A hip "pointer" is an injury of the superior iliac crest and overlying tissues that occurs in many sports and some industrial accidents. It is very painful and slow to heal. The easily irritated epiphysis of the iliac crest does not close until about 24 years of age and is easily injured by a shoulder, helmet, knee, or shoe blow. In addition, ilioinguinal and iliohypogastric nerve contusion, painful avulsion of the iliolumbar ligament from the ilium and/or sprain at its L4L5 attachment, and/or crushing of the muscle bulge overlapping the crest may be involved. Muscles are richly innervated.
Clinical Features. Symptoms often mimic fracture; ie, acute, steadily increasing pain, and severe progressing disability. On onset, a moderate injury will present tenderness below the iliac wing and at the overlapping muscle bulge but not on the crest itself. This indicates a bone bruise with nerve contusion. An impact to the anterior spine may actually strip attachments along the crest. Thus, severe injury presents extreme tenderness throughout and above the crest, indicating torn attachments. The pain is agonizing, easily aggravated, and often requires hospitalization. If examination is delayed, bleeding, spasm, and swelling obscure localization of diagnostic signs.
Management. Initial care requires cold packs to stop the bleeding, swelling, and spasm, and careful strapping to tilt the trunk toward the ipsilateral pelvis to prevent further spasm. Disability and swelling must be monitored daily during the early stage. In minor strains with minimal bleeding and swelling, cold may be discontinued after 24 hours. Active motion without heat may begin at this time. Ultrasound and interferential therapy have been found especially helpful in resolution. Active motion with support and padding are beneficial, but heat is usually contraindicated. Activity of an athlete may be resumed in 310 days, depending on the extent of injury. In severe strains with extensive swelling, cold must be continued for 4872 hours.
Posttraumatic Hip Spasm
Two forms of postinjury spasm are common in the hip joint: (1) spasm due to irritation of the psoas alone, and (2) spasm in which all muscles moving the hip are contracted to some degree. The normal range of hip flexion is 120°. Limited motion from muscle spasm is also seen with special frequency in joint disease and spinal dysarthrias, but it may occur in almost any form of joint trouble, particularly the larger joints. General spasm of the hip muscles is tested via Patrick's test.
Screening. Once the possibility of fracture, dislocation or gross pathology has been eliminated, general spasm of the hip muscles can be tested with the patient supine on a table, bench, or bed and the involved leg flexed at a right angle, both at the knee and at the hip. A child may be tested on its parent's lap. Using the uninvolved limb as a standard of comparison, draw the knee away from the midline (abduction), toward and then past the midline (adduction) and toward the patient's chest (flexion). Rotation can be tested by holding the knee still and moving the foot away from the median line of the body or toward and across it.
Management. To relieve muscle spasm, heat is helpful, but cold and vapocoolant sprays may be more effective. Mild passive stretch is an excellent method of reducing spasm in the long muscles, but heavy passive stretch destroys beneficial reflexes. Quadriceps spasm can usually be relaxed by passive hip and knee flexion. Peripheral inhibitory afferent impulses can be generated to partially close the theoretical presynaptic gate by acupressure, acupuncture, or transcutaneous nerve stimulation.
This diagnostic sign refers to an audible or palpable "click" heard or felt on the lateral surface of the upper thigh near the head of the femur. The cause is thought to be a taut fascial band that slips over the greater trochanter as the hip is rotated internally while being partially flexed. This band is often found on surgery to be either a thickened posterior border of the iliotibial band or the anterior tendon of the gluteus maximus muscle. Besides the crepitation, local tenderness will manifest during hip motion, especially internal rotation.
Management. The first priority after pain relief is to relieve any fixations found within the pelvis, hip, and knee. Adjunctive care generally includes the common procedures for acute sprain during the early stage (eg, cold, rest); later, the common procedures for chronic sprain such as massage, ultrasound, diathermy, and graded exercise are used. With the poorly nourished, manganese, vitamin C, and vitamin A may be helpful.
Trigger Points of the Hip and Thigh
Trigger points of the pelvis are commonly located (1) over the greater sciatic notch through the gluteal muscles, (2) over the crest of the ilium, (3) over the belly of the tensor fascia lata, (4) in the ischiorectal fossa apex, and (5) at the sciatic outlet onto the back of the thigh from under the gluteus maximus.
HIP SPRAINS AND STRAINS
The hip articulation sits deeply beneath heavy muscles, fascia, ligaments, and fat that protect the joint but often obscure physical signs. Fortunately, severe injury is rare. One should always consider the possibility of hip pain being referred from pelvic, intra-abdominal, or retroperitoneal disease or a biomechanical fault in the lumbar, pelvic, knee, or ankle joints. The symptoms of hip strains and sprains should always be differentiated from mimicking contusions (eg, hip pointer), abscess, arthritis, bursitis, and fatigue fractures.
Sprains of the hip in the young frequently injure the upper femoral epiphysis. In adults, trauma usually damages the muscles about the hip rather than to harm the joint itself.
Around the hip, two forms of spasm are common: (1) those due to irritation of the psoas alone, and (2) those in which all muscles moving the joint are more or less contracted. General spasm of hip muscles can be evaluated by Patrick's test.
Motion is restricted and pain is often referred to the medial aspect of the knee. A limp is invariably present. Laguere's, Ely's, Patrick's FABERE, and Ober's tests are used to support the diagnosis. Thomas' sign is positive in hip contracture; Trendelenburg's sign in hip dislocation; and Allis' knee sign in hip fracture. In hip sprain, the mechanism is usually a twisting or wrenching motion. Occasionally, a stubborn case will show pus on aspiration.
Laguere's Test. With the patient supine, the thigh and knee are flexed and the thigh is abducted and rotated outward. This forces the head of the femur against the anterior portion of the coxa capsule. Increased groin pain and spasm are positive signs of a hip lesion, iliopsoas muscle spasm, or a sacroiliac lesion. It differentiates from a lumbosacral disorder.
