral ○ Head slips downward on
femoral neck
● Painful hip
○ Most frequent presenting
complaint

● Symptoms of SCFE
○ Vague pain
■ Knee
■ Thigh
■ Hip
○ AROM restricted: ​flexion ​ and
IR
Slipped femoral epiphysis ○ (+) leg length discrepancy
● Separation of the head from the femur at ○ As hip flexes, it ER and abducts
the growth plate of the bone ○ Trendelenberg gait (chronic)
● Boys (10-17 years) > girls (8-15 years ) ● Diagnostic test
● The individual tends to ​hold the ○ Plain film imaging show a (+)
affected limb in flexion and ER displacement of femoral
epiphysis

Slipped capital femoral epiphysis

Degrees of severity
● Mild
○ Approximately ⅓ of the femoral
head slips off of the femur
● Moderate
○ Approximately ⅓ - ½ of the
femoral head slips off of the
femur
● Severe
○ More than ½ of the femoral
head slips off of the femur
Total hip arthroplasty

Medications Cemented
● Acetaminophen ● Allows very early postoperative
● NSAIDs weight ​bearing and shortened
rehabilitation
● Commonly used today for ​elderly, and
physically inactive​ younger patients
● Complication includes ​loosening of the
prosthetic​ component

Cementless
● Takes ​longer ​before allowed to bear
weight compared with cemented
procedure
● Cementless fixation for the patient
under 60 years ​of age who ​is
physically active​ and has good bone
quality

Surgical approach
● Posterior or posterolateral approaches
 ○ This approach preserves the
integrity of the g. Med and
vastus lateralis muscle
● Lateral approach
○ associated with postoperative
weakness of the abductors
(positive trendelenburg sign)
and giant asymmetry
● Anterior approach
○ Weight bearing as tolerated on
the operated extremity is
permitted immediately after
surgery