Hip Abduction Stress Test. The patient is placed in the sidelying position with the underneath lower limb flexed acutely at the hip and knee. While the patient's upper limb is held straight and extended at the knee, ask the patient to try to abduct the upper limb while you apply resistance. Pain initiated in the area of the uppermost sacroiliac joint or the hip joint suggests an inflammatory process of the respective joint.
Other Kinematic Tests. Ely's, Patrick's, and Ober's tests support the diagnosis. Thomas' sign is positive in hip contracture; Trendelenburg's sign in hip dislocation; and Allis' knee sign in hip fracture. Increased groin pain and spasm during Laguere's test are usually positive signs of a lesion of the hip joint, iliopsoas muscle spasm, or a sacroiliac lesion. This latter test can also help to differentiate a hip disorder from a lumbar lesion.
Management. When symptoms of joint involvement are present, functional rest is indicated until signs of irritation disappear. Treat as any joint sprain in accord with the stage in progress. Strapping should be provided as well as crutches during the acute stage. The patient should be carefully monitored for at least a month.
BURSITIS IN THE HIP AREA
It was reviewed in the previous monograph that a bursa lies between the lateral capsule of the proximal femur and the gluteus maximus muscle's tendon as it courses over the greater trochanter to insert into the iliotibial tract. Inflammation from an external blow on this bursa is not unusual.
Another bursa is formed at the internal obturator tendon and the superior and inferior gemelli. It runs under the piriformis and courses posteriorly to round the sciatic notch, largely filling the lesser sciatic foramen. A clue to inflammation of this bursa is gained by testing thigh external rotation against resistance and signs of tenderness on deep palpation. An attempt to elicit a buttock sign should be attempted unless contraindicated by other features.
The involved lower extremity of a supine patient is passively flexed at the hip with the knee extended as in an SLR test. If flexion of the limb on the trunk is restricted by local or radiating buttock pain (rather than pain in the hip or lower back), it signifies an inflammatory pelvic lesion such as ischiorectal abscess, coxa bursitis, or sacroiliac septic arthritis. It may also signal osteomyelitis of or near the hip joint or an advanced pelvic neoplasm.
Trochanteric bursitis is often associated with tendinitis of the gluteus medius. It is characterized by pain radiating laterally downward along the iliotibial band. Thus, it must be differentiated from an iliotibial or low-back lesion. Point tenderness will be found over the head of the femur, and this is a helpful sign in differential diagnosis.
Management. Treat as any bursitis: cold and rest initially; later with deep heat, interferential therapy, and stretching exercises. Special care should be made to rule out pelvic and femur fatigue fractures; hamstring, piriformis, and iliopsoas strains; and hip joint contractures. Dr. John Palo adds the following comment: "My experience has been that many cases of trochanteric bursitis come from a longer lower limb. The longer limb forces its greater trochanter to protrude more. The tensor fascia lata or iliotibial tract is then forced to override or snap over the protruding greater trochanter. This irritating action can produce trochanteric bursitis. Solution? A heel lift placed under the contralateral (shorter) lower limb." See the previous monograph for the application of shoe lifts.
Iliopectinal bursitis closely resembles and is often confused with signs of iliopsoas abscess. It is characterized by abrupt hip pain (mild--severe) that is aggravated by hip flexion and adduction. A deep ache may radiate along the course of the femoral nerve down the anterior thigh and possibly to the leg. Palpation reveals tenderness deep within Scarpa's triangle, the inguinal groove may be swollen, and Thomas' test is invariably positive.
Management. The primary objectives following pain relief are to release any fixations found within the lumbar spine, pelvis, and lower extremities, and treat the swelling. During the acute stage, treat locally as an acute sprain with cold and rest. Later, apply stretching exercises to the patient's tolerance, active exercise within a painless range, and physiotherapy to reduce the inflammatory process and prevent posttraumatic complications.
OSTEOARTHRITIS OF THE HIP
Osteoarthritis of the hip is a common noninflammatory disorder that afflicts about 200,000 Americans over 65 years of age. As in osteoarthritis elsewhere, the cause is thought at this writing to be a posttrauma reaction. There are signs of deteriorated articular cartilage, diminished joint lubrication, new bone formation at joint margins, loss of soft-tissue elasticity, and a reduced range of joint motion. Morning stiffness is common. Overstress produces pain in the anterolateral thigh that may extend to the knee.
Management. Free all fixations found in the lumbar spine, pelvis, upper cervicals, and lower extremities. Moist heat, interferential therapy, massage, diathermy, ultrasound, stretching exercises, hydrotherapy, and nutritional supplementation are commonly used. Obesity is often a complicating factor.
The quadriceps group forms the anterior muscles of the thigh; viz, the rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius.
A common bruise of the thigh results from an anterior blunt blow. The effect may be a minor but disabling "charley horse" if the muscles are contracted during the injury. A severe rupture of the rectus femoris or vastus intermedius can result, producing extensive intramuscular bleeding leading to myositis ossificans if not treated quickly and adequately.
Clinical Features. A quadriceps contusion can be one of the most crippling of all contusions. Even when carefully fitted padding is provided in contact sports, it is not always adequate for the impacts received. Hemorrhage may extend from knee to groin. If the mass tenses the overlying tensor fascia lata, signs of circulatory impairment will be noted in the toes requiring immediate fasciotomy. Such "ballooning" of the thigh occurring many hours after injury is typical of a massive "charley horse." It sometimes results from what was initially thought a trivial injury.
The tendency for bleeding to recur may remain for a week after injury. The time for resorption of the mass extends from several weeks to months. In the "low Charley" contusion of the vastus medialis, a complication may occur with hemarthrosis of the knee joint, which offers false signs of joint injury. In such cases, delayed diagnosis allows fibrosis to become extensive. This may require many weeks to overcome.
Management. Bleeding is the first problem. Cold packs, a pressure bandage, and elevation should be started immediately. This therapy must be continued up to 72 hours or more if a mass can be felt and flexion is limited. Heat should not be applied for 5 days, and even then there is a risk for a few days. When bleeding has been controlled and other acute signs subside, walking can begin and slowly progress to jogging if symptoms do not return. Premature postinjury activity may easily lead to greater disability. Running should always be preceded by slow stretching exercises (eg, pulling heel toward buttocks).
Clinical Features. Symptoms of quadriceps strain may be exaggerated at either the hip or the knee, and may not appear for several hours in mild strains. Pain is aggravated by movement, especially going down stairs. Swelling is usually mild, but spasm is always present to some degree depending on the extent of injury. Normal quadriceps action reveals a distinct degree of limitation. Note that it is almost impossible to have a strong knee and weak quadriceps, and the quadriceps group is the first to show atrophy after knee injury.
Management. Treat as any long, bulky muscle strain, keeping in mind that the quadriceps is the largest muscle group in the body. In comparison to moderate strains, even mild tears (highly disabling) are more difficult to manage. Bleeding is always a concern, thus heat should not be applied for 35 days. Support consists of criss-crossed adhesive straps up the anterior thigh. This requires 1014 diagonal strips anchored by overlapping semicircular horizontal strips extending from the medial to the lateral aspects of the thigh. Any taping procedure for the quadriceps is helpful but never fully adequate for full activity. Special care must be used to avoid posttraumatic contracture.
The quadriceps flexion test and Nachlas' test will aid the diagnosis of quadriceps contracture.
Quadriceps Flexion Test. Posttraumatic scars in a muscle always limit the working length of all muscles in the group. Quadriceps contracture is tested simply by placing the patient prone, flexing the leg toward the buttock to tolerance, and measuring the distance from the heel to the buttock. Once the point of tolerance is reached, the lumbosacral spine will arch and the buttocks will rise to prevent further stretch. This test may prove a lesion too deep to palpate as well as evaluate progress during treatment. Activity should be restricted until flexion exceeds 90°. Squatting activities must be avoided until full healing is demonstrated. Premature postinjury activity may easily tear a weakened muscle. Ely's test may also be helpful.
Nachlas' Test. After placing the patient in the prone position, flex the patient's knee to a right angle. Then, with pressure against the anterior surface of the ankle, slowly direct the heel straight toward the patient's ipsilateral buttock. The contralateral ilium should be stabilized by your other hand. If a sharp pain arises in the ipsilateral buttock or sacral area, a sacroiliac disorder should be suspected. If pain occurs in the lower back area or is sciatica-like in nature, a lumbar disorder (especially L3 or L4) is suggested. If pain occurs in the upper lumbar area, groin, or anterior thigh, quadriceps spasticity/contracture or a femoral nerve lesion should be suspected.
The hamstring group forms the posterior muscles of the thigh; viz, the semimembranosus, semitendinosus, and the biceps femoris. The semimembranosus arises from the ischial tuberosity and inserts at the medial condyle of the femur and the medial condyle and border of the tibia. The semitendinosus originates at the ischial tuberosity and inserts on the upper part of the medial surface of the tibia. The long head of the biceps femoris arises from the ischial tuberosity and the short head from the linea aspera of the femur. Both divisions of the biceps femoris insert by a common tendon at the head of the fibula and lateral condyle of the femur.
Hamstring strains are usually the result of weakness plus poor warm-up before exertion. The pain involved is rarely referred to the leg as in sciatica. Gross hamstring weakness is tested by simultaneously extending the thigh and flexing the knee against resistance.
Clinical Features. Symptoms develop slowly with progressive disability. The characteristics of severe hamstring strain include acute pain (generally at the origin of the short head of the biceps femoris), restricted motion, hamstring dyskinesia, loss of strength exhibited by poor coordination, and an altered gait. Bleeding is usually mild, and general spasm is common. Tenderness is found at the ischial origins and attachments at the musculotendinous junctions. A palpable, compensatory, fibrous thickening may manifest. Special care must be taken to differentiate strain of the lower biceps femoris from sprain of the lateral ligaments or lateral meniscus tear.
Management. Treat as a strain of any large muscle group with emphasis initially on the control of bleeding and pain. Provide support (eg, taping) and later on flexibility and strengthening exercises. Check lower lumbar and the sacroiliac joints for fixations. Because bleeding may be a problem in soft-tissue overstress, light compression by an elastic bandage can be used. Heat should not be applied for 35 days when the fear of inducing bleeding fades. Once bleeding has been controlled, walking is the first exercise, followed by "high knee" exercises and graduated jogging. The latter is necessary only if the patient is involved in demanding athletic activities. During rehabilitation, ultrasound, high-volt therapy, or interferential therapy are often applied to encourage healing. Magnesium and vitamin C may be helpful.
Taping. The patient should stand with his weight on the uninjured leg. A series of 3inch overlapping strips is firmly applied vertically from just above the popliteal space to just below the rib line. A single strip is run diagonally from the PSIS, around the hip, and then to the anterolateral thigh. All strips are anchored with semicircular strips applied at the waist and from the inferior aspect of the buttocks to the popliteal fossa.
Special Concerns. Return to full activity should not be rushed, and any attempt by the patient to "work out" the discomfort should be discouraged. Reinjury readily leads to severe tear and scar formation. To prevent a chronic problem, rehabilitation with emphasis on stretching exercises (eg, knee flexion when erect) should continue until complete recovery. If the patient is returning to athletic activity, races and hill running should be avoided until full strength and flexibility have returned. The optimal balance between quadriceps and hamstring strength is in the ratio of 60:40. Management should also consider rehabilitation of the gluteus maximus.
In contrast to a severe stretch, a hamstring tear features a history of bursting pain during activity and a highly tender mass at the site of hemorrhage. The size of the mass can vary from that of a walnut to that of a melon, and it parallels the degree of spasm and weight-bearing disability. During recovery, a startling ecchymosis usually appears in the popliteal fossa and slowly extends caudally. Bicipital tendinitis is a frequent complication of distal bicipital strain. Symptoms may be exaggerated at either the hip or the knee. Roentgenographs may show avulsion fracture at the head of the fibula.
Besides direct trauma, hamstring spasm may be the result of any lower motor irritation located between the midthoracic spine and the lower sacrum. The clinical procedures listed below have proved helpful in differentiating hamstring spasm from mimicking disorders.
Tripod Sign. The patient is placed prone with the knees flexed over the edge of the table. Active and passive muscle strength and range of motion of knee extension are then evaluated. If the patient must pull backward (extend the trunk on the pelvis) and grasp the table to support body weight on the arms when the knees are bilaterally extended, hamstring spasm is indicated.
Lewin's Knee Sign. If quick extension of a knee in the standing position produces pain and a sharp flexion response, hamstring spasm should be suspected.
Neri's Bowing Sign. This general sign is positive when a standing patient can flex the trunk further without low-back discomfort when the ipsilateral leg is flexed than when both knees are held in extension. The sign suggests hamstring spasm, contractures of the posterior thigh and/or leg muscles, sciatic neuritis, a lumbar IVD lesion, or a sacroiliac subluxation syndrome.
Tight, often scarred, hamstrings are customarily the result of improperly treated strains and tears. Contracture is a common cause of prolonged immobility. In some cases, etiology can be traced to excessive exercise producing a horizontal tear across the belly of the muscle. Recurring episodes are typical. A program of carefully graduated activity must be undertaken quickly because prolonged rest encourages tightening and functional disability.
Berry's Sign. This sign is positive if a patient with a history of lower trunk discomfort and fatigue is fairly comfortable when sitting with the knees flexed but experiences discomfort in the standing position. It is typically seen in spasticity or contractures of the posterior thigh and/or leg muscles.
Two normal hamstring reflexes have significance: (1) Internal: With the patient recumbent, knee slightly flexed, leg abducted and partially externally rotated, the examiner's fingers are placed on the medial aspect of the leg below the knee, over the muscles and tendons, and the fingers are percussed. A reflex supplied by L4S2 results in increased flexion of the leg on the thigh. (2) External: Similar to above, the examiner's fingers are placed over the tendon of the biceps femoris muscle just above its insertion on the lateral side of the head of the fibula and lateral tibia condyle, and the fingers are percussed. A reflex supplied by L5S3 results in flexion of the leg on the thigh and moderate external rotation of the leg.
Groin strains are frequently caused by slips on a slick surface where severe hip abduction or adduction overstress might occur. A wrenching-type disability arises slowly rather than suddenly (as in a quickly torn muscle). Also refer to this topic in the previous monograph.
Management. The management of severe groin strain sometimes requires great patience on the part of both doctor and patient, especially if it is associated with the sedentary patient with muscle shortening in the groin. Standard physiotherapy relieves attending muscle spasm due to the irritation from the inflammatory reaction. Despite extensive ecchymosis, there is usually immediate relief after correcting attending sacroiliac and pubic subluxations if avulsion has not taken place. Cold, compression, pressure by an elastic figure8 bandage to inhibit hyperextension, and rest will rapidly control the swelling. Carefully monitored graduated exercises must be initiated as soon as possible to avoid posttraumatic contractures that will produce recurrent disability.
Painful groin strains may involve the gracilis, abductor longus, or iliopsoas muscles, but precise differentiation is usually not necessary in management. Interfiber bleeding is always a problem. Healing is slow (eg, 23 months). Low adductor strains, contusions, and bone bruises near the medial femoral epicondyle often mimic knee joint injury. Such strains usually result from a fall on the adducted knee producing overadduction and avulsion of the adductor tendon leading to periosteal calcification (Pellegrini-Stieda disease). Fortunately, severe posttraumatic disability is rarely a factor except with the aged and severely unconditioned patient.
Phelp's Test. Place the patient in the prone position with both lower limbs extended in the relaxed position. Abduct the patient's thighs just short of the patient's threshold of pain, and then flex the patient's knees to 90° angles with the thighs. If this flexion allows greater abduction of a thigh on the hip without undue discomfort, a contracture of the gracilis muscle is suggested.
An adductor strain referring pain to the pelvis is frequently suffered by athletes. The presenting complaint includes stiffness, tenderness, and pain high in the groin during abduction. Besides regular strain therapy, treatment should include progressive adductor tendon stretching that does not exceed patient tolerance.
Soccer Syndrome. A severe "scissors" kick, common in soccer, frequently leads to instability of the sacroiliac and symphysis pubis joints. Groin pain is aggravated during running and jumping, and in the stretching motion of kicking with power. Roentgenography may show a periosteal reaction at the origin of the adductor muscles (gracilis syndrome).
Rider's Strain. An adductor strain is frequently suffered by horsemen, cyclists, runners, and fast bowlers. The patient's complaint includes stiffness, tenderness, and pain high in the groin during abduction.
Management. Treat as any strain; however, a first-aid analgesic pack added to the regimen is often beneficial. The pack consists of spreading a balm such as menthol salicylate, about a half an inch thick, over the site of injury and covering it with an 8 X 10inch or larger cotton pad. Secure the pack with tape, and cover it with an elastic bandage. In strapping, the final strips should be applied so that medial traction is maintained (ie, around the contralateral hip and posteriorly). Rehabilitation should emphasize stretching and massage to avoid posttraumatic contractures.
Sartorius Strain and Tears
Sartorius strains are usually mild but present with a persistent disability that is often seen with activities requiring excessive and unaccustomed "squatting" or rowing positions. The associated discomfort is aggravated by abduction and extension of the thigh, and eased after a mild warm-up.
The tensor fascia lata muscle arises from the iliac crest and inserts into the iliotibial band (ITB). The ITB is neither a muscle nor a tendon or is it a ligament. It is the long distal extension of the thick lateral fascia of the thigh, and as such, it serves as a supplemental support of the knee laterally. The ITB arises proximally from the fascia lata and gluteus maximus and inserts distally into Gerdy's tubercle on the lateral tibial condyle.
During flexion, the knee depends primarily on muscular support rather than on ligamentous straps. This is performed laterally by the ITB and biceps femoris; medially by the combined action of the semitendinosus, semimembranosus, gracilis, and sartorius; anteriorly by the quadriceps femoris; and posteriorly by the action of the popliteus. Because the ITB crosses the knee joint, its effect on the knee varies according to the position of the hip. Evans, reports Hazel, believes that the ITB greatly assists rest during standing.
The ITB Syndrome
The Iliotibial band syndrome, an overuse symptom complex common in runners, is the result of excessive friction between the iliotibial band and the lateral femoral epicondyle during prolonged flexion-extension activity of the knee. The bursa overlying the lateral femoral epicondyle becomes inflamed, and periostitis at the attachment of the iliotibial band is usually associated. Knee flexion-extension (eg, climbing stairs) aggravates the pain (a stinging sensation). Crepitus and tenderness around the lateral epicondyle can be found, but lax ligaments and para-articular effusion are absent.
The importance of the ITB syndrome within athletics has been pointed out in a paper by John Nash of Texas Chiropractic College. It has also been described by R. H. Hazel who feels it is essentially limited to long distance runners. A summary of their findings is described below.
During the walking cycle, the knee is normally in full extension at heel strike --and this is the only time in the cycle when this occurs. At other phases of the cycle, the knee is in various degrees of flexion. When running on flat terrain, the knee does not accomplish full extension at heel strike. However, it is close enough that lateral stability is satisfactorily accomplished by the ligament straps. This situation changes when running on hills, particularly during an up-hill phase where flexion of the knee reduces the support contributed by the ligaments and places more emphasis on dynamic muscle tissue.
Etiologic Considerations. Three factors can and will alter the ITB system sufficiently to produce symptoms:
The first factor occurs during semiflexion of the knee. During this action, as mentioned above, the dynamic muscle groups must stabilize the knee. When done repetitively, this can hasten trigger-point development in the overstressed muscles, especially when (even slight) biomechanical faults are associated. Thus, during strenuous physical activity, the ITB is easily victimized because it has such a high connective-tissue content. The resulting trigger points can produce aberrant control of the leg during performance and produce pain.
The second factor involves contracture and inelasticity of the hamstrings. This is a common finding among the general population as well as in athletics. Hamstring shortening prevents complete extension of the knee at heel strike, which precipitates the same negative situation that is seen in up-hill running.
The third factor is related to contracture of the triceps surae. This alters normal gait by producing push-off before the full stride is accomplished, thus producing the characteristic knee posture and semiflexion at heel strike. The result is the same as in Factors 1 and 2 described above.
Athletes, either serious or the weekend variety, can fall victim to this problem when they alter their activity suddenly, either by an increase in duration or intensity. A change in terrain or footwear can also be a causative or precipitate factor. Other contributing situations include novice runners with tibia vera and pronated ankles, excessive length in stride, and/or excessive wear on the outer sole of a running shoe.
Clinical Features. An afflicted individual reports pain during or immediately following a workout, but there is usually no sign of effusion. Tests for ligament or meniscus faults in the knee prove negative. The ITB can be palpated distally by locating the tendon of the biceps femoris, moving anteriorly into the groove that separates it from the ITB. Palpation of the lateral thigh distally invariably shows evidence of single or multiple trigger-point development. The usual sites are across the ITB, at or just above the joint line. Gerdy's tubercle will be surprisingly pain free. Gross ITB weakness can be judged by testing thigh flexion and medial rotation against resistance.
Hazel recommends three tests that he believes are a must in the accurate diagnosis of an ITB syndrome: (1) Have the patient jog to (but not beyond) the point of pain. This will help localize the focal point of stressed tissues. Running beyond the threshold of pain causes it to become diffuse, and point tenderness will then be lost. (2) The sitting patient should flex and extend the involved leg while the examiner applies pressure to the lateral femoral epicondyle. (3) The patient is placed in the lateral recumbent position and instructed to rapidly abduct the leg (to about 20°) several times. This puts considerable tension on the tensor fascia lata and gluteus maximus, helping to bring out a subtle lesion.
Management. After relaxing (eg, stripping) the tensor fascia lata muscle, the lower extremity should be checked for articular fixations at the hip or knee. Treat as an acute sprain. Initial cryotherapy and adequate rest are vital to rapid recovery. Nash recommends that the treatment of associated trigger points incorporate transverse friction over the reactive points for 3--4 minutes on alternate days for 1--2 weeks, depending on the severity and the responsive nature of the patient. Each treatment is followed by negative pole high-volt therapy, which may be preceded by ice massage for 15-20 minutes for anesthetic purposes. Stretching exercises to tolerance are emphasized early and continued until recovery is full. Shoe orthoses, reduced activity, moist heat, interferential therapy, and/or phonophoresis with some type of anti-inflammatory agent are the common adjunctive procedures used.
A regimen of bilateral passive and then active stretching exercises for the tensor fascia lata, ITB, quadriceps, and hamstrings should be prescribed, but exercises designed to strengthen the quadriceps should be avoided. Activity is modified according to the signs at hand, and consideration is given to nontraumatic activities such as swimming or mild bicycling in the interim period. Ice massage can be applied to the involved area after each workout. If conservative measures fail, one alternative is referral for surgical release of the ITB or removal of the lateral epicondyle.
Recurrence Prevention. To prevent return, close evaluation of the patient, environment, and activity situation must be made. This might include footwear, foot mechanics, knee mechanics, pelvic motion, and even the terrain on which the workout is performed. Walking upstairs can be especially aggravating, but walking on level ground may have no ill effects. As with most posttraumatic problems, clinical success can only be achieved through careful analysis of all factors involved.
Ober calls attention to the frequency of a negative roentgenogram in the presence of clinical signs and symptoms of irritation of the sacroiliac or lumbosacral joints. He refers to the importance of the iliotibial band as a factor in the occurrence of lame backs, with or without associated sciatica. To differentiate, he believes that pain on extension and abduction points to a sacroiliac lesion; pain when the knee is released suggests lumbosacral strain; and contraction of the iliotibial band is indicated when the thigh does not return to the table on being released. Ely's test helps to pinpoint femoral nerve (L3--L4) involvement, and Lasegue's SLR test aids differentiating lumbosacral from upper lumbar involvement.
Ober's Test. This is the classic test for iliotibial band contractures. The patient is placed directly on his side with the unaffected side next to the table. The examiner places one hand on the pelvis or under the thigh to steady it and grasps the patient's ankle with the other hand, holding the knee flexed near a right angle. The thigh is abducted and extended in the coronal plane of the body. In the presence of iliotibial band contracture, the leg remains abducted --the degree of abduction depending on the amount of contracture present.
Prolonged inflammation of muscle tissue or using heat over an active hematoma can encourage ossification. Because of the large muscle volume of the thigh and its vulnerability to collision, traumatic myositis ossificans may result. The major features of myositis ossificans are stiffness, a palpable mass (often painless), a history of trauma, and diagnostic x-ray signs. As the trauma may not be remembered, the mass can initially be mistaken for a neoplasm. Even early biopsy often confuses the disorder with osteosarcoma at certain stages.
Radiographic signs vary according to duration: from an early cloud of mineralized tissue to a bone mass with a definite cortical rim containing trabeculae. Sometimes following a direct blow, posttraumatic masses will be seen developing on the surface of the bone's shaft where the bone has formed a periosteal focus.
Causalgia is a reflex sympathetic dystrophy characterized by an agonizing diffuse burning pain, paresthesia, swelling, trigger points, and redness or pallor. Trauma is usually in the history. It is often followed by organic changes such as bone atrophy and mottling resulting from persistently recurring nutrient artery spasms as well as skin and muscle atrophy. Complicating emotional disturbances are often associated. The syndrome is a vasomotor and sympathetic disorder wherein trophic disturbance in which any thermic, tactile, sensory, or even psychic stimulus may result in an explosive attack. It may involve either or both the lower or upper extremities.
The skin of the involved limb exhibits thickening, edema, and atrophy, with loss of normal skinfold creases. Joint immobility with or without pain, and scleroderma may occur. In time, muscle atrophy, contractures, immobility, and osteoporosis develop. Its most distinguishing features from early arthritis are that joint tenderness is lacking and the patient's report of persistent burning pain, paresthesia, and vasospastic coolness. When the upper extremity is involved, initial differentiation must be made from nerve root compression, thoracic outlet syndromes, and myocardial lesions.
The hip is the most proximal joint of the lower extremity and is a near-perfect ball-and-socket joint. It provides stability for the body above and gross control for the extremity segments below. From a biomechanical and kinesiologic viewpoint, the hip joint is one of the most complex joints of the body in its role of providing both large ranges of motion and large muscle torques in attempting to meet the requirements of imposed body weight during static and dynamic postures in the upright position.
Considerations Prior to Adjustive Therapy
It has been the author's experience that almost any technic designed to release a soft-tissue fixation or reduce a subluxation within a synovial joint should incorporate procedures (eg, manual axial traction) to assure slight physiologic distraction and biomechanical tissue adaptation before a corrective maneuver. If not, there is a possibility (likely, a probability) of injuring the cartilage of the articular surfaces and thus add to the development of further fixation. Obviously, distracted articular surfaces are much easier to move. Forcing motion on jammed articular surfaces will likely injure the apposed structures and set up an imposed inflammatory process leading to fibrosis, cartilage sclerosis, adhesion development, pain from excited mechanoreceptors and effected splinting, etc. Any clinical procedure should be uniquely patient-oriented, not prescripted by doctrine.
As with any clinical program, this procedure to assure articular distraction can be overdone. If too much distraction is used, the articular surfaces might become so separated (eg, in an unstable joint) as to dislocate during a poorly controlled adjustment. Another consideration is that stretched arteriosclerotic vessels are disposed to rupture when a strong longitudinal or rotational force is applied because structural plasticity is already at its limit. Even if bleeding may be minute, a degree of contribution to an adverse situation has been initiated. Knowing just how much joint distraction to apply and how much force, velocity, and depth to bestow during the adjustment in an individual situation is part of the art of chiropractic and just one factor that differentiates the chiropractic physician from the therapist or technician.
These principles are just as applicable to adjustive technics involving spinal and other extraspinal joints. In many extremity joints and the cervical vertebrae (C1--C6), it is fairly easy to dislocate an overly distracted joint that is unstable or normally very "loose." This is infrequently found, however, with thoracic, lumbar, sacroiliac, or the extraspinal axial articulations that have strong short ligaments. Typical exceptions would be with acrobats, contortionists, gymnasts accustomed to performing "somersaults and backflips," and others whose occupations require extremely unusual postural distortions. In these people, the ligament restraints may be lengthened through prolonged conditioning to such a degree that dislocation (and spontaneous reduction) is commonplace.
Special Clinical Considerations
Because the head of the femur articulates deeply within the acetabulum, the joint is highly stable. Unfortunately, this asset excludes the advantages of direct palpation during examination. Most of the physical clues of joint dysfunction must therefore be analyzed indirectly from the effects expressed in the thigh as a whole during passive motion studies in the nonweight-bearing position, gait and upright postural analyses, muscle strength testing, subjective symptoms (eg, pain, tenderness), superficial signs (eg, skin characteristics and temperature changes), reflexes, etc.
Degenerative changes and fractures predisposed by structural changes (eg, osteoporosis, biomechanical failure) in the hip are common. This is likely because the hip is frequently subjected to heavy repetitive loading that must be tolerated during function. Cortisone therapy, especially, appears to attack the hip (necrosis) more than other joints.
Muscle and ligament shortening affecting the hip is prevalent in the nonathletic individual, frequently producing complicating secondary effects in musculoskeletal architecture above and below. Overstress imposed on such fixations (added to the large muscle torques required for hip function) appears to encourage the development of acute and chronic subluxation syndromes. While chronic hip subluxations may exhibit themselves locally, they can express remotely anywhere in the kinematic chain (eg, lumbosacral area, feet, upper cervical spine).
Common Differentiation Clues
In testing hip flexion with the knee locked (straight-leg test), sciatic neuritis would be aggravated. In testing full hip flexion with the knee relaxed, a sacroiliac lesion may be aggravated. However, testing internal and external rotation of the hip with the hip and knee flexed to 90° should not normally ignite low-back or sacroiliac pain unless there is complicating psoas or piriformis spasm.
Mennell considers long-axis (downward) joint play to be the most important motion of the hip joint. The gross degree of distraction available can easily be judged by placing the patient supine in a position of rest, stabilizing one foot against your thigh and then applying traction on the thigh to be examined.
Many types of hip dysfunction are associated with a limitation in joint distraction. In osteoarthritic hip disease and certain adhesions, forced flexion of the thigh on the involved side toward the abdomen causes the contralateral thigh to raise from the table. This occurs because the motion limitation in the involved socket forces the pelvis as a whole to rotate upward. It suggests a restriction in hip flexion and points to a posterior adhesion or shortened tissues posteriorly (eg, hamstrings).
The same procedure can be used when testing forced extension with the patient in the prone position. If the contralateral thigh rises before normal extension is reached, the examiner should suspect an anterior joint fixation or shortening of the quadriceps.
Note: The maneuvers described below must be applied gently and not beyond patient tolerance, with special caution used with the elderly and very young. Too forceful an application, especially during forced extension, can cause a torsion fracture of the neck of the femur in the elderly or dislocate the head of the femur in a youngster. At the same time, it must be kept in mind that the hip joint is much more stable than the shoulder and requires a greater force to overcome larger muscle and ligament restrictions.
Releasing Inferior Distraction Fixations
Soft-tissue distraction (separation of intra-articular space) restrictions can be released simply by axial traction (manual or mechanical). Some type of belt or harness to stabilize the patient's pelvis is helpful. Once long-axis joint play is restored, at least to a modest degree, attention can be given to flexion, extension, abduction, and adduction fixations.
Straight distraction inferiorly is achieved by holding the supine patient's leg distally with one hand and the proximal aspect of the leg with your other hand and applying a pulling force, thus directing a distraction force to the hip via the knee. If the patient has a knee problem, contact must be taken on the distal thigh.
Releasing Flexion Fixations
To improve posterior glide with the patient supine, stand perpendicular to the involved thigh. Place your cephalad palm firmly on the most superior aspect of the anterior surface of the patient's thigh as possible, and grasp the underside of the patient's proximal thigh with your caudad hand. In this position, apply a slow pushing force directed to the floor with your cephalad hand (elbow locked) and a slight upward pull with your caudad hand.
To further improve flexion range of motion, stand on the opposite side of involvement perpendicular to the supine patient and approximately centered to the patient's knees. Flex the uninvolved knee and hip toward the patient's abdomen. Place your contact (cephalad) hand over the knee of the uninvolved side, and reach over the patient with your caudad hand and stabilize the distal aspect of the patient's thigh on the involved side. Flex the uninvolved limb toward the patient's abdomen just to the point where the contralateral (involved) femur begins to rise from the table. At this point, apply firm pressure against the involved limb as you continue to apply flexion pressure to the uninvolved hip.
Another technic is to place the patient supine with the hip and knee flexed at a right angle. Stand obliquely to the involved thigh, and grasp the patient's kneecap with your cephalad hand. Reach under the patient's leg with your caudad hand and place that hand on top of your other hand, thus supporting the patient's leg in the angle of your caudal arm and forearm. In this position, apply pressure toward the floor (through the vertical axis of the femur).
Also with the supine patient, specific posteroinferior distraction of the hip can be applied in hip flexion and slight abduction by facing the patient, placing the patient's flexed knee over your medial shoulder, grasping the upper thigh of the patient anteriorly with both hands and fingers interlaced, and applying a pulling force directed to your chin.
Releasing Extension Fixations
To improve anterior glide with the patient prone, stand perpendicular to the involved thigh. Place your cephalad palm firmly on the most superior aspect of the posterior surface of the patient's thigh as possible, and grasp the patient's flexed knee with your caudad hand. In this position, apply a slow pushing force directed to the floor with your cephalad hand (elbow locked) and a mild upward pull with your caudad hand.
To further improve extension range of motion, stand on the opposite side of involvement perpendicular to the prone patient --approximately centered to the patient's knee. Grasp under the uninvolved extended knee, and start to lift the limb upward. Reach over the patient with your caudad hand and stabilize the distal aspect of the patient's thigh on the involved side. Extend the uninvolved limb just to the point where the contralateral (involved) hip begins to rise from the table. At this point, apply firm pressure against the involved limb as you continue to apply extension pressure to the uninvolved hip.
Releasing Lateral Hip Fixations
A lateral fixation within the hip joint is not an uncommon finding. On the involved side, abduction and internal rotation will be restricted and the psoas muscle will usually test weak.
Psoas Strength. Psoas strength can be tested by the supine patient lifting the extended limb to 45°, externally rotating the foot, and resisting your attempt to move the patient's foot laterally and toward the floor. Stand at the foot of the table so that your inactive hand can stabilize the patient's contralateral pelvis.
Adjustment. Place the patient supine with the involved hip and knee flexed so that the foot rests flat on the table without strain. Stand at the foot of the table, and face the patient. Interlock your fingers over the patient's flexed knee, and lean forward so your sternum is almost above the knee. With the medial aspect of your forearm, press the patient's leg laterally to internally rotate the femur approximately 25°. While holding this pressure, make a gentle thrust through the longitudinal axis of the femur. Check if the fixation has been freed by evaluating bilateral internal rotation of the hip and psoas strength.
Active Exercise. In chronic cases, the following bed exercise is recommended. Have the patient assume the sidelying position with the involved side upward. The patient's body should be positioned near the edge of the bed, with the patient facing away from the near edge. A small pillow should be placed between the upper thighs. The underlying uninvolved hip and knee should be moderately flexed. The patient then slightly extends the limb and allows the leg to drop over the edge of the bed, thus producing hip adduction in mild extension. The patient should then actively abduct the limb a few inches and let it drop by its own weight several times. This will stretch soft-tissue restrictions to external rotation and inferior distraction.
Internally Subluxated Femur
An internally subluxated femur is commonly associated with restricted femoral external rotation, anterior pelvic tilting, external tibia rotation, and subtalar pronation. Some genu valgum and hip pain are usually associated.
Adjustment. Place the patient supine with flexed knees so that the buttocks are near the end of the table. Stand medially, facing perpendicular to the thigh of the involved hip. Contact the medial aspect of the upper thigh. While your stabilizing hand grasps the patient's upper calf, externally rotate the femur, apply traction with your stabilizing hand, and make a gentle thrust with your contact hand, directed toward further external rotation.
Externally Subluxated Femur
An externally subluxated femur is related to restricted femoral internal rotation, internal tibia rotation, and subtalar pronation. A degree of genu varum and hip pain are usually related.
Adjustment. With the patient supine, stand lateral to the patient on the side of involvement, facing obliquely medial. Contact the superolateral aspect of the femur at midshaft with your cephalad hand, while your stabilizing hand is wrapped over the patient's leg so that your palm supports the patient's upper calf. Internally rotate the femur, apply caudal traction with your stabilizing hand, and make a gentle thrust with your contact hand that is directed toward further internal rotation.
Superiorly Subluxated Femur
A superiorly subluxated femur is usually found when nagging hip pain complicates low back pain. A degree of fixed internal or external rotation is often involved.
Adjustment. With the patient supine, stand at the foot of the table and face the patient. Grasp the lower leg of the involved limb just above the ankle, and stabilize the patient's contralateral foot against your thigh. Apply traction, and make a gentle pull --taking into consideration any internal or external rotation involved by rotating your hands accordingly.
Anteriorly Subluxated Femur
Occasionally one comes upon a lesser degree of an anterior (obturator) dislocation. The cause is usually a severe fall or being forced backward against an obstacle. On the involved side of an anteriorly subluxated femur, the patient exhibits hip pain and an externally rotated limb that is lengthened. The head of the femur lies nearer the obturator foramen than normal.
Adjustment. With the patient supine, stand at the foot of the table, near the side of involvement, and face the patient. With your lateral hand, grasp the patient's posterior-distal aspect of the leg just above the ankle. With your medial hand, reach across the patient's foot and grasp the heel. Both hands should be on the lateral aspect of the patient's ankle area. Apply gentle traction and medial rotation to the limb. Adduct the patient's involved limb across the patient's other leg, maintaining control. Constant traction, medial rotation, and adduction should reset the displaced femoral head.
Posteriorly Subluxated Femur
When the femur is subluxated backward, the patient has difficulty in extending the thigh. Measurement will indicate limb shortening. The mechanism of injury is usually a fall, long jump, or severe upper-thigh blow directed from the anterior.
Adjustment. Place the patient supine. Stand on the side of involvement at a level near the patient's flexed knee, and face obliquely medial to the patient. Bring the patient's knee laterally so that it is firm against your upper abdomen. With your cephalad hand, stabilize the patient's contralateral ilium. With your caudad contact hand, grasp the patient's ankle from the anterior. Apply abduction to the flexed knee with your body weight, and simultaneously use superior pressure with your contact hand to increase hip flexion and carry the patient's lower leg medially. This hip flexion, abduction, and external rotation should realign the displaced femoral head.
Sciatic displacement of the head of the femur is a chronic postural disorder associated with pelvic tilt where weight balance is decidedly unilateral on the involved side. The head of the femur is found near the lesser sciatic notch --thus its name. Acute trauma is rarely involved, but injury may be in the patient's history. The patient presents with hip pain, internal limb rotation, and a shortened limb.
Adjustment. This maneuver is essentially the opposite of adjusting an anteriorly subluxated femur. Place the patient supine, stand at the foot of the table near the side of involvement, and face the patient. With your lateral hand, grasp the patient's posterodistal aspect of the leg just above the ankle. With your medial hand, reach across the patient's foot and grasp the heel. Both hands should be on the lateral aspect of the patient's ankle area. Apply gentle traction and lateral rotation to the limb. Abduct the patient's involved limb. In this position, constant traction, lateral rotation, and abduction should reset the displaced femoral head.
The hip, knee, and ankle work as a functional unit (kinematic chain). Thus, all three joints must be considered when correcting an obvious postural distortion of any one joint.
The common muscles to be strengthened in postural distortions of the hip are the lateral and medial hip rotators, hip adductors, knee extensors and flexors, foot invertors, metatarsophalangeal flexors, and the abductors, flexors, and extensors of the toes. The common muscles to be stretched in lower extremity postural distortions are the flexors, medial rotators, and adductors of the thigh and the plantar flexors, evertors, and invertors of the ankle.
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